Tennessee CoverRx Covered Drug List Effective February 12 ...
Tennessee CoverRx Covered Drug List - Effective 9/1/2023
ANTIBIOTICS Amoxicillin Amoxicillin / Clavulanate Ampicillin Azithromycin Cefaclor capsules Cefadroxil Cefpodoxime tablets Cefuroxime tablets Cephalexin capsules (except 750 mg) Ciprofloxacin (except 750 mg & XR) Clindamycin capsules Dicloxacillin Doxycycline Monohydrate capsule Erythromycin / Sulfisoxazole Levofloxacin tablets Metronidazole (except lotion,
0.75% vaginal gel, & 1% gel) Minocycline capsules Neomycin Sulfate Nitrofurantoin Macrocrystals Paromomycin Sulfate Penicillin V Potassium Sulfamethoxazole / Trimethoprim Trimethoprim
ANTICONVULSANTS Divalproex DR tablets Lamotrigine IR tablets Levetiracetam IR tablets Oxcarbazepine IR tablets Phenytoin 100 mg capsules Phenytoin suspension Valproic Acid
ANTIVIRALS Acyclovir (except topicals) Amantadine Molnupiravir * Oseltamivir 75 mg capsules* Paxlovid * Rimantadine
ANTIVIRALS (CONT'D) *QUANTITY LIMITS: Molnupiravir: 40 capsules per 5 days
2 courses per year Oseltamivir: 20 capsules per 180 days Paxlovid: 30 tablets per 5 days
2 courses per year
ARTHRITIS AND PAIN Allopurinol Dexamethasone Diclofenac Sodium tablets Hydroxychloroquine Sulfate Indomethacin Ketoprofen Ketorolac* Meloxicam tablets Methotrexate Methylprednisolone Nabumetone Prednisolone Sod-Phos solution Prednisone tablets Salsalate Sulindac *QUANTITY LIMITS: Ketorolac: 20 tablets per 60 days
ASTHMA AND RESPIRATORY Albuterol HFA Ipratropium-Albuterol Nebulizer Solution Montelukast 5mg chew, 10mg tablet Terbutaline Sulfate tablets Theophylline, Anhydrous, ER
BEHAVIORAL HEALTH Amitriptyline Aripiprazole tablets (not ODT)* Benztropine Bupropion SR Bupropion XL 150 & 300 mg Buspirone
BEHAVIORAL HEALTH (CONT'D)
CHOLESTEROL
Citalopram tablets
Atorvastatin
Clozapine (except 200 mg tablets)
Fenofibrate 54 mg and 160 mg tablets
Doxepin
Gemfibrozil
Duloxetine capsules*
Lovastatin
Escitalopram tablets
Pravastatin
Fluoxetine capsules (except DR)
Rosuvastatin
Fluphenazine
Simvastatin
Fluphenazine Decanoate
Haloperidol
DIABETES
Haloperidol Decanoate
Glimepiride
Haloperidol Lactate 2 mg/ml
Glipizide
Hydroxyzine Pamoate
Glipizide ER/XL
Imipramine HCL
Glyburide
Lithium Carbonate Loxapine Lurasidone (except 120 mg tablets)* Mirtazapine Nortriptyline Olanzapine IR tablets* Paroxetine tablets (not CR tablets)
Glyburide/Metformin Humalog? cartridge* Humalog? / Humalog? Mix pen* & KwikPen?* Humalog? / Humalog? Mix vial* Humulin? cartridge* Humulin? pen & KwikPen? (except U-500)* Humulin? vial (except U-500)*
Perphenazine Quetiapine tablets (not ER tablets)
Jardiance?* Lantus? vials & Lantus? Solostar pens*
Risperidone tablets
Metformin tablets
Sertraline tablets
Metformin ER (excluding osmotic ER &
Thiothixene
modified release ER)
Trazodone Trifluoperazine
Pioglitazone Toujeo? Solostar / Max Solostar?
Trihexyphenidyl tablets Venlafaxine IR tablets Venlafaxine ER capsules* *QUANTITY LIMITS: Aripiprazole tablets: 1 tablet per day
Alcohol Swabs FreeStyle? Freedom Lite meter FreeStyle? InsuLinx meter / strips* FreeStyle? Libre 2 Sensor and Reader FreeStyle? Lite meter / strips*
Duloxetine capsules: 2 capsules per day
Insulin Syringes*
Olanzapine IR 2.5mg, 5mg, 7.5mg & 10mg tablets: 2 tablets per day
Lancet Devices / Lancets Precision? Xtra meter / strips*
Olanzapine IR 15mg & 20mg tablets: 1 tablet per day *QUANTITY LIMITS:
Venlafaxine ER capsules: 1 capsule per day
Insulin: Lesser of 30-Day supply or 40ml per fill per type
Lurasidone tablets: 1 tablet per day
Insulin Test Strips: 100 per 30 days or 300 per 90 days
Insulin Syringes: 100 per 30 days or 300 per 90 days
BLOOD MODIFIERS
Insulin Pen Needles: 100 per 30 days or 300 per 90 days
Clopidogrel 75 mg tablets
Alcohol Swabs: 100 per 30 days or 300 per 90 days
Dipyridamole
Lancets: 100 per 30 days or 300 per 90 days
Warfarin Sodium
Jardiance? tablets: 1 tablet per day
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Tennessee CoverRx Covered Drug List - Effective 9/1/2023
EYE CARE AND GLAUCOMA
HEART HEALTH & BLOOD PRESSURE (CONT'D) STOMACH HEALTH
Acetazolamide
Carvedilol
Dicyclomine capsules & tablets
Atropine Sulfate
Chlorthalidone
Hyoscyamine drops
Brimonidine Tartrate 0.2%
Clonidine tablet (not ER tablet)
Hyoscyamine IR tablets
Cyclopentolate HCl 1%
Digoxin
Mesalamine Suppositories
Dexamethasone Sod-Phos
Diltiazem, ER / XR
Metoclopramide
Dorzolamide / Timolol Eye Drops
Disopyramide Phosphate
Sulfasalazine
Erythromycin Eye Ointment
Enalapril / HCTZ
Ursodiol tablets
Gentamicin Sulfate 0.3%
Felodipine ER
Homatropine HBr 5% Latanoprost
Furosemide tablets Hydralazine
THYROID CONDITIONS Armour Thyroid?
Levobunolol HCl
Hydrochlorothiazide
Levothyroxine, Levo-T, Euthyrox
Ofloxacin Eye Drops
Indapamide
Methimazole
Pilocarpine Eye Drops
Isosorbide Mononitrate
Synthroid?
Polymyxin B / Trimethoprim
Lisinopril
Prednisolone Acetate
Lisinopril / HCTZ
UROLOGY
Sulfacetamide Sodium
Losartan
Bethanechol Chloride
Timolol Maleate
Losartan/HCTZ
Flavoxate
Tobramycin Sulfate
Metolazone
Oxybutynin HCl
Metoprolol, ER
Phenazopyridine HCl
FUNGAL INFECTIONS
Mexiletine
Clotrimazole
Nifedipine ER
VITAMINS AND MINERALS
Clotrimazole Troche
Nitroglycerin (except patch)
Calcitriol (except ointment)
Fluconazole
NitroStat
Ergocalciferol (Vitamin D2) capsules*
Ketoconazole (except foam)
Prazosin 1 mg & 2 mg capsules*
Folic acid 1 mg tablets
Nystatin (except powder)
Propafenone tablets
Potassium Chloride
Propranolol IR
Prenatal Vitamins ? All generics
HEART HEALTH & BLOOD PRESSURE Quinidine Gluconate
*QUANTITY LIMITS:
Amiodarone (except 100 mg)
Sotalol
Ergocalciferol: 13 capsules per 90 days
Amlodipine
Spironolactone
Amlodipine / Benazepril
Terazosin
WOMEN'S HEALTH
Atenolol
Triamterene / HCTZ
Estradiol oral tablets, cream
Atenolol / Chlorthalidone
Verapamil tablets, ER / PM / SR
Estropipate
Bisoprolol / HCTZ
*QUANTITY LIMITS:
Medroxyprogesterone (not injection)
Bisoprolol Fumarate
Prazosin: 1 capsule per day
Oral Contraceptives ? All generics &
Benazepril
Emergency Contraceptives
Tamoxifen
OTHER MEDICAL CONDITIONS Allergies Hydroxyzine HCL Bone Density Alendronate Ear Health Neomycin/Polymyxin/HC Ear Drops Migraines Sumatriptan tablets* Skin Cream Triamcinolone Acetonide Cream
Miscellaneous COVID-19 At-Home tests* Kloxxado? Nasal Spray*
Lactulose Megestrol Acetate Naloxone Nasal Spray* Narcan? Nasal Spray* NRT-Nicotine Transdermal Patches*: 7mg,14mg, 21mg NRT-Nicotine Gum*: 2mg, 4mg NRT-Nicotine Lozenges*: 2mg, 4 mg Promethazine tablets *QUANTITY LIMITS: COVID-19 At-Home tests: 8 tests per month Kloxxado? Nasal Spray: 1 kit per month (not available
by mail order) Naloxone Nasal Spray: 2 nasal spray bottles per month
(not available by mail order) Narcan? Nasal Spray: 1 kit per month (not available
by mail order) Sumatriptan tablets: 9 tablets per month NRT Patches: 8 weeks per each strength annually NRT Gum and Lozenges: 12 weeks per strength annually
VACCINES Afluria? Fluarix? Flublok? Flucelvax? Quad Flulaval? Fluvirin? Fluzone? Influenza A (H1N1) Pneumovax? Prevnar 13? COVID-19
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