Tennessee CoverRx Covered Drug List Effective July 1, 2019
Tennessee CoverRx Covered Drug List - Effective 7/1/2024
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 Oseltamivir 75 mg capsules* Rimantadine
ANTIVIRALS (CONT'D) *QUANTITY LIMITS: Oseltamivir: 20 capsules per 180 days
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
DIABETES
Haloperidol
Glimepiride
Haloperidol Decanoate
Glipizide
Haloperidol Lactate 2 mg/ml
Glipizide ER/XL
Hydroxyzine Pamoate
Glyburide
Imipramine HCL Lithium Carbonate Loxapine Lurasidone (except 120 mg tablets)* Mirtazapine Nortriptyline Olanzapine IR 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)*
Paroxetine tablets (not CR tablets) Perphenazine
Jardiance?* Lantus? vials & Lantus? Solostar pens*
Quetiapine tablets (not ER tablets)
Metformin tablets
Risperidone tablets
Metformin ER (excluding osmotic ER &
Sertraline tablets
modified release ER)
Thiothixene Trazodone
Pioglitazone Toujeo? Solostar / Max Solostar?
Trifluoperazine Trihexyphenidyl tablets Venlafaxine IR tablets Venlafaxine ER capsules* *QUANTITY LIMITS:
Alcohol Swabs FreeStyle? Freedom Lite meter FreeStyle? InsuLinx meter / strips* FreeStyle? Libre 2 Sensor and Reader FreeStyle? Lite meter / strips*
Aripiprazole tablets: 1 tablet per day
Insulin Syringes*
Duloxetine capsules: 2 capsules per day Olanzapine IR 2.5mg, 5mg,
Lancet Devices / Lancets Precision? Xtra meter / strips*
7.5mg & 10mg tablets: 2 tablets per day
*QUANTITY LIMITS:
Olanzapine IR 15mg & 20mg tablets: 1 tablet per day Insulin: Lesser of 30-Day supply or 40ml per fill per type
Venlafaxine ER capsules: 1 capsule per day 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 Warfarin Sodium
Lancets: 100 per 30 days or 300 per 90 days Jardiance? tablets: 1 tablet per day
Insulin, diabetic supplies, vaccines, nicotine replacement products,and Buprenorphine/Naloxone 8/2 mg SL tablets do not count against the monthly 5 script limit. Vaccines, Narcan, Kloxxado and Naloxone Nasal Sprays have $0 Copay.
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Tennessee CoverRx Covered Drug List - Effective 7/1/2024
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
Insulin, diabetic supplies, vaccines, nicotine replacement products and Buprenorphine/Naloxone 8/2 mg SL tablets do not count against the monthly 5 script limit. Vaccines, Narcan, Kloxxado and Naloxone Nasal Sprays have $0 Copay.
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 Buprenorphine/Naloxone 8mg/2mg SL tablets*
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:
Buprenorphine/Naloxone 8mg/2mg SL tablets: 2 tablets
per day 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?
Pneumovax?
Fluarix?
Prevnar 13?
Flublok?
COVID-19
Flucelvax? Quad
Abrysvo?
Flulaval?
Arexvy?
Fluvirin?
Fluzone?
Influenza A (H1N1)
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