PDF Tennessee CoverRx Covered Drug List Effective July 1, 2019

Tennessee CoverRx Covered Drug List - Effective 10/1/2021

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

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 Ipratropium-albuterol Montelukast 5mg chew, 10mg tablet ProAir? HFA ProAir? RespiClick Terbutaline Sulfate tablets Theophylline, Anhydrous, ER

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 *QUANTITY LIMITS: Oseltamivir: 20 capsules per 180 days

BEHAVIORAL HEALTH Amitriptyline Aripiprazole tablets (not ODT)* Benztropine Bupropion SR Bupropion XL 150 & 300 mg Buspirone Citalopram tablets Clozapine (except 200 mg tablets) Doxepin Duloxetine capsules* Escitalopram tablets Fluoxetine capsules (except DR) Fluphenazine Fluphenazine Decanoate

BEHAVIORAL HEALTH (CONT'D)

DIABETES

Haloperidol

Glimepiride

Haloperidol Decanoate

Glipizide

Haloperidol Lactate 2 mg/ml

Glipizide ER/XL

Hydroxyzine Pamoate

Glyburide

Imipramine HCL Lithium Carbonate Loxapine Mirtazapine Nortriptyline Olanzapine IR tablets* Paroxetine tablets (not CR tablets) Perphenazine

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)* 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*

Alcohol Swabs Freestyle? Freedom Lite meter FreeStyle? InsuLinx meter / strips* FreeStyle? Lite meter / strips*

*QUANTITY LIMITS:

Insulin Syringes*

Aripiprazole tablets: 1 tablet per day Duloxetine capsules: 2 capsules per day

Lancet Devices / Lancets Precision? Xtra meter / strips*

Olanzapine IR 2.5mg, 5mg,

*QUANTITY LIMITS:

7.5mg & 10mg tablets: 2 tablets per day

Insulin: Lesser of 30-Day supply or 40ml per fill per type

Olanzapine IR 15mg & 20mg tablets: 1 tablet per day Insulin Test Strips: 100 per 30 days or 300 per 90 days

Venlafaxine ER capsules: 1 capsule per day

Insulin Syringes: 100 per 30 days or 300 per 90 days

Insulin Pen Needles: 100 per 30 days or 300 per 90 days

BLOOD MODIFIERS

Alcohol Swabs: 100 per 30 days or 300 per 90 days

Clopidogrel 75 mg tablets

Lancets: 100 per 30 days or 300 per 90 days

Dipyridamole

Warfarin Sodium

CHOLESTEROL Atorvastatin Fenofibrate 54 mg and 160 mg tablets Gemfibrozil Lovastatin Pravastatin Simvastatin

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Tennessee CoverRx Covered Drug List - Effective 10/1/2021

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%

Furosemide tablets

THYROID CONDITIONS

Latanoprost

Hydralazine

Levothyroxine, Levo-T, Euthyrox

Levobunolol HCl

Hydrochlorothiazide

Methimazole

Ofloxacin Eye Drops

Indapamide

Pilocarpine Eye Drops

Isosorbide Mononitrate

UROLOGY

Polymyxin B / Trimethoprim

Lisinopril

Bethanechol Chloride

Prednisolone Acetate

Lisinopril / HCTZ

Flavoxate

Sulfacetamide Sodium

Losartan

Oxybutynin HCl

Timolol Maleate

Losartan/HCTZ

Phenazopyridine HCl

Tobramycin Sulfate

Metolazone

Metoprolol, ER

VITAMINS AND MINERALS

FUNGAL INFECTIONS

Mexiletine

Calcitriol (except ointment)

Clotrimazole

Nifedipine ER

Ergocalciferol (Vitamin D2) capsules*

Clotrimazole Troche

Nitroglycerin (except patch)

Folic acid 1 mg tablets

Fluconazole

NitroStat

Potassium Chloride

Ketoconazole (except foam)

Prazosin 1 mg & 2 mg capsules*

Prenatal Vitamins ? All generics

Nystatin (except powder)

Propafenone tablets

*QUANTITY LIMITS:

Propranolol IR

Ergocalciferol: 13 capsules per 90 days

HEART HEALTH & BLOOD PRESSURE Quinidine Gluconate

Amiodarone (except 100 mg)

Sotalol

WOMEN'S HEALTH

Amlodipine

Spironolactone

Estradiol oral tablets, cream

Amlodipine / Benazepril

Terazosin

Estropipate

Atenolol

Triamterene / HCTZ

Medroxyprogesterone (not injection)

Atenolol / Chlorthalidone

Verapamil tablets, ER / PM / SR

Oral Contraceptives ? All generics &

Bisoprolol / HCTZ

*QUANTITY LIMITS:

Emergency Contraceptives

Bisoprolol Fumarate

Prazosin: 1 capsule per day

Tamoxifen

Benazepril

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 Lactulose Megestrol Acetate Naloxone carpuject* Narcan? Nasal Spray*

NRT-Nicotine Transdermal Patches*: 7mg,14mg, 21mg Promethazine tablets *QUANTITY LIMITS: Naloxone carpuject: 2 inj. per month (not available

by mail order) Narcan? Nasal: 1 kit per month (not available

by mail order) Sumatriptan tablets: 9 tablets per month NRT Patches: 8 weeks per each strength annually VACCINES Afluria? Fluarix? Flublok? Flucelvax? Quad Flulaval? Fluvirin? Fluzone?

Influenza A (H1N1) Pneumovax? Prevnar 13? COVID-19

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