TennCare Preferred Drug List (PDL) - Magellan Health

TennCare Preferred Drug List (PDL)

Effective August 1, 2019

PA ? Prior Authorization required, subject to specific PA criteria; QL ? Quantity Limit (PA & NP agents require a PA before dispensing); B ? Budgetary Reduction edit for utilization control (Standard NP PA criteria does not apply); ID ? Class PA for patients with Intellectual or Developmental Disability Please note the following: All agents must be prescribed by a provider with a Tennessee Medicaid Provider ID Approval of NP agents requires trial and failure, contraindication, or intolerance of 2 preferred agents, unless otherwise indicated With the exception of the "Branded Drugs Classified as Generics" list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205).

Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via an FDA MedWatch form OR contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents. Unless otherwise noted, all agents listed on the PDL are referencing legend drugs which are prescription-required agents. Coverage of Over-the Counter (OTC) Products is listed at:

Preferred Drugs

Non-Preferred Drugs

I. Analgesics

naltrexone Bunavail? PA, QL Bunavail? PA, QL

celecoxib (50, 100, & 200 mg) QL N/A

Narcan? nasal spray QL nalbuphine PA, QL

Agents for Opiate Detoxification

Lucemyra? PA, QL

ReVia? PA

Buprenorphine and Buprenorphine/Naloxone

TennCare Medication Assisted Therapy (MAT) Providers Network only:

buprenorphine/naloxone tablets PA, QL buprenorphine PA, QL

Suboxone? film PA, QL

buprenorphine/naloxone film PA, QL Zubsolv? PA, QL

All other TennCare Providers:

buprenorphine PA, QL

Suboxone? film PA, QL

buprenorphine/naloxone film PA, QL Zubsolv? PA, QL

buprenorphine/naloxone tablets PA, QL

COX-II Inhibitors PA

Celebrex? QL

celecoxib 400 mg PA, QL

Transmucosal Fentanyl Products

Abstral? PA, QL

Fentora? PA, QL

Actiq? PA, QL

Lazanda ? PA, QL

fentanyl lozenge PA, QL

Subsys? PA, QL

Naloxone Products

n/a

Narcotics Agonist/Antagonists

butorphanol NS PA, QL

pentazocine/naloxone PA, QL

pentazocine/APAP PA, QL

* Note that agents not listed on PDL may be considered non-preferred

Proprietary & Confidential ? 2019 Magellan Health Services

Preferred Drugs

Non-Preferred Drugs

I. Analgesics

Narcotics, Long Acting Narcotics

Embeda? PA, QL

Arymo ER? PA, QL

fentanyl patch (excluding 37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr) PA, QL Avinza? PA, QL

Nucynta? ER PA, QL

Belbuca? PA, QL

buprenorphine patch PA, QL

Butrans? PA, QL ConZip? PA, QL Dolophine? PA, QL Duragesic? PA, QL Exalgo? PA, QL

fentanyl patch (37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr) PA, QL hydromorphone ER PA, QL Hysingla? ER PA, QL

codeine/APAP PA (< 19 years old), QL

Endocet? QL hydrocodone/APAP QL

(excluding generic for Xodol?) hydrocodone/ibuprofen QL hydromorphone QL

(excluding suppositories)

Kadian? PA (100 mg), QL

methadone PA, QL

Methadose? PA, QL

Short-Acting Narcotics QL

morphine IR QL (excluding suppositories)

Apadaz? QL

oxycodone tabs QL

benzhydrocodone/APAP PA, QL

oxycodone/APAP QL

butalbital/APAP/caff/codeine PA, QL

tramadol QL

butalbital/ASA/caff/codeine PA, QL Capital with Codeine? PA, QL

codeine PA, QL Demerol? PA, QL dihydrocodeine/APAP/caffeine PA, QL dihydrocodeine/ASA/caffeine PA, QL Dilaudid? PA, QL Fioricet? with Codeine PA, QL Fiorinal? with Codeine PA, QL Hycet? PA, QL hydrocodone/APAP 5/300 PA, QL hydrocodone/APAP 10/300 PA, QL hydromorphone suppositories PA Ibudone? PA, QL levorphanol PA, QL Lorcet? PA, QL Lortab? PA, QL meperidine PA, QL morphine sulfate soln 20 mg/ml PA morphine suppositories PA, QL Norco? PA, QL Nucynta? PA, QL

Morphabond? ER PA, QL morphine sulfate ER caps PA, QL morphine sulfate SA PA, QL morphine sulfate SR 24hr (generic for Avinza?) PA, QL MS Contin? PA, QL Opana ER? PA, QL OxyContin? PA, QL oxymorphone ER PA, QL oxycodone ER PA, QL tramadol ER PA, QL

tramadol ER 24 hr PA, QL tramadol ER PA, QL (generic for Conzip?) Ultram ER? PA, QL Xtampza ER? PA, QL Zohydro ER? PA, QL

Opana? PA, QL

Oxaydo? PA, QL oxycodone caps PA, QL

oxycodone oral concentrate PA oxycodone/ASA PA, QL

oxycodone/IBU PA, QL oxymorphone PA, QL Percocet? PA, QL Primlev? PA, QL Reprexain? PA, QL Roxicet? PA, QL Roxicodone? PA, QL RoxyBond? QL Synalgos?-DC PA, QL tramadol/APAP PA, QL Tylenol? with Codeine PA, QL Ultracet? PA, QL Ultram? PA, QL Vicodin? PA, QL Vicodin HP PA, QL Vicoprofen? PA, QL XartemisTM XR PA, QL Xodol? PA, QL Zamicet? PA, QL

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: August 1, 2019

TennCare Preferred Drug List (PDL) | Page 2

Preferred Drugs

Non-Preferred Drugs

I. Analgesics

N/A

choline mag trisalicylate QL

diclofenac 1% gel (generic for Voltaren? gel) QL diclofenac potassium diclofenac sodium diclofenac sodium ER ibuprofen

NSAID/Anti-Ulcer Agents

Arthrotec? PA, QL

diclofenac/misoprostol PA, QL

Salicylates and Non-Narcotic Combination Agents

salsalate QL

diflunisal QL

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

indomethacin

Anaprox?

ketorolac QL meloxicam tablets nabumetone sulindac

Anaprox DS? Cambia? Cataflam? Clinoril? Daypro? diclofenac patch PA, QL diclofenac sodium 1.5% PA EC-Naprosyn? etodolac etodolac ER Feldene? fenoprofen Flector? PA, QL flurbiprofen indomethacin ER ketoprofen ketoprofen ER meclofenamate mefenamic acid meloxicam suspension Mobic?

Duexis? PA, QL Vimovo? PA, QL

Rhinoflex 650? QL

Motrin?

Nalfon? Naprelan? naproxen tabs and suspension naproxen sodium ER Naprosyn? Naproxen? CR Pennsaid? PA piroxicam Ponstel? oxaprozin Sprix? PA, QL Tivorbex? PA tolmetin Toradol? QL Vivlodex? PA, QL Voltaren? Voltaren? gel QL Voltaren-XR? VOPAC MDS Kit PA Zipsor? Zorvolex? PA

Preferred Drugs

Non-Preferred Drugs

II. ANTI-INFECTIVES

cefadroxil capsules cefadroxil suspension cefaclor capsules cefprozil cefdinir

N/A

Antibiotics: Cephalosporins First Generation

cephalexin capsules

cefadroxil tablets

cephalexin suspension

cephalexin tablets

Antibiotics: Cephalosporins Second Generation

cefuroxime tabs PA

cefaclor suspension

cefaclor ER

Antibiotics: Cephalosporins Third Generation

Suprax?

Cedax?

cefditoren

cefixime capsules & suspension

cefpodoxime suspension PA

Antibiotics: Ketolides

Ketek? PA

Keflex?

Ceftin? suspension PA Ceftin? tabs

cefpodoxime tablets ceftibuten Spectracef?

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: August 1, 2019

TennCare Preferred Drug List (PDL) | Page 3

Preferred Drugs

Non-Preferred Drugs

II. ANTI-INFECTIVES

azithromycin QL

azithromycin suspension PA clarithromycin

Antibiotics: Macrolides

erythromycin generic products (excluding erythromycin base tabs and erythromycin ethylsuccinate suspension 400 mg/5mL)

Biaxin?

erythromycin/sulfisoxazole

Biaxin XL? QL

clarithromycin ER/XL QL

Eryped? 400 mg/5mL suspension all generic combinations of

methenamine, phenyl salicylate, hyoscyamine, atropine, etc. N/A N/A neomycin ethambutol isoniazid

N/A clindamycin caps nitrofurantoin capsules

N/A

amoxicillin amoxicillin/clavulanate ciprofloxacin

Dificid? PA, QL

Antibiotics: Methenamine and Combo

methenamine mandelate methenamine hippurate

all brand combinations of methenamine, phenyl salicylate, hyoscyamine, atropine, etc.

Antibiotics: Miscellaneous Agents for UTI

Monurol? QL, PA

Antibiotics: Non-Absorbable Rifamycin

Xifaxan? PA, QL

Antibiotics: Oral Aminoglycosides

Neo-Fradin?

N/A

Antibiotics: Oral Anti-Tuberculosis

pyrazinamide

cycloserine

rifabutin PA

Myambutol?

rifampin

Mycobutin? PA

Paser?

Priftin?

Antibiotics: Oral Glycopeptides

Firvanq? PA, QL

Antibiotics: Oral Lincosamines

clindamycin pediatric solution PA Cleocin?

Antibiotics: Oral Nitrofurans

nitrofurantoin suspension PA

Furadantin? PA

Macrobid?

Antibiotics: Oxazolidinones

linezolid suspension QL

linezolid tabs PA, QL

Antibiotics: Penicillins

dicloxacillin

all brand penicillins

penicillin

amoxicillin/clavulanic acid XR

Antibiotics: Quinolones

levofloxacin tabs

Baxdela? PA, QL

Cipro? tablets

Cipro? suspension PA

ciprofloxacin suspension PA

ciprofloxacin ER QL

erythromycin base tablets

erythromycin ethylsuccinate suspension 400 mg/5mL erythromycin brand products (except Eryped? 400 mg/5mL suspension) Zithromax? QL Hiprex? Uroqid Acid #2?

Rifadin? Rifamate? PA Rifater? PA Trecator?

vancomycin caps PA Cleocin? Pediatric granules PA Macrodantin?

Sivextro? PA, QL Zyvox? PA, QL amoxicillin ER

Levaquin? tabs levofloxacin solution PA moxifloxacin PA ofloxacin

* Note that agents not listed on PDL may be considered non-preferred

Effective Date: August 1, 2019

TennCare Preferred Drug List (PDL) | Page 4

Preferred Drugs

Non-Preferred Drugs

II. ANTI-INFECTIVES

Antibiotics: Tetracyclines

doxycycline hyclate 50 and 100mg QL

Adoxa? QL

doxycycline monohydrate 50 and 100 mg caps QL

demeclocycline PA

minocycline capsules

Doryx? QL

tetracycline

doxycycline hyclate DR particles tabs QL doxycycline hyclate 20mg PA, QL

doxycycline monohydrate 75 mg and 150 mg caps QL

doxycycline monohydrate powder for suspension PA

doxycycline monohydrate tabs QL

Dynacin?

minocycline ER PA, QL

Antibiotics: Sulfonamides, Folate Antagonist

sulfadiazine PA

trimethoprim (TMP) TMP/sulfamethoxazole

Bactrim?

Sulfatrim?

Bactrim DS?

Antifungals: Oral

clotrimazole troches

griseofulvin suspension

Ancobon? PA

fluconazole suspension PA

nystatin

Cresemba? PA

fluconazole tablets QL

terbinafine PA, QL

Diflucan? suspension PA

griseofulvin ultramicrosize

Diflucan? tablets QL

flucytosine PA

Grifulvin V?

griseofulvin microsize

Gris-Peg?

itraconazole PA, QL

Antifungals: Vaginal

miconazole-3 kit

terconazole QL

AVC? cream QL

nystatin QL

Gynazole-1? QL

Anti-Infectives: Amebicides

paromomycin

N/A

Anti-Infectives: Antimalarials

atovaquone/proguanil

mefloquine

Aralen?

chloroquine

primaquine

Coartem?

dapsone

quinine sulfate

Daraprim?

Anti-Infectives: Anthelmintics

albendazole PA

praziquantel

Albenza? PA

ivermectin

pyrantel pamoate (OTC)

Biltricide?

Anti-Infectives: Miscellaneous Antiprotozoal Agents

metronidazole tabs

atovaquone PA

benznidazole PA, QL

Flagyl?

Anti-Infectives: Oral Nitroimidazoles

metronidazole tabs

Flagyl?

Flagyl? ER

metronidazole caps

* Note that agents not listed on PDL may be considered non-preferred

minocycline capsules and tablets Minolira ER? PA, QL Morgidox? PA, QL Nuzyra? PA, QL Ocudox? Kit Oracea? QL

Periostat? PA, QL

Solodyn? PA, QL Vibramycin? QL Ximino? ER PA, QL

Primsol?

ketoconazole PA Lamisil? PA, QL Noxafil? PA Onmel? PA, QL Oravig? PA Sporanox? PA, QL Vfend? PA voriconazole PA

miconazole-3 vaginal supp Terazol?

Malarone? Qualaquin?

Emverm? PA Stromectol?

Flagyl? ER Mepron? PA metronidazole caps

Solosec? PA, QL Tindamax? Tinidazole

Effective Date: August 1, 2019

TennCare Preferred Drug List (PDL) | Page 5

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