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Tenncare Preferred Drug List (PDL)

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Tenncare Preferred Drug List (PDL) TennCare Preferred Drug List (PDL) Effective October 1, 2021 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: https://www.optumrx.com/content/dam/openenrollment/pdfs/Tenncare/presciber/program-information/Covered%20OTC%20List.pdf Preferred Drugs Non-Preferred Drugs I. ANALGESICS Agents for Opioid Use Disorder naltrexone Lucemyra® PA, QL Buprenorphine and Buprenorphine/Naloxone Buprenorphine Enhanced Supportive Medication-Assisted Recovery and Treatment (BESMART) Network Provider only: buprenorphine/naloxone tabs PA, QL Suboxone® film PA, QL Bunavail® PA, QL buprenorphine/naloxone film PA, QL buprenorphine PA, QL Zubsolv® PA, QL All other TennCare Providers: buprenorphine/naloxone tabs PA, QL Bunavail® PA, QL buprenorphine PA, QL Suboxone® film PA, QL buprenorphine/naloxone filmPA, QL Zubsolv® PA, QL COX-II Inhibitors celecoxib (50, 100, & 200 mg) QL Celebrex® QL celecoxib 400 mg PA, QL Transmucosal Fentanyl Products N/A Abstral® PA, QL Fentora® PA, QL Actiq® PA, QL Lazanda ® PA, QL fentanyl lozenge PA, QL Subsys® PA, QL Naloxone Products Narcan® nasal spray QL Kloxxado® nasal spray QL n/a Narcotics Agonist/Antagonists nalbuphine PA, QL butorphanol NS PA, QL pentazocine/naloxone PA, QL pentazocine/APAP PA, QL Long Acting Narcotics fentanyl patch (excluding 37.5mcg/hr, 62.5mcg/hr, and 87.5mcg/hr) PA, QL Arymo ER® PA, QL Morphabond® ER PA, QL morphine sulfate ER tabs PA, QL Belbuca® PA, QL morphine sulfate ER caps PA, QL Nucynta® ER PA, QL buprenorphine patch PA, QL morphine sulfate SA PA, QL Butrans® PA, QL morphine sulfate SR 24hr (generic for Avinza®) PA, QL ConZip® PA, QL MS Contin® PA, QL Dolophine® PA, QL Opana ER® PA, QL Duragesic® PA, QL OxyContin® PA, QL Exalgo® PA, QL oxymorphone ER PA, QL fentanyl patch (37.5mcg/hr, oxycodone ER PA, QL 62.5mcg/hr, and 87.5mcg/hr) PA, QL hydrocodone ER (generic Hysingla ER) PA, tramadol ER 24 hr PA, QL QL hydromorphone ER PA, QL tramadol ER PA, QL (generic Conzip®) Hysingla® ER PA, QL Ultram ER® PA, QL Kadian® PA (≥100 mg), QL Xtampza ER® PA, QL methadone PA, QL Zohydro ER® PA, QL * Note that agents not listed on PDL may be considered non-preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser Proprietary & Confidential to access the files on the TennCare site. Other browsers like Internet © 2021, OptumRx. All rights reserved. Explorer cause issues with functionality and links between files. Preferred Drugs Non-Preferred Drugs I. ANALGESICS Methadose® PA, QL Short-Acting Narcotics QL codeine/APAP PA (< 19 years old), QL oxycodone tabs QL Apadaz® QL meperidine PA, QL Endocet® QL oxycodone/APAP QL benzhydrocodone/APAP PA, QL morphine suppositories PA, QL hydrocodone/APAP QL oxycodone oral concentrate PA butalbital/APAP/caff/codeine PA, QL Nalocet® PA, QL (excluding generic for Xodol®) hydrocodone/ibuprofen QL oxycodone oral solution butalbital/ASA/caff/codeine PA, QL Norco® PA, QL hydromorphone QL tramadol QL codeine PA, QL Nucynta® PA, QL (excluding suppositories and liquid) morphine IR QL tramadol/APAP QL Demerol® PA, QL Oxaydo® PA, QL (excluding suppositories) morphine sulfate soln 20 mg/ml PA dihydrocodeine/APAP/caffeine PA, QL oxycodone caps PA, QL dihydrocodeine/ASA/caffeine PA, QL oxycodone/ASA PA, QL Dilaudid® PA, QL oxycodone/IBU PA, QL Fioricet® with Codeine PA, QL oxymorphone PA, QL Fiorinal® with Codeine PA, QL Percocet® PA, QL hydrocodone/APAP 5/300 PA, QL Primlev® PA, QL hydrocodone/APAP 10/300 PA, QL Roxicodone® PA, QL hydromorphone liquid PA, QL Tylenol® with Codeine PA, QL hydromorphone suppositories PA Ultracet® PA, QL Ibudone® PA, QL Ultram® PA, QL levorphanol PA, QL Vicodin® PA, QL Lorcet® PA, QL Vicodin HP PA, QL Lortab® PA, QL NSAID/Anti-Ulcer Agents N/A Arthrotec® PA, QL naproxen-esomeprazole PA,QL diclofenac/misoprostol PA, QL Vimovo® PA, QL Duexis® PA, QL Salicylates and Non-Narcotic Combination Agents choline mag trisalicylate QL salsalate QL diflunisal QL * Note that agents not listed on PDL may be considered non-preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site. Other browsers like Internet Explorer cause issues with functionality and links between files. Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 2 Preferred Drugs Non-Preferred Drugs I. ANALGESICS Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) diclofenac 1% gel QL ketorolac QL Anaprox® Mobic® diclofenac potassium meloxicam tablets Anaprox DS® Motrin® diclofenac sodium nabumetone Cambia® Nalfon® diclofenac sodium ER sulindac Cataflam® Naprelan® ibuprofen Voltaren® gel QL Clinoril® naproxen tabs and suspension indomethacin Daypro® naproxen sodium ER PA, QL ® diclofenac patch Naprosyn PA ® diclofenac sodium 1.5% Naproxen CR diclofenac 35mg capsules Oxaprozin ® ® PA EC-Naprosyn Pennsaid etodolac piroxicam ® etodolac ER Ponstel ® ® PA, QL Feldene Qmiiz ODT ® PA, QL fenoprofen Sprix ® PA, QL Flector Tolmetin ® QL flurbiprofen Toradol ® PA, QL indomethacin ER Vivlodex ® ketoprofen Voltaren ® ketoprofen ER Voltaren-XR PA ketorolac spray VOPAC MDS Kit ® meclofenamate Zipsor ® PA mefenamic acid Zorvolex PA ,QL meloxicam susp & capsules Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Cephalosporins First Generation cefadroxil capsules cephalexin capsules cefadroxil tablets Keflex® cefadroxil suspension cephalexin suspension cephalexin tablets Antibiotics: Cephalosporins Second Generation cefaclor capsules cefuroxime tabs cefaclor suspension Ceftin® suspension PA cefprozil cefaclor ER Ceftin® tabs Antibiotics: Cephalosporins Third Generation cefdinir Suprax® chewables cefditoren ceftibuten cefixime capsules and suspension cefpodoxime suspension PA Suprax® capsules and suspension cefpodoxime tablets Antibiotics: Macrolides azithromycin QL Eryped® 400 mg/5mL suspension clarithromycin ER/XL QL erythromycin base tablets azithromycin suspension QL erythromycin generic products Dificid® PA, QL tablet & suspension Zithromax® QL (excluding erythromycin base tabs) clarithromycin tablets & suspension erythromycin ethylsuccinate erythromycin brand products suspension 400 mg/5mL (except Eryped® 400 mg/5mL susp) * Note that agents not listed on PDL may be considered non-preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site. Other browsers like Internet Explorer cause issues with functionality and links between files. Effective Date: October 1, 2021 TennCare Preferred Drug List (PDL) | Page 3 Preferred Drugs Non-Preferred Drugs II. ANTI-INFECTIVES Antibiotics: Methenamine and Combo all generic combinations of methenamine mandelate all brand combinations of Hiprex® methenamine, phenyl salicylate, methenamine hippurate methenamine, phenyl salicylate, Uroqid Acid #2® hyoscyamine, atropine, etc. hyoscyamine, atropine, etc. Antibiotics: Miscellaneous Agents for UTI Monurol® QL, PA fosfomycin powder packets PA,QL Antibiotics: Agents for Diarrhea vancomycin caps PA Aemcolo® PA, QL vancomycin solution PA,QL Firvanq® PA, QL Vancocin® caps PA Antibiotics: Aminoglycosides neomycin Neo-Fradin® Arikayce® QL Antibiotics: Oral Anti-Tuberculosis ethambutol pyrazinamide Cycloserine Rifadin® isoniazid rifabutin PA Myambutol® Rifamate® PA rifampin Mycobutin® PA Rifater® PA Paser® Trecator® Priftin® Antibiotics: Oral Lincosamines clindamycin caps clindamycin pediatric solution PA Cleocin® Cleocin® Pediatric granules PA Antibiotics: Oral Nitrofurans nitrofurantoin capsules nitrofurantoin suspension PA Furadantin® PA Macrodantin® Macrobid® Antibiotics: Oxazolidinones linezolid tabs PA, QL linezolid suspension QL Zyvox® PA, QL Sivextro® PA, QL Antibiotics: Penicillins amoxicillin dicloxacillin all brand penicillins amoxicillin ER amoxicillin/clavulanate penicillin amoxicillin/clavulanic acid XR ampicillin Antibiotics: Quinolones ciprofloxacin levofloxacin tabs Baxdela® PA, QL Levaquin® tabs Cipro® tablets levofloxacin solution PA Cipro® suspension PA moxifloxacin PA ciprofloxacin suspension PA ofloxacin ciprofloxacin ER QL * Note that agents not listed on PDL may be considered non-preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site. 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