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Tenncare Covered OTC List - Effective 6/1/2021

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Tenncare Covered OTC List - Effective 6/1/2021 TennCare Covered OTC List - Effective 6/1/2021 NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults ANTIHELMENTIC Please refer to TennCare's PDL for coverage of the following: PYRANTEL PAMOATE EMERGENCY CONTRACEPTIVES Please refer to TennCare's PDL for coverage of the following: AFTERA® OTC PLAN B® ONE-STEP OTC TAKE ACTION® OTC DIABETES INSULIN PRODUCTS Please refer to TennCare's PDL for coverage of the following: HUMULIN 70/30 KWIKPEN HUMULIN 70-30 VIAL HUMULIN N VIAL HUMULIN R VIAL NOVOLIN R VIAL NOVOLIN 70-30 VIAL NOVOLIN N VIAL 00169183702 RELION NOVOLIN 70-30 VIAL INSULIN NPH HUM/REG INSULIN HM 70-30/ML 10 x x 00169183402 RELION NOVOLIN N 100 UNIT/ML INSULIN NPH HUMAN ISOPHANE 100/ML 10 x x 00169183302 RELION NOVOLIN R 100 UNIT/ML INSULIN REGULAR, HUMAN 100/ML 10 x x GLUCOSE 00574006930 GLUTOSE 15 GEL DEXTROSE 40 % 37.5 x x 00574007030 GLUTOSE 15 GEL 40% DEXTROSE 40 % 37.5 x x 11917004681 GLUCOSE CHW ORANGE DEXTROSE 4 GM 50 x x 11917006843 GLUCOSE CHW 4GM DEXTROSE 4 GM 10 x x 11917006844 GLUCOSE CHW 4GM DEXTROSE 4 GM 10 x x 11917013294 GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 11917013315 GLUCOSE CHW TROP FRT GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 11917016740 GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 11917016741 GLUCOSE CHW 4GM DEXTROSE 4 GM 50 x x 11917016744 GLUCOSE CHW RASPBRRY GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 11917016944 GLUCOSE GEL 15GM/33G GLUCOSE GEL 15 GM/33GM 33 x x 38396051691 TGT GLUCOSE CHW GRAPE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 38396054132 GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 38396054363 DEX4 CHW GRAPE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 38396055025 GLUCOSE GEL 40% DEXTROSE 40 % 38 x x 38396055675 CVS GLUCOSE CHW TROP BLS GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 38396061375 CVS GLUCOSE CHW FRUIT GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 100 x x 49348073401 SM GLUCOSE CHW SOUR APP DEXTROSE 4 GM 10 x x 50428001769 CVS GLUCOSE CHW ORANGE GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 50 x x 50428235154 CVS GLUCOSE CHW RASPBERY GLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG 10 x x 56151162501 TRUEPLS GLUC GEL 15/32ML GLUCOSE GEL 15 GM/32ML 32 x x 80681010000 GLUCOSE CHW 4GM DEXTROSE 4 GM 10 x x 83744025204 GLUCO BURST GEL 40% DEXTROSE 40 % 37.5 x x SYRINGES/NEEDLES 08290301604 BD 10 ML SYRINGE SYRINGE, DISPOSABLE, 10 ML 100 x x 86227048125 10ML SYRINGE MIS LUER LOK SYRINGE, DISPOSABLE, 10 ML 100 x x 81131031167 RELION INS SYR 0.3 ML 29GX1/2" SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 10 x x 08222092397 ULTICARE SYRIN 0.3 ML 29GX1/2" SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x 11917001492 INSULIN 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 29 GAUGE 100 x x 56151171101 TRUEPLUS SYR 0.3ML 29GX1/2" SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x 86227090035 SURE COMFORT 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 29 G X1/2" 100 x x 57515017459 INSULIN SYRIN 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 10 x x 81131031177 RELION SYRING 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 10 x x 08222074591 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08222093394 ULTICARE SYR 0.3 ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 08222094599 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08290328431 BD SYRINGE 0.3 ML 12.7MMX30G SYRING-NEEDL,DISP,INSUL,0.3 ML 30GX1/2" 100 x x 08290328468 BD INSULIN SYR 0.5 ML 8MMX31G SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08396801000 ULTRA COMFORT 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08396801900 CA INS SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08496303601 EASY TOUCH INSULIN SYR 0.3 ML SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 08496315601 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08881609231 MONOJECT SYRINGE 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 08881609800 ULTRA COMFORT 0.3 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 11917002527 INSULIN 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 30 GAUGE 100 x x 38396042008 LEADER SYRING 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 56151172101 TRUEPLUS SYR 0.3ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x Proprietary Confidential © 2021, OptumRx. All Rights Reserved. 1 TennCare Covered OTC List - Effective 6/1/2021 NDC Label Name Gen Name Package Covered- PA only- Covered- PA only- Not Size Kids Kids Adults Adults Covered- Adults 56151173201 TRUEPLUS SYR 0.5ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 57515009459 ULTICARE SYR 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 81131031176 RELION SYRING 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 86227065055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 86227070035 SURE COMFORT 3/10 ML SYRINGE SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 89134072202 ULTRA-THIN II INS 0.3 ML 30G SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 90166005635 INSULIN SYRG MIS 0.3/30G SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 90166015655 INSULIN SYRIN 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 90166045635 INSULIN SYRIN 0.3 ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 91237000188 EASY COMFORT 0.5 ML 31GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 98302013930 COMFORT EZ INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 31 GX5/16" 100 x x 98302013931 COMFORT EZ INS 0.3ML 30GX5/16" SYRING-NEEDL,DISP,INSUL,0.3 ML 30G X5/16" 100 x x 90166045035 INSULIN SYRG MIS 0.3/30G INSULIN SYRINGE/NEEDLE,0.3 ML 30 X 1/2" 100 x x 89134074202 INSULIN SYRG MIS 0.5/31G INSULIN SYRINGE/NEEDLE,0.5 ML 31 X 5/16" 200 x x 08222082589 ULTICARE SYRIN 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08290329461 BD INSULIN SYR 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08290329465 BD INSULIN SYR 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08396800100 ULTRA COMFORT 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08496285501 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 08881600004 MONOJECT INSUL SYR U100 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 38396076339 SM INSULIN SYR 0.5 ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 56151170201 TRUEPLUS SYR 0.5ML 28GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 86227080055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 28GX1/2" 100 x x 81131031165 INSULIN SYRG MIS 0.5/29G SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 10 x x 08222092595 ULTICARE SYR 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08290305932 INSULIN SYRG MIS 0.5/29G SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08496295501 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08881600350 MONOJECT INSUL SYR U100 SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 08881609350 ULTRA COMFORT 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 11917001489 INSULIN 1/2 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 29 GAUGE 100 x x 38396040408 LEADER INS SYR 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 38396044364 GNP ULTRA COMFORT 0.5 ML SYR SYRINGE-NEEDLE,INSULIN,0.5 ML 29 GAUGE 100 x x 56151171201 TRUEPLUS SYR 0.5ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 57515009259 ULTICARE SYR 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 86227090055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 90166095055 INSULIN SYRIN 0.5 ML 29GX1/2" SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 100 x x 89134052802 INSULIN SYRG MIS 0.5/29G SYRINGE-NEEDLE,INSULIN,0.5 ML 29 G X1/2" 200 x x 08222093592 ULTICARE SYR 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08290305934 BD SAFTGLD INS SYR 0.5 ML 30G SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08396800700 INSULIN SYRG MIS 0.5/30G SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08496305601 EASY TOUCH INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08881609700 ULTRA COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 11917002528 INSULIN 1/2 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30 GAUGE 100 x x 38396041537 TOPCARE ULTRA COMFORT SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 56151172201 TRUEPLUS SYR 0.5ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 57515009359 ULTICARE SYR 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 86227070055 SURE COMFORT 0.5 ML SYRINGE SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 89134061802 ULTRA-THIN II INS 0.5 ML 30G SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 90166005655 INSULIN SYRIN 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 94046000164 ADVOCATE INS 0.5 ML 30GX5/16" SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 98302013932 COMFORT EZ INSULIN SYR 0.5 ML SYRINGE-NEEDLE,INSULIN,0.5 ML 30G X5/16" 100 x x 08290328279 INSULIN SYRG MIS 0.5/30G INSULIN SYRINGE/NEEDLE,0.5 ML 30 X 1/2" 90 x x 08290329651 BD INSULIN SYR 1 ML 25GX5/8" SYRINGE AND NEEDLE,INSULIN,1ML 25GX5/8" 100 x x 08290324909 BD INSULIN SYR 0.3 ML 6MMX31G SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 100 x x 08290324910 BD SYR 0.3 ML 6MMX31G (1/2) SYRING-NEEDL,DISP,INSUL,0.3 ML 31GX15/64" 100 x x 81131013838 RELION INS SYR 0.3 ML 31GX6MM SYRING-NEEDL,DISP,INSUL,0.3
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