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Tenncare Autoexempt List September 1, 2021 This Is a Current List of the Drugs and Supplies That Do Not Count Toward an Enrollee’S Monthly Drug Limit

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Tenncare Autoexempt List September 1, 2021 This Is a Current List of the Drugs and Supplies That Do Not Count Toward an Enrollee’S Monthly Drug Limit TennCare AutoExempt List September 1, 2021 This is a current list of the drugs and supplies that do not count toward an enrollee’s monthly drug limit. This list is subject to change. Go to the following link to see the most current version: www.optumrx.com/tenncare ALZHEIMER’S AGENTS • donepezil • memantine • rivastigmine • galantamine • memantine-donepezil ANTI-ANXIETY AGENTS • buspirone ANTIDEPRESSANTS • citalopram • fluoxetine • sertraline • escitalopram • fluvoxamine • paroxetine ANTINEOPLASTICS • abemaciclib (Verzenio) • epirubicin (Ellence) • paclitaxel (Onxol, Abraxane, Taxol) • abiraterone acetate (Zytiga) • erdafitinib (Balversa) • palbociclib (Ibrance) • acalabrutinib (Calquence) • erlotinib (Tarceva) • panitumumab (Vectibix) • afatinib (Gilotrif) • estramustine (Emcyt) • panobinostat (Farydak) • alectinib (Alecensa) • etoposide (VP-16-213, Toposar, • pazopanib (Votrient) • alpelisib (Piqray) VePesid, Etopophos) • pegaspargase (Oncaspar) • anastrazole (Arimidex) • everolimus (Afinitor) • pembrolizumab (Keytruda) • apalutamide (Erleada) • exemestane (Aromasin) • pemetrexed (Alimta) • arsenic trioxide (Trisenox) • fedratinib (Inrebic) • pemigatinib (Pemazyre) • asparaginase (Elspar, Erwinaze) • floxuridine (FUDR) • pentostatin (DCF) (Nipent) • axitinib (Inlyta) • fludarabine (Fludara, Oforta) • pertuzumab (Perjeta) • azacitidine (Vidaza, Onureg) • fluorouracil (Adrucil, Carac, Tolak) • plicamycin (Mithracin) • bcg vaccine (TheraCys, TICE BCG) • flutamide (Eulexin) • pomalidomide (Pomalyst) • bendamustine (Treanda) • fulvestrant (Faslodex) • porfimer sodium (Photofrin) • bevacizumab (Avastin) • gallium nitrate (Ganite) • pralatrexate (Folotyn) • bexarotene (Targretin) • gefitinib (Iressa) • pralsetinib (Gavreto) • bicalutamide (Casodex) • gemcitabine (Gemzar) • procarbazine (Matulane) • binimetinib (Mektovi) • gemtuzumab (Mylotarg) • ramucirumab (Cyramza) • bleomycin (Blenoxane) • gilteritinib (Xospata) • regorafenib (Stivarga) • bortezomib (Velcade) • glasdegib (Daurismo) • relugolix (Orgovyx) • bosutinib (Bosulif) • goserelin (Zoladex) • ribociclib (Kisqali) • brentuximab (Adcetris) • hydroxyurea (Droxia, Hydrea, Mylocel) • ribociclib/letrozole (Kisqali/Femara) • busulfan (Busulfex, Myleran) • ibritumomab tiuxetan(Zevalin) • ripretinib (Qinlock) • cabazitaxel (Jevtana) • ibrutinib (Imbruvica) • rituximab (Rituxan) • cabozantinib (Cabometyx, Cometriq) • idarubicin (Idamycin PFS) • romidepsin (Istodax) • capecitabine (Xeloda) • idelalisib (Zydelig) • rucaparib (Rubraca) • carboplatin (Paraplatin) • ifosfamide (Ifex) • ruxolitinib (Jakafi) • carfilzomib (Kyprolis) • imatinib mesylate (Gleevec) • samarium SM 153 lexidronam • carmustine (BCNU, BiCNU, Gliadel) • ipilimumab (Yervoy) (Quadramet) • ceritinib (Zykadia) • irinotecan (Camptosar) • selumetinib (Koselugo) • cetuximab (Erbitux) • ivosidenib (Tibsovo) • selinexor (Xpovio) • chlorambucil (Leukeran) • ixabepilone (Ixempra) • siltuximab (Sylvant) • cisplatin (Platinol) • ixazomib (Ninlaro) • sonidegib (Odomzo) • cladribine (CdA) (Leustatin) • larotrectinib (Vitrakvi) • sorafenib (Nexavar) • clofarabine (Clolar) • lenalidomide (Revlimid) • streptozocin (Zanosar) • cobimetinib (Cotellic) • lenvatinib (Lenvima) • strontium-89 chloride (Metastron) • crizotinib (Xalkori) • letrozole (Femara) • sunitinib (Sutent) • cyclophosphamide (Cytoxan, Neosar) • leucovorin (Wellcovorin) • talazoparib (Talzenna) • cytarabine, conventional (Cytosar-U, • leuprolide (Eligard, Lupron, Lupron • talc powder, sterile (Sclerosol) Tarabine PFS) Depot, Viadur) • talimogene laherparepvec (Imlygic) • cytarabine, liposomal (DepoCyt) • lomustine (CeeNU, Gleostine) • tamoxifen (Nolvadex, Soltamox) • lorlatinib (Lorbrena) Proprietary & Confidential © 2021, OptumRx. All rights reserved. ANTINEOPLASTICS • dabrafenib (Tafinlar) • mercaptopurine (6-MP, Purinethol) • temozolomide (Temodar) • dacarbazine (DTIC-Dome) • mesna (Mesnex) • temsirolimus (Torisel) • dacomitinib (Vizimpro) • methotrexate (Mexate, Trexall, • tepotinib (Tepmetko) • dactinomycin (actinomycin D, Abitrexate, Folex, Otrexup, Rasuvo, • topotecan (Hycamtin) Cosmegen) Reditrex) • toremifene citrate (Fareston) • darolutamide (Nubeqa) • mitomycin (MTC, Mutamycin) • tositumomab (Bexxar) • dasatinib (Sprycel) • mitotane (Lysodren) • trabectedin (Yondelis) • daunorubicin (Cerubidine) • mitoxantrone (Novantrone) • trametinib (Mekinist) • daunorubicin citrate liposomal • nelarabine (Arranon) • trastuzumab (Herceptin) (DaunoXome) • neratinib (Nerlynx) • tretinoin • decitabine (Dacogen) • nilotinib (Tasigna) • trifluridine/tipiracil (Lonsurf) • degarelix (Firmagon) • nilutamide (Nilandron) • triptorelin pamoate (Trelstar) • denileukin diftitox (Ontak) • nintedanib (Ofev) • umbralisib (Ukoniq) • dexrazoxane (Zinecard, Totect) • niraparib (Zejula) • uracil mustard • dinutuximab (Unituxin) • nivolumab (Opdivo) • valrubicin (Valstar) • docetaxel (Taxotere) • ofatumumab (Arzerra) • vandetanib (Caprelsa) • doxorubicin (Adriamycin, Rubex) • olaparib (Lynparza) • vemurafenib (Zelboraf) • doxorubicin, liposomal (Doxil) • omacetaxine (Synribo) • venetoclax (Venclexta) • duvelisib (Copiktra) • osimertinib (Tagrisso) • vinblastine (Velban, Velsar) • enasidenib (Idhifa) • oxaliplatin (Eloxatin) • vincristine (Oncovin, Vincasar PFS) • encorafenib (Braftovi) • pexidartinib (Turalio) • vinorelbine tartrate (Navelbine) • enzalutamide (Xtandi) • teniposide (VM-26, Vumon) • vismodegib (Erivedge) • mechlorethamine (Mustargen) • thalidomide (Thalomid) • vorinostat (Zolinza) • melphalan (L-PAM) (Alkeran) • thioguanine (TG, Tabloid) • zanubrutinib (Brukinsa) • thiotepa (TSPA, Thioplex) • ziv-aflibercept (Zaltrap) ANTIPARKINSON’S AGENTS • benztropine (Cogentin) • carbidopa (Lodosyn) ANTITUBERCULAR AGENTS • aminosalicylic acid (PAS, Paser) • isoniazid (INH, Isohydrazide, Niazid, • rifampin/isoniazid (Rifamate) • capreomycin (Capastat) Nydrazid, Niazid-B6) • rifampin/pyrazinamide/isoniazid • cycloserine (Seromycin Pulvules) • pyrazinamide (Rifater) • ethambutol (Myambutol) • rifabutin (Mycobutin) • rifapentine (Priftin) • ethionamide (Trecator-SC) • rifampin (Rifadin) • streptomycin ANTIVIRALS • abacavir (Ziagen) • dolutegravir/abacavir/lamivudine • ganciclovir (DHPG, Cytovene IV) • abacavir/lamivudine (Epzicom) (Triumeq) • indinavir sulfate (Crixivan) • abacavir/lamivudine/zidovudine • dolutegravir/rilpivirine (Juluca) • lamivudine (3TC, Epivir, Epivir HBV) (Trizivir) • doravirine (Pifeltro) • lamivudine/tenofovir (Cimduo) • adefovir (Hepsera) • doravirine/lamivudine/tenofovir • lamivudine/zidovudine (Combivir) • amantadine (Delstrigo) • letermovir (Prevymis) • amprenavir (Agenerase) • efavirenz (Sustiva) • maraviroc (Selzentry) • atazanavir (Reyataz) • efavirenz/emtricitabine/tenofovir • nelfinavir (Viracept) • atazanavir/cobicistat (Evotaz) (Atripla) • nevirapine (Viramune, Viramune XR) • bictegravir/emtricitabine/tenofovir • efavirenz/lamivudine/tenofovir (Symfi, • raltegravir (Isentress, Isentress HD) (Biktarvy) Symfi Lo) • rilpivirine (Edurant) • cidofovir (Vistide) • elvitegravir (Vitekta) • ritonavir (Norvir) • cobicistat (Tybost) • emtricitabine (Emtriva) • ritonavir/lopinavir (Kaletra) • cobicistat/elvitegravir/ • emtricitabine/tenofovir (Descovy, • saquinavir (Fortovase, Invirase) emtricitabine/tenofovir (Stribild, Truvada) • stavudine (d4T, Zerit) Genvoya) • emtricitabine/rilpivirine/tenofovir • telbivudine (Tyzeka) • darunavir ethanolate (Prezista) (Complera, Odefsey) • tenofovir disoproxil fumarate (Viread) • darunavir/cobicistat (Prezcobix) • enfuvirtide (Fuzeon) • tenofovir alafenamide fumarate • darunavir/cobicistat/emtricitabine/ten • entecavir (Baraclude) (Vemlidy) ofovir (Symtuza) • etravirine (Intelence) • tipranavir (Aptivus) • delavirdine mesylate (Rescriptor) • fomivirsen (Vitravene) • valganciclovir (Valcyte) • didanosine (ddl) (Videx) • fosamprenavir calcium (Lexiva) • zalcitabine (ddC, Hivid) Effective Date: 9/1/2021 TennCare AutoExempt List | Page 2 ANTIVIRALS • dolutegravir (Tivicay and Tiviacy PD) • foscarnet (Foscavir) • zidovudine (AZT, Retrovir) CARDIOVASCULAR DISEASE (ORAL FORMULATIONS ONLY) Note: Brand names in this category are provided for reference only. Only generic cardiovascular medications are exempt from the script limit. If classified as a brand in Medispan, the product will not be exempt from the script limit. • acebutolol (Sectral) • ethacrynic acid (Edecrin) • olmesartan/HCTZ (Benicar HCT) • acetazolamide (Diamox) • felodipine ER • olmesartan (Benicar) • amiloride/HCTZ (Moduretic) • fosinopril (Monopril) • perindopril (Aceon) • amiloride (Midamor) • fosinopril/HCTZ (Monopril-HCT) • pindolol (Visken) • amlodipine (Norvasc, Katerzia) • furosemide (Lasix) • prazosin (Minipress) • amlodipine/benazepril (Lotrel) • HCTZ (Microzide, Oretic) • propranolol (Inderal) • atenolol (Tenormin) • hydralazine/isosorbide (BiDil) • propranolol LA (Inderal LA) • atenolol/chlorthalidone (Tenoretic) • indapamide • propranolol/HCTZ (Inderide) • benazepril (Lotensin) • irbesartan (Avapro) • quinapril (Accupril) • benazepril/HCTZ (Lotensin HCT) • irbesartan/HCTZ (Avalide) • quinapril/HCTZ (Accuretic) • betaxolol (Kerlone) • isradipine (DynaCirc) • ramipril (Altace) • bisoprolol fumarate (Zebeta) • labetalol (Trandate) • sacubitril-valsartan (Entresto) • bisoprolol/HCTZ (Ziac) • lisinopril (Prinivil, Zestril) • simvastatin (Flolipid) • bumetanide (Bumex) • lisinopril/HCTZ (Prinzide, Zestoretic) • sotalol (Betapace, Sorine, Sotylize ) • candesartan (Atacand) • losartan (Cozaar) • sotalol AF (Betapace AF) • candesartan/HCTZ (Atacand HCT) • losartan/HCTZ
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