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

ANTIBIOTICS ARTHRITIS AND PAIN BEHAVIORAL HEALTH (CONT'D) DIABETES Amoxicillin Allopurinol Haloperidol Glimepiride Amoxicillin / Clavulanate Dexamethasone Haloperidol Decanoate Glipizide Ampicillin Diclofenac Sodium tablets Haloperidol Lactate 2 mg/ml Glipizide ER/XL Azithromycin Hydroxychloroquine Sulfate Hydroxyzine Pamoate Glyburide Cefaclor capsules Indomethacin Imipramine HCL Glyburide/Metformin Cefadroxil Ketoprofen Lithium Carbonate Humalog® cartridge* Cefpodoxime tablets Ketorolac* Loxapine Humalog® / Humalog® Mix pen* & KwikPen®* Cefuroxime tablets Meloxicam tablets Mirtazapine Humalog® / Humalog® Mix vial* Cephalexin capsules (except 750 mg) Methotrexate Nortriptyline Humulin® cartridge* Ciprofloxacin (except 750 mg & XR) Methylprednisolone Olanzapine IR tablets* Humulin® pen & KwikPen® (except U-500)* Clindamycin capsules Nabumetone Paroxetine tablets (not CR tablets) Humulin® vial (except U-500)* Dicloxacillin Prednisolone Sod-Phos solution Perphenazine Lantus® vials & Lantus® Solostar pens* Doxycycline Monohydrate capsule Prednisone tablets Quetiapine tablets (not ER tablets) Metformin tablets Erythromycin / Sulfisoxazole Salsalate Risperidone tablets Metformin ER (excluding osmotic ER & Levofloxacin tablets Sulindac Sertraline tablets modified release ER) Metronidazole (except lotion, *QUANTITY LIMITS: Thiothixene Pioglitazone 0.75% vaginal gel, & 1% gel) Ketorolac: 20 tablets per 60 days Trazodone Toujeo® Solostar / Max Solostar® Minocycline capsules ASTHMA AND RESPIRATORY Trifluoperazine Alcohol Swabs Neomycin Sulfate Ipratropium-albuterol Trihexyphenidyl tablets Freestyle® Freedom Lite meter Nitrofurantoin Macrocrystals Montelukast 5mg chew, 10mg tablet Venlafaxine IR tablets FreeStyle® InsuLinx meter / strips* Paromomycin Sulfate ProAir® HFA Venlafaxine ER capsules* FreeStyle® Lite meter / strips* Penicillin V Potassium ProAir® RespiClick *QUANTITY LIMITS: Insulin Syringes* Sulfamethoxazole / Trimethoprim Terbutaline Sulfate tablets Aripiprazole tablets: 1 tablet per day Lancet Devices / Lancets Trimethoprim Theophylline, Anhydrous, ER Duloxetine capsules: 2 capsules per day Precision® Xtra meter / strips* Olanzapine IR 2.5mg, 5mg, *QUANTITY LIMITS: ANTICONVULSANTS BEHAVIORAL HEALTH 7.5mg & 10mg tablets: 2 tablets per day Insulin: Lesser of 30-Day supply or 40ml per fill per type Divalproex DR tablets Amitriptyline Olanzapine IR 15mg & 20mg tablets: 1 tablet per day Insulin Test Strips: 100 per 30 days or 300 per 90 days Lamotrigine IR tablets Aripiprazole tablets (not ODT)* Venlafaxine ER capsules: 1 capsule per day Insulin Syringes: 100 per 30 days or 300 per 90 days Levetiracetam IR tablets Benztropine Insulin Pen Needles: 100 per 30 days or 300 per 90 days Oxcarbazepine IR tablets Bupropion SR BLOOD MODIFIERS Alcohol Swabs: 100 per 30 days or 300 per 90 days Phenytoin 100 mg capsules Bupropion XL 150 & 300 mg Clopidogrel 75 mg tablets Lancets: 100 per 30 days or 300 per 90 days Phenytoin suspension Buspirone Dipyridamole Valproic Acid Citalopram tablets Warfarin Sodium Clozapine (except 200 mg tablets) ANTIVIRALS Doxepin CHOLESTEROL Acyclovir (except topicals) Duloxetine capsules* Atorvastatin Amantadine Escitalopram tablets Fenofibrate 54 mg and 160 mg tablets Oseltamivir 75 mg capsules* Fluoxetine capsules (except DR) Gemfibrozil Rimantadine Fluphenazine Lovastatin *QUANTITY LIMITS: Fluphenazine Decanoate Pravastatin Oseltamivir: 20 capsules per 180 days Simvastatin

Page 1 of 2 Tennessee CoverRx Covered Drug List - Effective 10/1/2021

EYE CARE AND GLAUCOMA HEART HEALTH & BLOOD PRESSURE (CONT'D) STOMACH HEALTH OTHER MEDICAL CONDITIONS Acetazolamide Carvedilol Dicyclomine capsules & tablets Allergies Atropine Sulfate Chlorthalidone Hyoscyamine drops Hydroxyzine HCL Brimonidine Tartrate 0.2% Clonidine tablet (not ER tablet) Hyoscyamine IR tablets Bone Density Cyclopentolate HCl 1% Digoxin Mesalamine Suppositories Alendronate Dexamethasone Sod-Phos Diltiazem, ER / XR Metoclopramide Ear Health Dorzolamide / Timolol Eye Drops Disopyramide Phosphate Sulfasalazine Neomycin/Polymyxin/HC Ear Drops Erythromycin Eye Ointment Enalapril / HCTZ Ursodiol tablets Migraines Gentamicin Sulfate 0.3% Felodipine ER Sumatriptan tablets* Homatropine HBr 5% Furosemide tablets THYROID CONDITIONS Skin Cream Latanoprost Hydralazine Levothyroxine, Levo-T, Euthyrox Triamcinolone Acetonide Cream Levobunolol HCl Hydrochlorothiazide Methimazole Miscellaneous Ofloxacin Eye Drops Indapamide Lactulose Pilocarpine Eye Drops Isosorbide Mononitrate UROLOGY Megestrol Acetate Polymyxin B / Trimethoprim Lisinopril Bethanechol Chloride Naloxone carpuject* Prednisolone Acetate Lisinopril / HCTZ Flavoxate Narcan® Nasal Spray* Sulfacetamide Sodium Losartan Oxybutynin HCl NRT-Nicotine Transdermal Patches*: 7mg,14mg, 21mg Timolol Maleate Losartan/HCTZ Phenazopyridine HCl Promethazine tablets Tobramycin Sulfate Metolazone *QUANTITY LIMITS: Metoprolol, ER VITAMINS AND MINERALS Naloxone carpuject: 2 inj. per month (not available FUNGAL INFECTIONS Mexiletine Calcitriol (except ointment) by mail order) Clotrimazole Nifedipine ER Ergocalciferol (Vitamin D2) capsules* Narcan® Nasal: 1 kit per month (not available Clotrimazole Troche Nitroglycerin (except patch) Folic acid 1 mg tablets by mail order) Fluconazole NitroStat Potassium Chloride Sumatriptan tablets: 9 tablets per month Ketoconazole (except foam) Prazosin 1 mg & 2 mg capsules* Prenatal Vitamins – All generics NRT Patches: 8 weeks per each strength annually Nystatin (except powder) Propafenone tablets *QUANTITY LIMITS: VACCINES Propranolol IR Ergocalciferol: 13 capsules per 90 days Afluria® HEART HEALTH & BLOOD PRESSURE Quinidine Gluconate Fluarix® Amiodarone (except 100 mg) Sotalol WOMEN’S HEALTH Flublok® Amlodipine Spironolactone Estradiol oral tablets, cream Flucelvax® Quad Amlodipine / Benazepril Terazosin Estropipate Flulaval® Atenolol Triamterene / HCTZ Medroxyprogesterone (not injection) Fluvirin® Atenolol / Chlorthalidone Verapamil tablets, ER / PM / SR Oral Contraceptives – All generics & Fluzone® Bisoprolol / HCTZ *QUANTITY LIMITS: Emergency Contraceptives Influenza A (H1N1) Bisoprolol Fumarate Prazosin: 1 capsule per day Tamoxifen Pneumovax® Benazepril Prevnar 13® COVID-19

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