TennCare Attestation List September 1, 2021 Medications on this list can be approved for patients currently at their monthly prescription limit (greater than 5 prescriptions or greater than 2 brand medications), who are at a high risk for adverse health consequences and could be hospitalized, institutionalized, or die within the next 90 days without the requested drug(s). This list is independent of the preferred drug list (PDL) and other criteria. All drugs on this list are still subject to existing TennCare edits, including non- preferred status on the PDL, clinical criteria, step therapy criteria, and quantity limits.* ANTI-INFECTIVES Aminoglycosides • amikacin (Amikin, Arikayce) • neomycin (Neo-Fradin) • gentamicin (Garamycin) • paromomycin • kanamycin • streptomycin Cephalosporins, 1st Generation • cefadroxil (Duricef) • cephalexin (Keflex) • cefazolin (Ancef) Cephalosporins, 2nd Generation • cefaclor (Ceclor) • cefprozil (Cefzil) • cefoxitin (Mefoxin) • cefuroxime (Ceftin, Zinacef) Cephalosporins, 3rd Generation • cefdinir • ceftazidime (Fortaz, Tazicef) • cefditoren (Spectracef) • ceftibuten (Cedax) • cefixime (Suprax) • ceftizoxime (Cefizox) • cefotaxime (Claforan) • ceftriaxone (Rocephin) • cefpodoxime (Vantin) Cephalosporins, 4th Generation • cefepime (Maxipime) Ketolides • telithromycin (Ketek) Lincosamides • clindamycin (Cleocin) • lincomycin (Lincocin) Macrolides • azithromycin (Zithromax) • erythromycin (E.E.S., Eryc, Ery-Tab, EryPed) • clarithromycin (Biaxin, Biaxin XL) • erythromycin/sulfisoxazole (Eryzole, Pediazole) • fidaxomicin (Dificid) Nitrofurans • nitrofurantoin (Furadantin, Macrodantin, Macrobid) Nitroimidazoles • metronidazole HCl (Flagyl) • tinidazole (Tindamax) Oxazolidinones • linezolid (Zyvox) • tedizolid (Sivextro)

ANTI-INFECTIVES Penicillins • amoxicillin/potassium clavulanate (Augmentin, Augmentin XR) • oxacillin • amoxicillin (Amoxil, Moxatag) • penicillin G (Bicillin C-R, Bicillin L-A, Permapen) • ampicillin • penicillin V potassium (Veetids) • ampicillin/sulbactam (Unasyn) • piperacillin • dicloxacillin • piperacillin/tazobactam (Zosyn) • nafcillin • ticarcillin/potassium clavulanate (Timentin) Quinolones • ciprofloxacin (Cipro, Cipro XR, Proquin XR) • moxifloxacin • delafloxacin (Baxdela) • norfloxacin (Noroxin) • gemifloxacin (Factive) • ofloxacin (Floxin) • levofloxacin (Levaquin) Sulfonamides • sulfadiazine • sulfasalazine (Azulfidine) • sulfamethoxazole/trimethoprim (Bactrim, Septra) • trimethoprim Tetracyclines • demeclocycline • minocycline (Arestin, Dynacin, Minocin, Myrac) • doxycycline (Adoxa, Atridox, Dory MPC, Doryx, Monodox, • tetracycline (Sumycin) Oracea, Oraxyl, Periostat, Vibramycin) Vancomycin and Derivatives • vancomycin (Firvanq, Vancocin) Miscellaneous Antibiotics • fosfomycin (Monurol) • methenamine (Hiprex, Urex) • Lefamulin (Xenleta) Antifungals • amphotericin B (Abelcet, AmBisome, Amphocin, Amphotec) • itraconazole (Sporanox, Tolsura) • anidulafungin (Cancidas) • ketoconazole • caspofungin (Eraxis) • micafungin (Mycamine) • fluconazole (Diflucan) • miconazole (Monistat) • flucytosine (Ancobon) • posaconazole (Noxafil) • griseofulvin (Fulvicin U/F, Gris-PEG, Grifulvin V) • voriconazole (Vfend) • isavuconazonium (Cresemba) Antiparasitics • albendazole (Albenza) • nitazoxanide (Alinia) • artemether/lumefantrine (Coartem) • paromomycin • atovaquone/proguanil (Malarone) • pentamidine (NebuPent, Pentam 300) • atovaquone (Mepron) • praziquantel (Biltricide) • chloroquine (Aralen) • primaquine • dapsone • pyrantel (Pin-X, Reese Pinworm) • iodoquinol (Yodoxin) • pyrimethamine (Daraprim) • ivermectin (Stromectol) • quinine (Qualaquin) • mebendazole (Emverm, Vermox) • tafenoquine (Krintafel) • mefloquine Antivirals • acyclovir (Zovirax) • penciclovir (Denavir) • baloxavir (Xofluza) • valacyclovir (Valtrex) • famciclovir (Famvir) • zanamivir (Relenza) • oseltamivir (Tamiflu) • ledipasvir/sofosbuvir (Harvoni and Harvoni Pak) • dolutegravir (Tivicay and Tivicacy PD) • sofosbuvir (Sovaldi and Sovaldi Pak)

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CARDIOVASCULAR Antianginal Agents, Miscellaneous • ranolazine (Ranexa) Antiarrhythmics • adenosine (Adenocard) • ibutilide (Corvert) • amiodarone (Cordarone, Pacerone) • lidocaine (Xylocaine) • bretylium • mexiletine (Mexitil) • disopyramide IR/SA (Norpace/Norpace CR) • procainamide • dofetilide (Tikosyn) • propafenone (Rythmol/Rythmol SR) • dronedarone (Multaq) • quinidine gluconate • flecainide (Tambocor) • quinidine sulfate (Quinidex) Anticoagulants • apixaban (Eliquis) • fondaparinux (Arixtra) • dalteparin (Fragmin) • heparin (Heparin) • dabigatran etexilate (Pradaxa) • tinzaparin (Innohep) • edoxaban (Savaysa) • warfarin (Coumadin, Jantoven) • enoxaparin (Lovenox) Antifibrinolytics • aminocaproic acid (Amicar) • avatrombopag (Doptelet) • aprotinin (Trasylol) • tranexamic acid (Cyklokapron, Lysteda) Cardiac Glycosides • digoxin (Lanoxin) Calcium Channel Blockers • amlodipine (Katerzia) • nimodipine (Nymalize/Nymalize ER) Hypotensives, Angiotensin Receptor Blockers • azilsartan (Edarbi) • eprosartan/HCTZ (Teveten HCT) • azilsartan/chlorthalidone (Edarbyclor) Hypotensives, Direct Renin Inhibitors • aliskiren (Tekturna) • aliskiren/HCTZ (Tekturna HCT) Hypotensives, Sympatholytics • clonidine (Catapres, Catapres TTS) • methyldopa/HCTZ • guanfacine (Tenex) • methyldopate • mecamylamine (Vecamyl) • reserpine • methyldopa (Aldomet) Hypotensives, Vasodilators • diazoxide (Hyperstat I.V.) • hydralazine HCl (Apresoline) • fenoldopam mesylate (Corlopam) • minoxidil (Minoxidil) Miscellaneous, Cardiovascular • ecallantide (Kalbitor) • ivabradine (Corlanor) • icatibant (Firazyr) Oral Thrombopoietic Agonists • eltrombopag (Promacta) • lusutrombopag (Mulpleta) • fostamatinib (Tavalisse) Pheochromocytoma Agents • metyrosine (Demser) Platelet Aggregation Inhibitors/Intermittent Claudication • abciximab (ReoPro) • omeprazole/aspirin (Yosprala) • anagrelide (Agrylin) • pentoxifylline (Trental) • aspirin (Durlaza) • prasugrel (Effient) • aspirin/dipyridamole (Aggrenox) • ticagrelor (Brilinta) • cilostazol (Pletal) • ticlopidine (Ticlid) • clopidogrel (Plavix) • tirofiban (Aggrastat) • dipyridamole (Persantine) • vorapaxar (Zontivity) • eptifibatide (Integrilin)

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CARDIOVASCULAR Pulmonary Arterial Hypertension Agents • ambrisentan (Letairis) • riociguat (Adempas) • bosentan (Tracleer) • selexipag (Uptravi) • epoprostenol (Flolan) • sildenafil (Revatio) • iloprost (Ventavis) • tadalafil (Adcirca) • macitentan (Opsumit) • treprostinil (Remodulin, Tyvaso, Orenitram) Statins • simvastatin (Flolipid) Vasodilators • amyl nitrite • nitroglycerin (Minitran, Nitrek, Nitro-Bid, Nitro-Dur, • isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil) Nitrolingual, NitroQuick, Nitrostat, Nitrotab, Nitro-Time, • isosorbide mononitrate (Imdur, Monoket) NitroMist) Vasopressors • midodrine

CNS Alzheimer’s Agents • donepezil • memantine-donepezil • galantamine • rivastigmine • memantine Anticonvulsants • brivaracetam (Briviact) • lamotrigine ODT (Lamictal ODT) • cannabidiol (Epidiolex) • levetiracetam (Keppra, Keppra XR) • carbamazepine (Carbatrol, Tegretol, Tegretol XR) • methsuximide (Celontin) • clobazam (Onfi, Sympazan) • midazolam spray (Nayzilam) • clonazepam (Klonopin) • oxcarbazepine (Trileptal, Oxtellar XR) • clonazepam ODT (Klonopin Wafer) • perampanel (Fycompa) • diazepam rectal gel (Diastat) • phenobarbital • diazepam spray (Valtoco) • phenytoin (Dilantin, Dilantin Kapseals, Phenytek) • divalproex sodium (Depakote, Depakote ER, Depakote • pregabalin (Lyrica) Sprinkles) • primidone (Mysoline) • eslicarbazepine (Aptiom) • rufinamide (Banzel) • ethosuximide (Zarontin) • stiripentol (Diacomit) • ethotoin (Peganone) • tiagabine (Gabitril) • ezogabine (Potiga) • topiramate (Topamax, Trokendi XR, Qudexy XR) • felbamate (Felbatol) • valproate sodium (Depacon) • fosphenytoin (Cerebyx) • valproic acid (Depakene, Stavzor) • gabapentin (Neurontin) • vigabatrin (Sabril) • lacosamide (Vimpat) • zonisamide (Zonegran) • lamotrigine (Lamictal, Lamictal XR) • fenfluramine (Fintepla) Antidepressants, New Generation • bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Forfivo XL) • nefazodone (Serzone) • maprotiline • trazodone (Oleptro) • mirtazapine (Remeron, Remeron SolTab) • vilazodone (Viibryd) Antidepressants, SNRIs, and SSRIs • (Celexa) • milnacipran (Savella) • desvenlafaxine (Pristiq, Khedezla) • (Paxil, Paxil CR, Pexeva) • duloxetine (Cymbalta, Irenka) • (Zoloft) • (Lexapro) • venlafaxine (Effexor XR) • (Prozac, Prozac Weekly, Sarafem) • vortioxetine (Trintellix) • (Luvox) Antiparkinson Agents • apomorphine (Apokyn, Kynmobi) • rasagiline (Azilect) • bromocriptine (Parlodel) • ropinirole (Requip, Requip XL) • carbidopa/levodopa (Sinemet, Sinemet CR, Rytary) • safinamide (Xadago) • carbidopa/levodopa/entacapone (Stalevo) • selegiline (Zelapar, Eldepryl) • entacapone (Comtan) • tolcapone (Tasmar) • pramipexole (Mirapex, Mirapex ER) • trihexyphenidyl (Artane)

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CNS Antipsychotics, Atypical • aripiprazole (Abilify, Abilify Discmelt, Abilify Maintena, • lumateperone (Caplyta) Aristada) • lurasidone (Latuda) • asenapine (Saphris, Secuado) • olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) • brexpiprazole (Rexulti) • paliperidone (Invega, Invega Sustenna, Invega Trinza) • cariprazine (Vraylar) • pimavanserin (Nuplazid) • clozapine (Clozaril, FazaClo) • quetiapine (Seroquel, Seroquel XR) • iloperidone (Fanapt) • risperidone (Risperdal, Risperdal Consta) • ziprasidone (Geodon) Antipsychotics, Typical • chlorpromazine (Thorazine) • perphenazine • droperidol (Inapsine) • pimozide (Orap) • fluphenazine • prochlorperazine (Compazine) • haloperidol (Haldol) • thioridazine • loxapine (Loxitane) • thiothixene (Navane) • molindone (Moban) • trifluoperazine MAOIs • isocarboxazid (Marplan) • selegiline (Eldepryl, Emsam, Zelapar) • phenelzine (Nardil) • tranylcypromine (Parnate) Mood Stabilizers • lithium carbonate (Lithobid) • lithium citrate • lithium carbonate ER SSRI/Antipsychotic Combos • olanzapine/fluoxetine (Symbyax) TCAs • amitriptyline • imipramine (Tofranil, Tofranil-PM) • amoxapine • nortriptyline (Pamelor) • clomipramine (Anafranil) • protriptyline (Vivactil) • desipramine (Norpramin) • trimipramine (Surmontil) • doxepin

ENDOCRINE AGENTS Glucocorticoids, Oral • cortisone • hydrocortisone (Alkindi, Cortef) • betamethasone solution (Celestone) • methylprednisolone (Medrol) • budesonide (Entocort EC) • prednisolone (Millipred, Orapred, Prelone) • dexamethasone (Dexpak, Dekpak Jr.) • prednisone Miscellaneous • osilodrostat (Isturisa) •

GASTROINTESTINAL AGENTS Anti-Emetics • dolasetron (Anzemet) • ondansetron (Zofran, Zofran ODT, Zofran solution, Zuplenz) • granisetron (Kytril, Sancuso)

IMMUNOGOLOGIC AGENTS Immunomodulators • abatacept (Orencia) • golimumab (Simponi) • adalimumab (Humira) • guselkumab (Tremfya) • anakinra (Kineret) • ixekizumab (Taltz) • apremilast (Otezla) • lanadelumab (Takhzyro) • baricitinib (Olumiant) • C1 esterase inhibitor (Haegarda, Takhyzro) • berotralstat (Orladeyo) • secukinumab (Cosentyx) • brodalumab (Siliq) • tocilizumab (Actemra) • certolizumab pegol (Cimzia) • tofacitinib (Xeljanz) • etanercept (Enbrel) • ustekinumab (Stelara) Immune Globulins • Gammagard • Hizentra • Gamunex-C • Vivaglobin

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IMMUNOGOLOGIC AGENTS Multiple Sclerosis • cladribine (Mavenclad) • interferon beta-1b (Betaseron, Extavia) • daclizumab (Zinbryta) • peginterferon beta-1a (Plegridy) • dimethyl fumarate (Tecfidera) • siponimod (Mayzent) • fingolimod (Gilenya) • teriflunomide (Aubagio) • glatiramer acetate (Copaxone)interferon beta-1a (Avonex, • ozanimod (Zeposia) Avonex Administration Pack, Rebif) • ofatumumab (Kesimpta)

MISCELLANEOUS • epinephrine (EpiPen, EpiPen Jr., Symjepi®) • dextromethorphan/quinidine (Nuedexta) • epoetin alfa (Retacrit) • pemigatinib (Pemazyre)

ONCOLOGY Oncology miscellaneous • pemigatinib (Pemazyre) • selumetinib (Koselugo)

OPHTHALMICS Antibiotic/Corticoid Combinations • gentamicin/prednisolone (Pred-G) • neomycin/polymyxin B/prednisolone (Poly-Pred) • neomycin/bacitracin/polymyxin/hydrocortisone (Cortisporin) • tobramycin/dexamethasone (Tobradex ointment, Tobradex • neomycin/polymyxin B/dexamethasone (Maxitrol) ST) • neomycin/polymyxin B/hydrocortisone (Cortisporin) • tobramycin/loteprednol (Zylet) Antibiotics • azithromycin (AzaSite) • levofloxacin (Iquix, Quixin) • bacitracin • moxifloxacin (Moxeza, Vigamox) • bacitracin/polymyxin B (AK-Poly-Bac, Polycin-B, Polysporin) • neomycin/ polymyxin B/bacitracin (Neosporin) • besifloxacin (Besivance) • neomycin/polymyxin B/gramicidin (Neosporin Eye Drops) • chloramphenicol (Chloromycetin) • ofloxacin (Ocuflox) • ciprofloxacin (Ciloxan) • polymyxin B/trimethoprim (Polytrim) • erythromycin (Ilotycin, Romycin) • sulfacetamide sodium (Bleph-10) • gatifloxacin (Zymar, Zymaxid)) • tobramycin (AK-Tob, Tobrasol, Tobrex) • gentamicin (Garamycin, Genoptic, Gentak, Gentasol) Antifungals • natamycin (Natacyn) Antivirals • ganciclovir (Zirgan) • trifluridine (Viroptic) Anti-inflammatory Agents • bromfenac (Xibrom) • ketorolac (Acular, Acular LS, Acular PF) • dexamethasone (Hemady, Maxidex) • loteprednol (Alrex, Lotemax, Eysuvis) • diclofenac (Voltaren) • nepafenac (Nevanac) • difluprednate (Durezol) • prednisolone (Pred Mild, Pred Forte) • fluorometholone (Flarex, FML Forte, FML Liquifilm, FML S.O.P.) • rimexolone (Vexol) • flurbiprofen (Ocufen) Miotics/IOP Reducers • acetylcholine chloride (Miochol-E) • latanoprost (Xalatan, Xelpros) • apraclonidine (Iopidine) • latanoprostene bunod (Vyzulta) • betaxolol (Betoptic-S) • levobunolol (Betagan) • bimatoprost (Lumigan) • metipranolol (OptiPranolol) • brimonidine (Alphagan P) • netarsudil (Rhopressa) • brinzolamide (Azopt) • netarsudil/latanoprost (Rocklatan) • carbachol (Isopto Carbachol, Miostat) • pilocarpine (Isopto Carpine, Pilopine HS, Piloptic) • carteolol • timolol (Betimol, Istalol, Timoptic, Timoptic-XE GFS) • dorzolamide (Trusopt) • timolol/dorzolamide (Cosopt) • travoprost (Travatan Z) Miscellaneous • cenegermin-bkbj (Oxervate) Sulfonamides • sodium sulfacetamide/prednisolone (Blephamide S.O.P.) • sulfacetamide sodium (Bleph-10, Ocusulf-10, Sulfac, Sulfamide)

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OTICS Antibiotics/Anti-inflammatory Agents • ciprofloxacin (Cetraxal) • neomycin/colistin/hydrocortisone (Coly-Mycin S) • ciprofloxacin/dexamethasone (Ciprodex) • neomycin/polymyxin B/hydrocortisone (Cortisporin Otic) • ciprofloxacin/hydrocortisone (Cipro HC Otic) • ofloxacin • neomycin/colistin/hydrocortisone/thonzonium (Cortisporin-TC Otic)

RESPIRATORY Anticholinergics • aclidinium (Tudorza) • tiotropium (Spiriva) • glycopyrrolate (Lonhala Magnair, Seebri Neohaler) • tiotropium/olodaterol (Stiolto Respimat) • indacaterol/glycopyrrolate (Utibron Neohaler) • umeclidinium (Incruse Ellipta) • revefenacin (Yupelri) • umeclidinium/vilanterol (Anoro Ellipta) Beta Agonist/Anticholinergic Combinations • albuterol/ipratropium (Combivent, Combivent Respimat, DuoNeb) Beta Agonists: Other • arformoterol (Brovana) • olodaterol (Striverdi) • formoterol ( Perforomist) • pirbuterol (Maxair Autohaler) • indacaterol (Arcapta) • salmeterol (Serevent) • metaproterenol • terbutaline (Brethine) Beta Agonist/Corticosteroid Combinations • aclidinium/formoterol (Duaklir Pressair) • fluticasone/vilanterol (Breo Ellipta) • budesonide/formoterol (Symbicort) • fluticasone/vilanterol/umeclidinium (Trelegy Ellipta) • fluticasone/salmeterol (AirDuo RespiClick, Advair HFA, Advair • glycopyrrolate/formoterol (Bevespi) Diskus) Inhaled Corticosteroids • beclomethasone (QVAR Redihaler) • fluticasone inhaler (ArmonAir, Flovent Diskus, Flovent HFA, • budesonide (Pulmicort Respules, Pulmicort Flexhaler) Arnuity Ellipta) [excludes nasal spray] • flunisolide (Aerospan) Monoclonal Antibody • omalizumab (Xolair) Mucolytics • acetylcysteine Xanthines • aminophylline • dyphylline (Dylix, Lufyllin) • caffeine citrate (Cafcit) • theophylline anhydrous (Theo-24, Theochron, Uniphyl) • caffeine/sodium benzoate

VITAMINS AND ELECTROLYTES Potassium Supplements (Rx ONLY) • potassium chloride (Epiklor, Kaon-CL, Klor-Con, K-tabs, • potassium chloride, microencapsulated (Klor-Con M) K-Vescent, Micro K)

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