Prescriber Attestation List

TennCare Prescriber Attestation List Medications on this list can be approved for patients currently at their monthly prescription limit (> 5 prescriptions or >2 brand medications) who are at a high risk for adverse health consequences and could be hospitalized, institutionalized, or die, within the next ninety (90) days without the requested drug(s).

Please note: 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.

Therapeutic Category Generic Name* Brand Name ANTI-INFECTIVES Aminoglycosides AMIKACIN AMIKIN GENTAMICIN GARAMYCIN KANAMYCIN KANAMYCIN NEOMYCIN NEO-FRADIN PAROMOMYCIN HUMATIN STREPTOMYCIN STREPTOMYCIN TOBRAMYCIN NEBCIN, TOBI Nitroimidazoles METRONIDAZOLE HCL FLAGYL TINIDAZOLE TINDAMAX Antifungals AMPHOTERICIN B ABELCET, AMBISOME, AMPHOCIN, AMPHOTEC, FUNGIZONE,

ANIDULAFUNGIN CANCIDAS CASPOFUNGIN ERAXIS FLUCONAZOLE DIFLUCAN FLUCYTOSINE ANCOBON GRISEOFULVIN FULVICIN U/F, GRIS-PEG, GRIFULVIN V ITRACONAZOLE SPORANOX MICAFUNGIN MYCAMINE Antifungals MICONAZOLE MONISTAT POSACONAZOLE NOXAFIL UNDECYLENIC ACID UNDECYLENIC ACID VORICONAZOLE VFEND

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Therapeutic Category Generic Name* Brand Name ANTI-INFECTIVES Antiparasitics ALBENDAZOLE ALBENZA ATOVAQUONE / PROGUANIL MALARONE CHLOROQUINE CHLOROQUINE IODOQUINOL YODOXIN IVERMECTIN STROMECTOL MEBENDAZOLE VERMOX MEFLOQUINE LARIAM NITAZOXANIDE ALINIA PENTAMIDINE NEBUPENT, PENTAM 300 PRAZIQUANTEL BILTRICIDE PRIMAQUINE PRIMAQUINE PYRANTEL PIN-X, REESE PINWORM PYRIMETHAMINE DARAPRIM QUININE QUALAQUIN SULFADOXINE / PYRIMETHAMINE FANSIDAR THIABENDAZOLE MINTEZOL DAPSONE DAPSONE Antivirals ACYCLOVIR ZOVIRAX FAMCICLOVIR FAMVIR PENCICLOVIR DENAVIR VALACYCLOVIR VALTREX Cephalosporins, 1st Generation CEFADROXIL DURICEF CEFAZOLIN ANCEF CEPHALEXIN KEFLEX CEPHRADINE VELOSEF Cephalosporins, 2nd Generation CEFACLOR CECLOR CEFOXITIN MEFOXIN CEFPROZIL CEFZIL CEFUROXIME CEFTIN, ZINACEF Cephalosporins, 3rd Generation CEFDINIR OMNICEF CEFDITOREN SPECTRACEF CEFIXIME SUPRAX CEFOTAXIME CLAFORAN CEFPODOXIME VANTIN CEFTAZIDIME FORTAZ, TAZICEF CEFTIBUTEN CEDAX CEFTIZOXIME CEFIZOX CEFTRIAXONE ROCEPHIN Cephalosporins, 4th Generation CEFEPIME MAXIPIME

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Therapeutic Category Generic Name* Brand Name ANTI-INFECTIVES Ketolides TELITHROMYCIN KETEK Lincosamides CLINDAMYCIN CLEOCIN LINCOMYCIN LINCOSIN Macrolides AZITHROMYCIN ZITHROMAX, ZMAX CLARITHROMYCIN BIAXIN, BIAXIN XL ERYTHROMYCIN E.E.S., ERYC, ERY-TAB, ERYPED ERYTHROMYCIN / ERYZOLE, PEDIAZOLE SULFISOXAZOLE Nitrofurans NITROFURANTOIN FURADANTIN, MACRODANTIN, MACROBID Oxazolidinones LINEZOLID ZYVOX Penicillins AMOXICILLIN / POTASSIUM AUGMENTIN CLAVULANATE AMOXICILLIN AMOXIL AMPICILLIN AMPICILLIN AMPICILLIN / SULBACTAM UNASYN CARBENICILLIN GEOCILLIN DICLOXACILLIN DICLOXACILLIN NAFCILLIN NAFCILLIN OXACILLIN OXACILLIN PENICILLIN G BICILLIN C-R, BICILLIN L-A, PERMAPEN PENICILLIN V POTASSIUM VEETIDS PIPERACILLIN PIPERACILLIN PIPERACILLIN / TAZOBACTAM ZOSYN TICARCILLIN TICAR TICARCILLIN / POTASSIUM TIMENTIN CLAVULANATE Quinolones CIPROFLOXACIN CIPRO, CIPRO XR GEMIFLOXACIN FACTIVE LEVOFLOXACIN LEVAQUIN LOMEFLOXACIN MAXAQUIN MOXIFLOXACIN AVELOX NALIDIXIC ACID NEGGRAM NORFLOXACIN NOROXIN OFLOXACIN FLOXIN Sulfonamides SULFADIAZINE SULFADIAZINE SULFAMETHOXAZOLE / BACTRIM, SEPTRA TRIMETHOPRIM SULFASALAZINE AZULFIDINE SULFISOXAZOLE GANTRISIN PEDIATRIC

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Therapeutic Category Generic Name* Brand Name ANTI-INFECTIVES Tetracyclines DEMECLOCYCLINE DECLOMYCIN DOXYCYCLINE ATRIDOX, DORYX, MONODOX, PERIOSTAT, VIBRAMYCIN, VIBRA- TABS MINOCYCLINE ARESTIN, DYNACIN, MINOCIN, MYRAC OXYTETRACYCLINE TERRAMYCIN TETRACYCLINE SUMYCIN Vancomycin and Derivatives VANCOMYCIN VANCOCIN Misc. Antibiotics FOSFOMYCIN MONUROL METHENAMINE HIPREX, MANDELAMINE, UREX TRIMETHOPRIM PRIMSOL, PROLOPRIM

CARDIOVASCULAR Antiarryhthmics ADENOSINE ADENOCARD AMIODARONE CORDARONE, PACERONE BRETYLIUM BRETYLIUM DISOPYRAMIDE NORPACE DOFETILIDE TIKOSYN FLECAINIDE TAMBOCOR IBUTILIDE CORVERT LIDOCAINE XYLOCAINE MEXILETINE MEXITIL MORICIZINE ETHMOZINE PROCAINAMIDE PROCANBID, PRONESTYL PROPAFENONE RYTHMOL QUINIDINE GLUCONATE QUINIDINE GLUCONATE QUINIDINE SULFATE QUINIDEX Anticoagulants DALTEPARIN FRAGMIN ENOXAPARIN LOVENOX FONDAPARINUX ARIXTRA HEPARIN HEPARIN TINZAPARIN INNOHEP WARFARIN COUMADIN, JANTOVEN Antifibrinolytics AMINOCAPROIC ACID AMICAR APROTININ TRASYLOL TRANEXAMIC ACID CYKLOKAPRON

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Therapeutic Category Generic Name* Brand Name CARDIOVASCULAR Hypotensives, Angiotensin CANDESARTAN ATACAND Receptor Blockers CANDESARTAN / ATACAND HCT HYDROCHLOROTHIAZIDE EPROSARTAN TEVETEN EPROSARTAN / TEVETEN HCT HYDROCHLOROTHIAZIDE IRBESARTAN AVAPRO IRBESARTAN / AVALIDE HYDROCHLOROTHIAZIDE LOSARTAN POTASSIUM COZAAR LOSARTAN / HYZAAR HYDROCHLOROTHIAZIDE OLMESARTAN BENICAR OLMESARTN / BENICAR HCT HYDROCHLOROTHIAZIDE TELMISARTAN MICARDIS TELMISARTAN / MICARDIS HCT HYDROCHLOROTHIAZIDE VALSARTAN DIOVAN VALSARTAN / DIOVAN HCT HYDROCHLOROTHIAZIDE Hypotensives, Sympatholytics CLONIDINE CATAPRES, CATAPRES-TTS CLONIDINE / CHLORTHALIDONE CLORPRES GUANABENZ GUANABENZ GUANFACINE TENEX METHYLDOPA ALDOMET METHYLDOPA / METHYLDOPA / HYDROCHLOROTHIAZIDE HYDROCHLOROTHIAZIDE METHYLDOPATE METHYLDOPATE RESERPINE RESERPINE Hypotensives, Vasodilators DIAZOXIDE HYPERSTAT I.V. FENOLDOPAM MESYLATE CORLOPAM HYDRALAZINE HCL HYDRALAZINE HCL HYDRALAZINE / HYDRA-ZIDE HYDROCHLOROTHIAZIDE MINOXIDIL MINOXIDIL

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Therapeutic Category Generic Name* Brand Name CARDIOVASCULAR Platelet Aggregation Inhibitors ABCIXIMAB REOPRO ASPIRIN / DIPYRIDAMOLE AGGRENOX CILOSTAZOL PLETAL CLOPIDOGREL PLAVIX DIPYRIDAMOLE PERSANTINE EPTIFIBATIDE INTEGRILIN TICLOPIDINE TICLID TIROFIBAN AGGRASTAT Agents to Treat Hyperkalemia SODIUM POLYSTYRENE KAYEXALATE, KIONEX, SPS SULFONATE Pulmonary Hypertension Agents BOSENTAN TRACLEER EPOPROSTENOL FLOLAN ILOPROST VENTAVIS SILDENAFIL REVATIO TREPROSTINIL REMODULIN Vasodilators AMYL NITRITE AMYL NITRITE ISOSORBIDE DINITRATE DILATRATE-SR, ISOCHRON, ISORDIL ISOSORBIDE MONONITRATE IMDUR, ISMO, MONOKET NITROGLYCERIN MINITRAN, NITREK, NITRO-BID, NITRO-DUR, NITROLINGUAL, NITROQUICK, NITROSTAT, NITROTAB, NITRO-TIME, NITROMIST

Vasopressors MIDODRINE PROAMATINE

CNS Anticonvulsants CARBAMAZEPINE TEGRETOL DIVALPROEX SODIUM DEPAKOTE, DEPAKOTE ER ETHOSUXIMIDE ZARONTIN ETHOTOIN PEGANONE FELBAMATE FELBATOL FOSPHENYTOIN CEREBYX GABAPENTIN NEURONTIN LAMOTRIGINE LAMICTAL LEVETIRACETAM KEPPRA METHSUXIMIDE CELONTIN OXCARBAZEPINE TRILEPTAL PHENYTOIN DILANTIN, DILANTIN KAPSEALS, PHENYTEK

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Therapeutic Category Generic Name* Brand Name CNS Anticonvulsants PREGABALIN LYRICA PRIMIDONE MYSOLINE TIAGABINE GABITRIL TOPIRAMATE TOPAMAX VALPROATE SODIUM DEPACON VALPROIC ACID DEPAKENE ZONISAMIDE ZONEGRAN Antidepressants, New Generation MIRTAZAPINE REMERON, REMERON SOLTAB BUPROPION HCL WELLBUTRIN, WELLBUTRIN SR, WELLBUTRIN XL NEFAZODONE SERZONE TRAZODONE DESYREL Antidepressants, SNRIs DULOXETINE CYMBALTA VENLAFAXINE EFFEXOR, EFFEXOR XR CITALOPRAM CELEXA ESCITALOPRAM LEXAPRO FLUOXETINE PROZAC, PROZAC WEEKLY, SARAFEM FLUVOXAMINE FLUVOXAMINE PAROXETINE PAXIL, PAXIL CR, PEXEVA SERTRALINE HCL ZOLOFT Antipsychotics CHLORPROMAZINE THORAZINE DROPERIDOL INAPSINE FLUPHENAZINE FLUPHENAZINE HALOPERIDOL HALDOL LOXAPINE LOXITANE MOLINDONE MOBAN PALIPERIDONE INVEGA PERPHENAZINE PERPHENAZINE PIMOZIDE ORAP PROCHLORPERAZINE COMPAZINE THIORIDAZINE THIORIDAZINE THIOTHIXENE NAVANE TRIFLUOPERAZINE TRIFLUOPERAZINE Antipsychotics, Atypical ARIPIPRAZOLE ABILIFY, ABILIFY DISCMELT CLOZAPINE CLOZARIL OLANZAPINE ZYPREXA QUETIAPINE SEROQUEL RISPERIDONE RISPERDAL, RISPERDAL CONSTA ZIPRASIDONE GEODON

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Therapeutic Category Generic Name* Brand Name CNS MAOIs ISOCARBOXAZIDE MARPLAN PHENELZINE NARDIL SELEGILINE CARBEX, ELDEPRYL, EMSAM, ZELAPAR TRANYLCYPROMINE PARNATE Mood Stabilizers LITHIUM CARBONATE ESKALITH, LITHOBID LITHIUM CITRATE LITHIUM CITRATE SSRI/Antipsychotic Combination OLANZAPINE / FLUOXETINE HCL SYMBYAX TCAs AMITRIPTYLINE ELAVIL AMOXAPINE AMOXAPINE CLOMIPRAMINE ANAFRANIL DESIPRAMINE NORPRAMIN DOXEPIN SINEQUAN IMIPRAMINE TOFRANIL, TOFRANIL-PM MAPROTILINE MAPROTILINE NORTRIPTYLINE PAMELOR PROTRIPTYLINE VIVACTIL TRIMIPRAMINE SURMONTIL

ENDOCRINE Glucocorticoids BECLOMETHASONE QVAR BETAMETHASONE CELESTONE BUDESONIDE PULMICORT RESPULES, PULMICORT TURBUHALER CORTISONE ACETATE CORTISONE ACETATE DEXAMETHASONE DECADRON, DEXACEN LA-8, DEXAMETHASONE INTENSOL, HEXADROL FLUNISOLIDE AEROBID, AEROBID-M, AEROSPAN FLUTICASONE FLOVENT DISKUS, FLOVENT HFA, FLOVENT ROTADISK HYDROCORTISONE CORTEF, SOLU-CORTEF METHYLPREDNISOLONE MEDROL, DEPO-MEDROL, SOLU- MEDROL MOMETASONE ASMANEX TWISTHALER PREDNISOLONE ECONOPRED PLUS, ORAPRED, PEDIAPRED, PRED MILD, PRED FORTE, PREDNISOL, PRELONE

PREDNISONE DELTASONE, METICORTEN, ORASONE, PANASOL-S, PREDNISONE INTENSOL, STERAPRED TRIAMCINOLONE AZMACORT

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Therapeutic Category Generic Name* Brand Name ENDOCRINE Thyroid Hormones LEVOTHYROXINE LEVOTHROID, LEVOXYL, SYNTHROID LIOTHYRONINE CYTOMEL LIOTRIX THYROLAR THYROID ARMOUR THYROID, NATURE- THROID, THYROID USP, WESTHROID THYROID, PORK BIO-THROID, NATURE-THROID, WESTHROID Drugs to Treat Hereditary NITISINONE ORFADIN Tyrosinemia

IMMUNOLOGIC AGENTS IL-1 Receptor Antagonists ANAKINRA KINERET Multiple Sclerosis GLATIRAMER ACETATE COPAXONE INTERFERON BETA-1A AVONEX, AVONEX ADMINISTRATION PACK, REBIF INTERFERON BETA-1B BETASERON TNF Inhibitors ADALIMUMAB HUMIRA ETANERCEPT ENBREL

OPHTHALMICS Antibiotic-Corticoid Combinations GENTAMICIN / PREDNISOL PRED-G NEOMYCIN / POLYMYXIN B / MAXITROL DEXAMETHASONE NEOMYCIN / BACITRACIN / CORTISPORIN POLYMYXIN / HYDROCORTISONE NEOMYCIN / POLYMYXIN B / CORTISPORIN HYDROCORTISONE NEOMYCIN / POLYMYXIN B / POLY-PRED PREDNISOLONE TOBRAMYCIN / TOBRADEX DEXAMETHASONE TOBRAMYCIN / LOTEPREDNOL ZYLET

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Therapeutic Category Generic Name* Brand Name OPHTHALMICS Antibiotics BACITRACIN BACITRACIN BACITRACIN / POLYMYXIN B POLYCIN-B, POLYSPORIN CHLORAMPHENICOL CHLOROMYCETIN CIPROFLOXACIN CILOXAN ERYTHROMYCIN ILOTYCIN GATIFLOXACIN ZYMAR GENTAMICIN GARAMYCIN, GENOPTIC, GENTAK LEVOFLOXACIN QUIXIN MOXIFLOXACIN VIGAMOX NATAMYCIN NATACYN NEOMYCIN / BACITRACIN / NEOMYCIN / BACITRACIN / POLYMYXIN B POLYMYXIN B NEOMYCIN / GRAMICIDIN D / NEOSPORIN EYE DROPS, POLYMYXIN B OCUTRICIN OFLOXACIN OCUFLOX OXYTETRACYCLINE / TERRAMYCIN W/ POLYMIXIN POLYMYXIN B POLYMYXIN B / TRIMETHOPRIM POLYTRIM TOBRAMYCIN TOBREX Anti-inflammatory Agents BROMFENAC XIBROM DICLOFENAC VOLTAREN FLUOROMETHOLONE FLAREX, FML FORTE, FML LIQUIFILM FML S.O.P. FLURBIPROFEN OCUFEN KETOROLAC ACULAR, ACULAR LS, ACULAR PF LOTEPREDNOL ALREX, LOTEMAX NEPAFENAC NEVANAC RIMEXOLONE VEXOL Antivirals FOMIVIRSEN VITRAVENE GANCICLOVIR VITRASERT TRIFLURIDINE VIROPTIC

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Therapeutic Category Generic Name* Brand Name OPHTHALMICS Miotics/IOP Reducers ACETYLCHOLINE CHLORIDE MIOCHOL-E APRACLONIDINE IOPIDINE BETAXOLOL BETOPTIC, BETOPTIC-S BIMATOPROST LUMIGAN BRIMONIDINE ALPHAGAN P BRINZOLAMIDE AZOPT CARBACHOL CARBASTAT, MIOSTAT CARTEOLOL OCUPRESS DORZOLAMIDE TRUSOPT LATANOPROST XALATAN LEVOBUNOLOL BETAGAN PILOCARPINE ISOPTO CARPINE, PILOCAR, PILOPINE HS TIMOLOL BETIMOL, ISTALOL, TIMPOTIC, TIMOPTIC GFS, TIMOPTIC-XE TIMOLOL / DORZOLAMIDE COSOPT TRAVOPROST TRAVATAN, TRAVATAN Z Sulfonamides SODIUM SULFACETMIDE / BLEPHAMIDE S.O.P., VASOCIDIN PREDNISOLONE SULFACETAMIDE SODIUM BLEPH-10, OCUSULF-10, SULFAC, SULFAMIDE

OTICS Antibiotics/Anti-inflammatory CIPROFLOXACIN / CIPRODEX Agents DEXAMETHASONE CIPROFLOXACIN / CIPRO HC OTIC HYDROCORTISONE Antibiotics NEOMYCIN / POLYMIXIN B / CORTISPORIN OTIC, OCTICAIR, HYDROCORTISONE PEDIOTIC NEOMYCIN / COLISTIN / CORTISPORIN-TC OTIC HYDROCORTISONE / THONZONIUM NEOMYCIN / COLISTIN / COLYMYCIN-S HYDROCORTISONE OFLOXACIN FLOXIN OTIC

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Therapeutic Category Generic Name* Brand Name RESPIRATORY Beta-adrenergic agonists ALBUTEROL / IPRATROPIUM COMBIVENT FORMOTEROL FORADIL LEVALBUTEROL XOPENEX, XOPENEX HFA METAPROTERENOL ALUPENT PIRBUTEROL MAXAIR AUTOHALER SALMETEROL SEREVENT TERBUTALINE BRETHINE Mucolytics ACETYLCYSTEINE MUCOMYST DORNASE ALFA PULMOZYME Xanthines AMINOPHYLLINE AMINOPHYLLINE CAFFEINE CITRATED CAFCIT CAFFEINE / SODIUM BENZOATE CAFFEINE / SODIUM BENZOATE DYPHYLLINE DYLIX, LUFYLLINE THEOPHYLLINE ANHYDROUS THEO-24, THEOCHRON, UNIPHYL

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