Tennessee Coverrx Covered Drug List – Effective July 1, 2017

Tennessee CoverRx Covered Drug List – Effective July 1, 2017

ALLERGIES ARTHRITIS AND PAIN (cont.) DIABETES (cont.) HEART HEALTH AND BLOOD PRESSURE MENTAL HEALTH VIRUSES Hydroxyzine HCL Meloxicam tablets Humulin vial* (except U-500) Amiodarone (except 100 mg) Amitriptyline Acyclovir (except ointment) Methotrexate Insulin Syringes Amlodipine Benztropine Amantadine ANTIBIOTICS Methylprednisolone Lancet Devices / Lancets Amlodipine / Benazepril Bupropion SR Rimantadine Amoxicillin Nabumetone Lantus vials & Lantus Solostar pens* Atenolol Bupropion XL 300 mg Amoxicillin / Clavulanate Prednisolone Sod-Phos solution Metformin, ER Atenolol / Chlorthalidone Buspirone VITAMINS AND MINERALS Ampicillin Prednisone tablets Pioglitazone Bisoprolol / HCTZ Citalopram tablets Calcitriol (except ointment) Azithromycin Salsalate Precision Xtra meter / strips Bisoprolol Fumarate Clozapine (except 200 mg tabs) Folic acid 1 mg tablets Cefaclor capsules Sulindac Benazepril Doxepin Potassium Chloride Cefadroxil EAR HEALTH Carvedilol Escitalopram tablets Prenatal Vitamins – All generics Cefpodoxime tablets ASTHMA/RESPIRATORY Neomycin/Polymyxin/HC Otic Chlorthalidone Fluoxetine capsules Cefuroxime tablets Ipratropium-albuterol Clonidine tablet (not ER tablet) Fluphenazine WOMEN’S HEALTH Cephalexin capsules (except 750 mg ) Montelukast 5mg chew, 10mg tab EYE CARE AND GLAUCOMA Digoxin Haloperidol Camila Ciprofloxacin (except 750 mg tab & XR) ProAir RespiClick Acetazolamide Diltiazem, ER / XR Haloperidol Decanoate Estradiol Clindamycin capsules Terbutaline Sulfate tablets Atropine Sulfate Disopyramide Phosphate Haloperidol Lactate 2 mg/ml Estropipate Dicloxacillin Theophylline, Anhydrous, ER Brimonidine Tartrate 0.2% Enalapril / HCTZ Hydroxyzine Pamoate Medroxyprogesterone (not Doxycycline Monohydrate capsule Cyclopentolate HCl 1% Felodipine ER Imipramine HCL injection) Erythromycin / Sulfisoxazole BLOOD MODIFIERS Dexamethasone Sod-Phos Furosemide tablets Lithium Carbonate Nora-be Levofloxacin tablets Dipyridamole Erythromycin Eye Ointment Hydralazine Loxapine Oral Contraceptives – All generics & Metronidazole (except lotion, 0.75% Warfarin Sodium Gentamicin Sulfate 0.3% Hydrochlorothiazide Mirtazapine Emergency Contraceptives vaginal gel, and 1% gel) Homatropine HBr 5% Indapamide Nortriptyline Tamoxifen Minocycline capsules CHOLESTEROL Latanoprost Isosorbide Mononitrate Paroxetine tabs (not CR tabs) Neomycin Sulfate Atorvastatin Levobunolol HCl Lisinopril Perphenazine OTHER MEDICAL CONDITIONS Nitrofurantoin Macrocrystals Fenofibrate 54 mg and 160 mg Pilocarpine Eye Drops Lisinopril / HCTZ Quetiapine tabs (not ER tabs) Hydroxychloroquine Sulf Ofloxacin tablets tablets Polymyxin B / Trimethoprim Losartan Risperidone tablets Lactulose Paromomycin Sulfate Gemfibrozil Prednisolone Acetate Losartan/HCTZ Sertraline tablets Megestrol Acetate Penicillin V Potassium Lovastatin Sulfacetamide Sodium Metolazone Thiothixene Promethazine tablets Sulfamethoxazole/Trimethoprim Pravastatin Timolol Maleate Metoprolol, ER Trazodone Sumatriptan tablets* Trimethoprim Simvastatin Tobramycin Sulfate Mexiletine Trifluoperazine Ofloxacin Eye Drops Nifedipine ER Trihexyphenidyl tablets FLU/PNEUMONIA VACCINES ANTICONVULSANTS DERMATOLOGY Nitroglycerin (except patch) Venlafaxine ER capsules* Afluria Divalproex, ER Triamcinolone Acetonide Cream FUNGAL INFECTIONS NitroStat Agriflu Levetiracetam IR tablets Clotrimazole Prazosin 1 mg & 2 mg capsules* OSTEOPOROSIS Fluarix Oxcarbazepine IR tablets DIABETES Clotrimazole Troche Propafenone tablets Alendronate Flulaval Phenytoin 100 mg capsules Alcohol Swabs Fluconazole Propranolol IR Fluvirin Phenytoin suspension Freestyle Freedom Lite meter Ketoconazole (except foam) Quinidine Gluconate THYROID CONDITIONS Fluzone Valproic Acid FreeStyle InsuLinx meter / strips Nystatin (except powder) Sotalol Levothyroxine Influenza A (H1N1) FreeStyle Lite meter / strips Spironolactone Methimazole Pneumovax ARTHRITIS AND PAIN Glimepiride GASTROINTESTINAL HEALTH Terazosin Allopurinol Glipizide, ER / XL Dicyclomine capsules & tablets Triamterene / HCTZ UROLOGY Dexamethasone Glyburide Hyoscyamine drops Verapamil tablets, ER / PM / SR Bethanechol Chloride Diclofenac Sodium tablets Glyburide/Metformin Hyoscyamine IR tablets Flavoxate Flurbiprofen Humalog cartridge* Mesalamine Suppositories Oxybutynin HCl Hydroxychloroquine Sulf Humalog/Humalog Mix pen & Metoclopramide Phenazopyridine HCl Indomethacin KwikPen* Sulfasalazine Ketoprofen Humalog/Humalog Mix vial* Ursodiol tablets Ketorolac Humulin cartridge* Quantity Limits: Humulin pen & KwikPen* (except − Insulins: 40 ml per fill U-500) − Prazosin: 1 capsule per day − Sumatriptan: 9 tablets per month − Venlafaxine: 1 capsule per day