TennCare Preferred Drug List (PDL) - landing | Optum RX ...

1 TennCare Preferred Drug List (PDL). Effective January 1, 2022. PA Prior Authorization required, subject to specific PA criteria; QL Quantity Limit (PA & NP agents require a PA before dispensing);. B Budgetary Reduction edit for utilization control (Standard NP PA criteria does not apply); ID Class PA for patients with Intellectual or Developmental Disability Please note the following: All agents must be prescribed by a provider with a Tennessee Medicaid Provider ID. Approval of NP agents requires trial and failure, contraindication, or intolerance of 2 Preferred agents, unless otherwise indicated With the exception of the Branded Drugs Classified as Generics list, TennCare is a mandatory generic program in accordance with state law (TCA 53-10-205). Approval of a branded product when a generic is available requires documentation of a serious adverse reaction from the generic via an FDA MedWatch form OR.

2 Contraindication to an inactive ingredient in the AB-rated generic equivalent. Therapeutic Failure of an AB-rated generic equivalent may be considered for approval of branded products in the following high-risk medication classes: Anticonvulsants, Atypical Antipsychotics, HIV antivirals, Immunosuppressants, and Oncology Agents. Unless otherwise noted, all agents listed on the PDL are referencing legend drugs which are prescription-required agents. Coverage of Over-the Counter (OTC). Products is listed at: Preferred Drugs Non- Preferred Drugs I. ANALGESICS. Agents for Opioid Use Disorder naltrexone Vivitrol Lucemyra PA, QL. Buprenorphine and Buprenorphine/Naloxone Buprenorphine Enhanced Supportive Medication-Assisted Recovery and Treatment (BESMART) Network Provider only: buprenorphine/naloxone tabs PA, QL Bunavail PA, QL Suboxone film PA, QL. buprenorphine/naloxone film PA, QL buprenorphine PA, QL Zubsolv PA, QL.

3 All other TennCare Providers: buprenorphine/naloxone tabs PA, QL Bunavail PA, QL Suboxone film PA, QL. buprenorphine PA, QL Zubsolv PA, QL. buprenorphine/naloxone filmPA, QL. COX-II Inhibitors celecoxib (50, 100, & 200 mg) QL Celebrex QL celecoxib 400 mg PA, QL. Transmucosal Fentanyl Products N/A Abstral PA, QL Fentora PA, QL. Actiq PA, QL Lazanda PA, QL. fentanyl lozenge PA, QL Subsys PA, QL. Naloxone Products Narcan nasal spray QL Kloxxado nasal spray QL n/a Narcotics Agonist/Antagonists nalbuphine injection PA, QL butorphanol NS PA, QL pentazocine/naloxone PA, QL. pentazocine/APAP PA, QL. Long Acting Narcotics fentanyl patch (excluding , , and ) PA, QL Arymo ER PA, QL Morphabond ER PA, QL. morphine sulfate ER tabs PA, QL Belbuca PA, QL morphine sulfate ER caps PA, QL. Nucynta ER. PA, QL buprenorphine patch PA, QL morphine sulfate SA PA, QL. Butrans PA, QL morphine sulfate SR 24hr (generic for Avinza ) PA, QL.

4 ConZip PA, QL MS Contin PA, QL. Dolophine PA, QL Opana ER PA, QL. Duragesic PA, QL OxyContin PA, QL. Exalgo PA, QL oxymorphone ER PA, QL. fentanyl patch ( , oxycodone ER PA, QL. , and ) PA, QL. hydrocodone ER (generic Hysingla ER) PA, tramadol ER 24 hr PA, QL. QL. hydromorphone ER PA, QL tramadol ER PA, QL (generic Conzip ). Hysingla ER PA, QL Ultram ER PA, QL. Kadian PA ( 100 mg), QL Xtampza ER PA, QL. methadone PA, QL Zohydro ER PA, QL. * Note that agents not listed on PDL may be considered non- Preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser Proprietary & Confidential to access the files on the TennCare site. Other browsers like Internet 2022, OptumRx. All rights reserved. Explorer cause issues with functionality and links between files. Preferred Drugs Non- Preferred Drugs I. ANALGESICS. Methadose PA, QL. Short-Acting Narcotics QL. codeine/APAP PA (< 19 years old), QL oxycodone tabs QL Apadaz QL meperidine PA, QL.

5 Endocet QL oxycodone/APAP QL benzhydrocodone/APAP PA, QL morphine suppositories PA, QL. hydrocodone/APAP QL oxycodone oral concentrate PA butalbital/APAP/caff/codeine PA, QL Nalocet PA, QL. (excluding generic for Xodol ). hydrocodone/ibuprofen QL oxycodone oral solution butalbital/ASA/caff/codeine PA, QL Norco PA, QL. hydromorphone QL tramadol QL codeine PA, QL Nucynta PA, QL. (excluding suppositories and liquid). morphine IR QL tramadol/APAP QL Demerol PA, QL Oxaydo PA, QL. (excluding suppositories). morphine sulfate soln 20 mg/ml PA dihydrocodeine/APAP/caffeine PA, QL oxycodone caps PA, QL. dihydrocodeine/ASA/caffeine PA, QL oxycodone/ASA PA, QL. Dilaudid PA, QL oxycodone/IBU PA, QL. Fioricet with Codeine PA, QL oxymorphone PA, QL. Fiorinal with Codeine PA, QL Percocet PA, QL. hydrocodone/APAP 5/300 PA, QL Primlev PA, QL. hydrocodone/APAP 10/300 PA, QL Roxicodone PA, QL.

6 Hydromorphone liquid PA, QL Tylenol with Codeine PA, QL. hydromorphone suppositories PA Ultracet PA, QL. Ibudone PA, QL Ultram PA, QL. levorphanol PA, QL Vicodin PA, QL. Lorcet PA, QL Vicodin HP PA, QL. Lortab PA, QL. NSAID/Anti-Ulcer Agents N/A Arthrotec PA, QL famotidine-ibuprofen PA, QL. diclofenac/misoprostol PA, QL naproxen-esomeprazole PA, QL. Duexis PA, QL Vimovo PA, QL. Salicylates and Non-Narcotic Combination Agents choline mag trisalicylate QL salsalate QL diflunisal QL. * Note that agents not listed on PDL may be considered non- Preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site. Other browsers like Internet Explorer cause issues with functionality and links between files. Effective Date: January 1, 2022 TennCare Preferred Drug List (PDL) | Page 2. Preferred Drugs Non- Preferred Drugs I. ANALGESICS.

7 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). diclofenac 1% gel QL ketorolac QL Anaprox Mobic . diclofenac potassium meloxicam tablets Anaprox DS Motrin . diclofenac sodium nabumetone Cambia Nalfon . diclofenac sodium ER sulindac Cataflam Naprelan . ibuprofen Voltaren gel QL Clinoril naproxen tabs and suspension indomethacin Daypro naproxen sodium ER. diclofenac patch PA, QL Naprosyn . diclofenac sodium PA Naproxen CR. diclofenac 35mg capsules Oxaprozin EC-Naprosyn Pennsaid PA. etodolac piroxicam etodolac ER Ponstel . Feldene Qmiiz ODT PA, QL. fenoprofen Sprix PA, QL. Flector PA, QL Tolmetin flurbiprofen Toradol QL. indomethacin ER Vivlodex PA, QL. ketoprofen Voltaren . ketoprofen ER Voltaren-XR . ketorolac spray VOPAC MDS Kit PA. meclofenamate Zipsor . mefenamic acid Zorvolex PA. meloxicam susp & capsules PA ,QL. Preferred Drugs Non- Preferred Drugs II. ANTI-INFECTIVES. Antibiotics: Cephalosporins First Generation cefadroxil capsules cephalexin capsules cefadroxil tablets Keflex.

8 Cefadroxil suspension cephalexin suspension cephalexin tablets Antibiotics: Cephalosporins Second Generation cefaclor capsules cefuroxime tabs cefaclor suspension Ceftin suspension PA. cefprozil cefaclor ER Ceftin tabs Antibiotics: Cephalosporins Third Generation cefdinir Suprax chewables cefditoren ceftibuten cefixime capsules and suspension cefpodoxime suspension PA Suprax capsules and suspension cefpodoxime tablets Antibiotics: Macrolides azithromycin QL Eryped 400 mg/5mL suspension clarithromycin ER/XL QL erythromycin base tablets azithromycin suspension QL erythromycin generic products Dificid PA, QL tablet & suspension Zithromax QL. (excluding erythromycin base tabs). clarithromycin tablets & suspension erythromycin ethylsuccinate erythromycin brand products suspension 400 mg/5mL (except Eryped 400 mg/5mL susp). * Note that agents not listed on PDL may be considered non- Preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site.

9 Other browsers like Internet Explorer cause issues with functionality and links between files. Effective Date: January 1, 2022 TennCare Preferred Drug List (PDL) | Page 3. Preferred Drugs Non- Preferred Drugs II. ANTI-INFECTIVES. Antibiotics: Methenamine and Combo all generic combinations of methenamine mandelate all brand combinations of Hiprex . methenamine, phenyl salicylate, methenamine hippurate methenamine, phenyl salicylate, Uroqid Acid #2 . hyoscyamine, atropine, etc. hyoscyamine, atropine, etc. Antibiotics: Miscellaneous Agents for UTI. Monurol QL, PA fosfomycin powder packets PA,QL. Antibiotics: Agents for Diarrhea vancomycin caps PA Aemcolo PA, QL vancomycin solution PA,QL. Firvanq PA, QL Vancocin caps PA. Antibiotics: Aminoglycosides neomycin Neo-Fradin Arikayce QL. Antibiotics: Oral Anti-Tuberculosis ethambutol pyrazinamide Cycloserine Rifadin . isoniazid rifabutin PA Myambutol Rifamate PA.

10 Rifampin Mycobutin PA Rifater PA. Paser Trecator . Priftin . Antibiotics: Oral Lincosamides clindamycin caps clindamycin pediatric solution PA Cleocin Cleocin Pediatric granules PA. Antibiotics: Oral Nitrofurans nitrofurantoin capsules nitrofurantoin suspension PA Furadantin PA Macrodantin . Macrobid . Antibiotics: Oxazolidinones linezolid tabs PA, QL linezolid suspension QL Zyvox PA, QL. Sivextro PA, QL. Antibiotics: Penicillins amoxicillin dicloxacillin all brand penicillins amoxicillin/clavulanic acid XR. amoxicillin/clavulanate penicillin ampicillin Antibiotics: Quinolones ciprofloxacin levofloxacin tabs Baxdela PA, QL Levaquin tabs Cipro tablets levofloxacin solution PA. Cipro suspension PA moxifloxacin PA. ciprofloxacin suspension PA ofloxacin ciprofloxacin ER QL. * Note that agents not listed on PDL may be considered non- Preferred Please use Google Chrome, Microsoft Edge, or Firefox as your browser to access the files on the TennCare site.