TennCare Attestation List
June 1, 2017
To initiate an attestation request for any agent on the attestation list, the prescribing physician or the prescribing
physician’s agent must call the Magellan Health Services Call Center at 1-866-434-5524. A completed Attestation List Prior
Authorization Fax Form is required for all requests and can be accessed at:
https://tenncare.magellanhealth.com/static/docs/Prior_Authorization_Forms/TennCare_RxLimit_Override_Attestation_Fax
_Form.pdf
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 nonpreferred status on the PDL, clinical criteria, step therapy criteria, and quantity limits.*
ANTI-INFECTIVES
Aminoglycosides
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amikacin (Amikin)
gentamicin (Garamycin)
kanamycin
neomycin (Neo-Fradin)
paromomycin
streptomycin
tobramycin (Bethkis, Nebcin, Tobi)
Cephalosporins, 1st Generation
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
cefadroxil (Duricef)
cefazolin (Ancef)
cephalexin (Keflex)
Cephalosporins, 2nd Generation
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cefaclor (Ceclor)
cefoxitin (Mefoxin)
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cefdinir
cefditoren (Spectracef)
cefixime (Suprax)
cefotaxime (Claforan)
cefpodoxime (Vantin)
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cefprozil (Cefzil)
cefuroxime (Ceftin, Zinacef)
Cephalosporins, 3rd Generation
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ceftazidime (Fortaz, Tazicef)
ceftibuten (Cedax)
ceftizoxime (Cefizox)
ceftriaxone (Rocephin)
Cephalosporins, 4th Generation

cefepime (Maxipime)

telithromycin (Ketek)

clindamycin (Cleocin)


azithromycin (Zithromax, Zmax)
clarithromycin (Biaxin, Biaxin XL)

nitrofurantoin (Furadantin, Macrodantin, Macrobid)

metronidazole HCl (Flagyl)
Ketolides
Lincosamides

lincomycin (Lincocin)
Macrolides


erythromycin (E.E.S., Eryc, Ery-Tab, EryPed)
erythromycin/sulfisoxazole (Eryzole, Pediazole)
Nitrofurans
Nitroimidazoles

tinidazole (Tindamax)
Oxazolidinones

linezolid (Zyvox)
Proprietary & Confidential
© 2017, Magellan Health Services. All Rights Reserved.
ANTI-INFECTIVES
Penicillins
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amoxicillin/potassium clavulanate (Augmentin)
amoxicillin
ampicillin
ampicillin/sulbactam (Unasyn)
dicloxacillin
nafcillin
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ciprofloxacin (Cipro, Cipro XR, Proquin XR)
gemifloxacin (Factive)
levofloxacin (Levaquin)


sulfadiazine
sulfamethoxazole/trimethoprim (Bactrim, Septra)


demeclocycline
doxycycline (Adoxa, Atridox, Dory MPC, Doryx, Monodox,
Oracea, Oraxyl, Periostat, Vibramycin)

vancomycin (Vancocin)

fosfomycin (Monurol)
oxacillin
penicillin G (Bicillin C-R, Bicillin L-A, Permapen)
penicillin V potassium (Veetids)
piperacillin
piperacillin/tazobactam (Zosyn)
ticarcillin/potassium clavulanate (Timentin)
Quinolones



moxifloxacin (Avelox)
norfloxacin (Noroxin)
ofloxacin (Floxin)
Sulfonamides


sulfasalazine (Azulfidine)
trimethoprim
Tetracyclines


minocycline (Arestin, Dynacin, Minocin, Myrac)
tetracycline (Sumycin)
Vancomycin and Derivatives
Miscellaneous Antibiotics

methenamine (Hiprex, Urex)
Antifungals
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amphotericin B (Abelcet, Ambisome, Amphocin, Amphotec)
anidulafungin (Cancidas)
caspofungin (Eraxis)
fluconazole (Diflucan)
flucytosine (Ancobon)
griseofulvin (Fulvicin U/F, Gris-Peg, Grifulvin V)
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albendazole (Albenza)
artemether/lumefantrine (Coartem)
atovaquone/proguanil (Malarone)
atovaquone (Mepron)
chloroquine (Aralen)
dapsone
iodoquinol (Yodoxin)
ivermectin (Stromectol)
mebendazole (Emverm, Vermox)

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acyclovir (Zovirax)
famciclovir (Famvir)
oseltamivir (Tamiflu)
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isavuconazonium (Cresemba)
itraconazole (Sporanox)
micafungin (Mycamine)
miconazole (Monistat)
posaconazole (Noxafil)
voriconazole (Vfend)
Antiparasitics
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mefloquine
nitazoxanide (Alinia)
paromomycin
pentamidine (Nebupent, Pentam 300)
praziquantel (Biltricide)
primaquine
pyrantel (Pin-X, Reese Pinworm)
pyrimethamine (Daraprim)
quinine (Qualaquin)
Antivirals

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
penciclovir (Denavir)
valacyclovir (Valtrex)
zanamivir (Relenza)
Effective Date: June 1, 2017
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CARDIOVASCULAR
Antianginal Agents, Miscellaneous
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ranolazine (Ranexa)
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adenosine (Adenocard)
amiodarone (Cordarone, Pacerone)
bretylium
disopyramide IR/SA (Norpace/Norpace CR)
dofetilide (Tikosyn)
dronedarone (Multaq)
flecainide (Tambocor)
ibutilide (Corvert)

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apixaban (Eliquis)
dalteparin (Fragmin)
dabigatran etexilate (Pradaxa)
edoxaban (Savaysa)
enoxaparin (Lovenox)


aminocaproic acid (Amicar)
aprotinin (Trasylol)

digoxin (Lanoxin)

ethacrynic acid (Edecrin)

patiromer (Veltassa)

perindopril (Aceon)
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azilsartan (Edarbi)
candesartan (Atacand)
candesartan/HCTZ (Atacand HCT)
eprosartan (Teveten)
eprosartan/HCTZ (Teveten HCT)
irbesartan (Avapro)
irbesartan/HCTZ (Avalide)


aliskiren/valsartan (Valturna)
aliskiren (Tekturna)

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
clonidine (Catapres, Catapres TTS, Nexiclon XR)
guanabenz
guanfacine (Tenex)
methyldopa (Aldomet)


diazoxide (Hyperstat I.V.)
fenoldopam mesylate (Corlopam)

ivabradine (Corlanor)

eltrombopag (Promacta)

metyrosine (Demser)
Antiarrhythmics
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lidocaine (Xylocaine)
mexiletine (Mexitil)
procainamide
propafenone (Rythmol/Rythmol SR)
quinidine gluconate
quinidine sulfate (Quinidex)
sotalol/sotalol af (Betapace/Betapace AF)
Anticoagulants
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fondaparinux (Arixtra)
heparin (Heparin)
rivaroxaban (Xarelto)
tinzaparin (Innohep)
warfarin (Coumadin, Jantoven)
Antifibrinolytics

tranexamic acid (Cyklokapron, Lysteda)
Cardiac Glycosides
Diuretics, Loop
Hyperkalemia Agents
Hypotensives, ACE Inhibitors
Hypotensives, Angiotensin Receptor Blockers
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olmesartan (Benicar)
olmesartan/HCTZ (Benicar HCT)
telmisartan (Micardis)
telmisartan/HCTZ (Micardis HCT)
valsartan (Diovan)
valsartan/HCTZ (Diovan HCT)
Hypotensives, Direct Renin Inhibitors

aliskiren/HCTZ (Tekturna HC)
Hypotensives, Sympatholytics
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
methyldopa/HCTZ
methyldopate
reserpine
Hypotensives, Vasodilators


hydralazine HCl (Apresoline)
minoxidil (Minoxidil)
Miscellaneous, Cardiovascular

ecallantide (Kalbitor)
Oral Thrombopoietic Agonists
Pheochromocytoma Agents
Effective Date: June 1, 2017
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CARDIOVASCULAR
Platelet Aggregation Inhibitors/Intermittent Claudication
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abciximab (ReoPro)
aspirin (Durlaza)
aspirin/dipyridamole (Aggrenox)
cilostazol (Pletal)
clopidogrel (Plavix)
dipyridamole (Persantine)
eptifibatide (Integrilin)

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ambrisentan (Letairis)
bosentan (Tracleer)
epoprostenol (Flolan)
iloprost (Ventavis)
macitentan (Opsumit)



amyl nitrite
isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil)
isosorbide mononitrate (Imdur, Monoket)

midodrine
pentoxifylline (Trental)
prasugrel (Effient)
ticagrelor (Brilinta)
ticlopidine (Ticlid)
tirofiban (Aggrastat)
vorapaxar (Zontivity)
Pulmonary Arterial Hypertension Agents

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riociguat (Adempas)
selexipag (Uptravi)
sildenafil (Revatio)
tadalafil (Adcirca)
treprostinil (Remodulin, Tyvaso, Orenitram)
Vasodilators

nitroglycerin (Minitran, Nitrek, Nitro-Bid, Nitro-Dur,
Nitrolingual, NitroQuick, Nitrostat, Nitrotab, Nitro-Time,
Nitromist)
Vasopressors
CNS
Anticonvulsants
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brivaracetam (Briviact)
carbamazepine (Tegretol, Tegretol XR)
clobazam (Onfi)
clonazepam (Klonopin)
clonazepam ODT (Klonopin Wafer)
diazepam rectal gel (Diastat)
divalproex sodium (Depakote, Depakote ER, Depakote
Sprinkles)
eslicarbazepine (Aptiom)
ethosuximide (Zarontin)
ethotoin (Peganone)
ezogabine (Potiga)
felbamate (Felbatol)
fosphenytoin (Cerebyx)
gabapentin (Neurontin)
lamotrigine (Lamictal, Lamictal XR)
lamotrigine ODT (Lamictal ODT)
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levetiracetam (Keppra, Keppra XR)
lacosamide (Vimpat)
methsuximide (Celontin)
oxcarbazepine (Trileptal, Oxtellar XR)
perampanel (Fycompa)
phenobarbital
phenytoin (Dilantin, Dilantin Kapseals, Phenytek)
pregabalin (Lyrica)
primidone (Mysoline)
rufinamide (Banzel)
tiagabine (Gabitril)
topiramate (Topamax, Trokendi XR, Qudexy XR)
valproate sodium (Depacon)
valproic acid (Depakene, Stavzor)
vigabatrin (Sabril)
zonisamide (Zonegran)
Antidepressants, New Generation



bupropion HCl
(Wellbutrin, Wellbutrin SR, Wellbutrin XL)
maprotiline
mirtazapine (Remeron, Remeron SolTab)

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citalopram (Celexa)
desvenlafaxine (Pristiq, Khedezla)
duloxetine (Cymbalta, Irenka)
escitalopram (Lexapro)
fluoxetine (Prozac, Prozac Weekly, Sarafem)
fluvoxamine



nefazodone (Serzone)
trazodone (Oleptro)
vilazodone (Viibryd)
Antidepressants, SNRIs, and SSRIs
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milnacipran (Savella)
paroxetine (Paxil, Paxil CR, Pexeva)
sertraline HCl (Zoloft)
venlafaxine (Effexor XR)
vortioxetine (Trintellix)
Effective Date: June 1, 2017
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CNS
Antiparkinson Agents
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apomorphine (Apokyn)
bromocriptine (Parlodel)
carbidopa/levodopa (Sinemet, Sinemet CR, Rytary)
carbidopa/levodopa/entacapone (Stalevo)
pramipexole (Mirapex, Mirapex ER)

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aripiprazole (Abilify, Abilify Discmelt, Abilify Maintena,
Aristada)
asenapine (Saphris)
brexpiprazole (Rexulti)
cariprazine (Vraylar)
clozapine (Clozaril, FazaClo)
iloperidone (Fanapt)
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chlorpromazine (Thorazine)
droperidol (Inapsine)
fluphenazine
haloperidol (Haldol)
loxapine (Loxitane)
molindone (Moban)


isocarboxazide (Marplan)
phenelzine (Nardil)


lithium carbonate (Lithobid)
lithium carbonate ER

olanzapine/fluoxetine (Symbyax)

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amitriptyline
amoxapine
clomipramine (Anafranil)
desipramine (Norpramin)
doxepin
entacapone (Comtan)
rasagiline (Azilect)
ropinirole (Requip, Requip XL)
selegiline (Zelapar, Eldepryl)
tolcapone (Tasmar)
Antipsychotics, Atypical
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lurasidone (Latuda)
olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv)
paliperidone (Invega, Invega Sustenna, Invega Trinza)
pimavanserin (Nuplazid)
quetiapine (Seroquel, Seroquel XR)
risperidone (Risperdal, Risperdal Consta)
ziprasidone (Geodon)
Antipsychotics, Typical
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perphenazine
pimozide (Orap)
prochlorperazine (Compazine)
thioridazine
thiothixene (Navane)
trifluoperazine
MAOIs


selegiline (Eldepryl, Emsam, Zelapar)
tranylcypromine (Parnate)
Mood Stabilizers

lithium citrate
SSRI/Antipsychotic Combos
TCAs

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

imipramine (Tofranil, Tofranil-PM)
nortriptyline (Pamelor)
protriptyline (Vivactil)
trimipramine (Surmontil)
ENDOCRINE AGENTS
Glucocorticoids, Oral
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cortisone
betamethasone solution (Celestone)
budesonide (Entocort EC)
dexamethasone (Dexpak, Dekpak Jr.)
hydrocortisone (Cortef)
methylprednisolone (Medrol)
prednisolone (Millipred, Orapred, Pediapred, Prelone)
prednisone
GASTROINTESTINAL AGENTS
Pancreatic Enzymes





6,000 L/19,000 P/30,000 A (Creon L 6,000 units)
12,000 L/38,000 P/60,000 A (Creon L 12,000 units)
24,000 L/76,000 P/120,000 A (Creon L 24,000 units)
36,000 L/114,000 P/180,000 A (Creon L 36,000 units)
Pancreaze


dolasetron (Anzemet)
granisetron (Kytril, Sancuso)

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
Pertyze
Ultresa
Viokace
ZenPep
Anti-Emetics

ondansetron (Zofran, Zofran ODT, Zofran solution, Zuplenz)
Effective Date: June 1, 2017
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IMMUNOGOLOGIC AGENTS
Immunomodulators
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anakinra (Kineret)
adalimumab (Humira)
brodalumab (Siliq)
etanercept (Enbrel)
certolizumab pegol (Cimzia)

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Gammagard
Gamunex-C

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
Daclizumab (Zinbryta)
dimethyl fumarate (Tecfidera)
fingolimod (Gilenya)
glatiramer acetate (Copaxone)interferon beta-1a (Avonex,
Avonex Administration Pack, Rebif)

epinephrine (TwinJect, EpiPen, EpiPen Jr., Adrenaclick,
Auvi-Q®)
golimumab (Simponi)
tocilizumab (Actemra)
tofacitinib (Xeljanz)
ustekinumab (Stelara)
Immune Globulins


Hizentra
Vivaglobin
Multiple Sclerosis



interferon beta-1b (Betaseron, Extavia)
peginterferon beta-1a (Plegridy)
teriflunomide (Aubagio)
MISCELLANEOUS

naloxone (Evzio, Narcan)
OPHTHALMICS
Antibiotic/Corticoid Combinations


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
gentamicin/prednisolone (Pred-G)
neomycin/bacitracin/polymyxin/hydrocortisone (Cortisporin)
neomycin/polymyxin B/dexamethasone (Maxitrol)
neomycin/polymyxin B/hydrocortisone (Cortisporin)

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
azithromycin (AzaSite)
bacitracin
bacitracin/polymyxin B (AK-Poly-BAC, Polycin-B, Polysporin)
besifloxacin (Besivance)
chloramphenicol (Chloromycetin)
ciprofloxacin (Ciloxan)
erythromycin (Ilotycin, Romycin)
gatifloxacin (Zymar)
gentamicin (Garamycin, Genoptic, Gentak, Gentasol)

natamycin (Natacyn)

ganciclovir (Zirgan)



neomycin/polymyxin B/prednisolone (Poly-Pred)
tobramycin/dexamethasone (Tobradex ointment)
tobramycin/loteprednol (Zylet)
Antibiotics

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
levofloxacin (Iquix, Quixin)
moxifloxacin (Vigamox)
neomycin/ polymyxin B/bacitracin (Neosporin)
neomycin/polymyxin B/gramicidin (Neosporin Eye Drops)
ofloxacin (Ocuflox)
polymyxin B/trimethoprim (Polytrim)
sulfacetamide sodium (Bleph-10)
tobramycin (AK-Tob, Tobrasol, Tobrex)
Antifungals
Antivirals

trifluridine (Viroptic)
Anti-inflammatory Agents

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
bromfenac (Xibrom)
diclofenac (Voltaren)
fluorometholone (Flarex, FML Forte, FML Liquifilm, FML S.O.P.)
flurbiprofen (Ocufen)
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
acetylcholine chloride (Miochol-E)
apraclonidine (Iopidine)
betaxolol (Betoptic-S)
bimatoprost (Lumigan)
brimonidine (Alphagan P)
brinzolamide (Azopt)
carbachol (Isopto Carbachol, Miostat)
carteolol




ketorolac (Acular, Acular LS, Acular PF)
loteprednol (Alrex, Lotemax)
nepafenac (Nevanac)
rimexolone (Vexol)
Miotics/IOP Reducers
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
dorzolamide (Trusopt)
latanoprost (Xalatan)
levobunolol (Betagan)
metipranolol (OptiPranolol)
pilocarpine (Isopto Carpine, Pilopine HS, Piloptic)
timolol (Betimol, Istalol, Timoptic, Timoptic-XE GFS)
timolol/dorzolamide (Cosopt)
travoprost (Travatan Z)
Effective Date: June 1, 2017
TennCare Attestation List
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OPHTHALMICS
Sulfonamides


sodium sulfacetamide/prednisolone (Blephamide S.O.P.)
sulfacetamide sodium (Bleph-10, Ocusulf-10, Sulfac,
Sulfamide)
OTICS
Antibiotics/Anti-inflammatory Agents



ciprofloxacin/dexamethasone (Ciprodex)

ciprofloxacin/hydrocortisone (Cipro HC Otic)

neomycin/colistin/hydrocortisone/thonzonium (Cortisporin-TC 
Otic)
neomycin/colistin/hydrocortisone (Coly-Mycin S)
neomycin/polymyxin B/hydrocortisone (Cortisporin Otic)
ofloxacin
RESPIRATORY
Anticholinergics




aclidinium (Tudorza)
glycopyrrolate (Seebri Neohaler)
indacaterol/glycopyrrolate (Utibron Neohaler)
ipratropium (Atrovent HFA)


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

albuterol (Accuneb, ProAir HFA, ProAir RespiClick, Proventil
HFA, Ventolin HFA)

albuterol/ipratropium (Combivent, Combivent Respimat,
Duoneb)




formoterol ( Perforomist)
indacaterol (Arcapta)
metaproterenol
olodaterol (Striverdi)


budesonide/formoterol (Symbicort)
fluticasone/salmeterol (Advair)



beclomethasone (QVAR)
budesonide (Pulmicort Respules, Pulmicort Flexhaler)
flunisolide (Aerospan)
tiotropium (Spiriva)
tiotropium/olodaterol (Stiolto Respimat)
umeclidinium (Incruse Ellipta)
umeclidinium/vilanterol (Anoro Ellipta)
Beta Agonist: Short-Acting

levalbuterol (Xopenex, Xopenex HFA)
Beta Agonist/Anticholinergic Combinations
Beta Agonists: Other



pirbuterol (Maxair Autohaler)
salmeterol (Serevent)
terbutaline (Brethine)
Beta Agonist/Corticosteroid Combinations


fluticasone/vilanterol (Breo Ellipta)
mometasone/formoterol (Dulera)
Inhaled Corticosteroids


fluticasone (Flovent Diskus, Flovent HFA, Arnuity Ellipta)
mometasone (Asmanex Twisthaler)
Miscellaneous

pirfenidone (Esbriet)

omalizumab (Xolair)

acetylcysteine
Monoclonal Antibody
Mucolytics

dornase alfa (Pulmozyme)
Xanthines





aminophylline
caffeine citrate (Cafcit)
caffeine/sodium benzoate
dyphylline (Dylix, Lufyllin)
theophylline anhydrous (Theo-24, Theochron, Uniphyl)
VITAMINS AND ELECTROLYTES
Potassium Supplements (Rx ONLY)

potassium chloride (Epiklor, Kaon-CL, Klor-Con, K-tabs,
K-Vescent, Micro K)

potassium chloride, microencapsulated (Klor-Con M)
Effective Date: June 1, 2017
TennCare Attestation List
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