Preferred Drug List - Tennessee - 2016 Page 2

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Tier 3
Cyclophosphamide
Purixan
Antivirals HIV/AIDS
Tier 1
didanosine
nevirapine
zidovudine
lamivudine/zidovudine
stavudine
Tier 3
Atripla
SPRx
Norvir
Trizivir
Complera
SPRx
Prezcobix
SPRx
Truvada
Crixivan
Prezista
Tybost
Edurant
Rescriptor
Viracept
Emtriva
Reyataz
Viramune XR
Epzicom
Selzentry
Viread
Evotaz
SPRx
Stribild
SPRx
Vitekta
SPRx
Isentress
Sustiva
Ziagen
Kaletra
Tivicay
SPRx
Lexiva
Triumeq
SPRx
Asthma/COPD
Tier 1
albuterol nebulizer soln
levabuterol nebulizer soln
zafirlukast
budesonide nebulizer susp
montelukast
ipratropium
theophylline
Tier 2
Adcirca
PA
Brovana
Proair Respiclick
Advair Diskus
Combivent Respimat
QVAR
Advair HFA
Daliresp
Serevent Diskus
Anoro Ellipta
Dulera
Spiriva
Arnuity Ellipta
Flovent HFA
Symbicort
Tudorza Pressair
Asmanex
Foradil
Asmanex HFA
Perforomist
Breo Ellipta
ProAir HFA
Tier 3
Aerospan
Proventil HFA
ST
Ventolin HFA
ST
Arcapta Neohaler
Pulmicort Flexhaler
Xopenex HFA
ST
Atrovent HFA
Striverdi Respimat
Cardiovascular Drugs Coagulation Therapy
Tier 1
clopidogrel
enoxaparin
QL
Jantoven
dipyridamole
fondaparinux
QL
warfarin
Tier 2
Brilinta
Eliquis
Xarelto
Effient
Pradaxa
Tier 3
Advate
SPRx
Bebulin
SPRx
Koate-DVI
SPRx
Advate H
SPRx
BeneFIX
SPRx
Kogenate FS
SPRx
Advate L
SPRx
Corifact
SPRx
Monoclate-P
SPRx

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Related forms

Preferred Drug List Preferred Drug List Medical
Form F-11092 - Prior Authorization / Preferred Drug List (pa/pdl) For Growth Hormone Drugs Form F-11092 - Prior Authorization / Preferred Drug List (pa/pdl) For Growth Hormone Drugs Business
Form F-11077 - Prior Authorization / Preferred Drug List For Non-steroidal Anti-inflammatory Drugs Form F-11077 - Prior Authorization / Preferred Drug List For Non-steroidal Anti-inflammatory Drugs Medical
Prior Authorization / Preferred Drug List Prior Authorization / Preferred Drug List Medical
F-00194 - Forwardhealth Prior Authorization/preferred Drug List (pa/pdl) For Antiemetics, Cannabinoids F-00194 - Forwardhealth Prior Authorization/preferred Drug List (pa/pdl) For Antiemetics, Cannabinoids Medical
Form F-11304 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Form F-11304 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Medical
Form F-11035 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Form F-11035 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Medical
Form F-11078 - Prior Authorization / Preferred Drug List (pa/pdl) For Proton Pump Inhibitor (ppi) Capsules And Tablets Form F-11078 - Prior Authorization / Preferred Drug List (pa/pdl) For Proton Pump Inhibitor (ppi) Capsules And Tablets Medical
Prior Authorization / Preferred Drug List Prior Authorization / Preferred Drug List Medical
Form F-00080 - Prior Authorization / Preferred Drug List (pa/pdl) For Symlin Form F-00080 - Prior Authorization / Preferred Drug List (pa/pdl) For Symlin Medical

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