Preferred Drug List - Tennessee - 2016 Page 3

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Advate M
SPRx
Fragmin
QL
Profilnine
SPRx
Advate UH
SPRx
Helixate FS
SPRx
Recombinate
SPRx
Alphanate
SPRx
Hemofil-P
SPRx
Tretten
SPRx
Alphanate SD
SPRx
Humate-P
SPRx
Wilate
SPRx
Cardiovascular Drugs High Blood Pressure
Tier 1
amlodipine
enalapril
metoprolol
amlodipine/benazepril
enalapril/hctz
metoprolol ext-rel
amlodipine/valsartan
eplerenone
nifedipine ext-rel
amlodipine/valsartan/hctz
eprosartan
propranolol
atenolol
fosinopril
quinapril
benazepril
fosinopril/hctz
quinapril/hctz
benazepril/hctz
furosemide
ramipril
bisoprolol
guanfacine
spironolactone
bisoprolol/hctz
hydrochlorothiazide
telmisartan
bumetanide
indapamide
telmisartan/amlodipine
candesartan/hctz
irbesartan
telmisartan/hctz
captopril
irbesartan/hctz
triamterene/hctz
captopril/hctz
lisinopril
valsartan
carvedilol
lisinopril/hctz
valsartan/hctz
clonidine
losartan
verapamil ext-rel
diltiazem ext-rel
losartan/hctz
Tier 2
Azor
Benicar HCT
Coreg CR
Benicar
Bystolic
Tribenzor
Tier 3
Atacand
Edarbyclor
ST
Teveten HCT
ST
Diovan
Micardis
Twynsta
Diovan HCT
Micardis HCT
Edarbi
ST
Teveten
ST
Cardiovascular Drugs High Cholesterol
Tier 1
atorvastatin
fluvastatin
pravastatin
cholestyramine
gemfibrozil
simvastatin
fenofibrate
lovastatin
fenofibric acid
niacin ext-rel
Tier 2
Crestor
Simcor
Zetia
Liptruzet
Vytorin
Tier 3
Altoprev
Livalo
Trilipix
Lescol XL
Niaspan
Welchol
Cardiovascular Drugs Other
Tier 1
amiodarone
propafenone
sotalol
digoxin
quinidine

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Preferred Drug List Preferred Drug List Medical
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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
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