Preferred Drug List - Tennessee - 2016 Page 4

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Tier 3
Corlanor
Central Nervous System Anxiety/Depression
Tier 1
alprazolam
diazepam
paroxetine
bupropion
duloxetine
paroxetine ext-rel
bupropion ext-rel
escitalopram
sertraline
chlordiazepoxide
fluoxetine
venlafaxine
citalopram
lorazepam
venlafaxine ext-rel
clorazepate
mirtazapine
Tier 2
Pristiq ER
Tier 3
Cymbalta
Central Nervous System Attention Deficit Disorder
Tier 1
Adderall XR
dextroamphetamine ext-rel
methylphenidate
clonidine ext-rel
guanfacine ext-rel
Tier 2
Quillivant XR
Strattera
Vyvanse
Tier 3
Daytrana
Focalin XR
Intuniv
Central Nervous System Migraine
Tier 1
almotriptan
QL
naratriptan
QL
sumatriptan
QL
butalbital compound
rizatriptan
QL
zolmitriptan
QL
Tier 2
Relpax
QL
Tier 3
Sumavel Dosepro
QL
Central Nervous System Seizure Disorders
Tier 1
carbamazepine
gabapentin
phenytoin
clonazepam
lamotrigine
primidone
divalproex
levetiracetam
topiramate
divalproex ext-rel
oxcarbazepine
valproic acid
felbamate
phenobarbital
zonisamide
Tier 2
Dilantin
Qudexy XR
Vimpat
Oxtellar XR
Trokendi XR
Tier 3
Aptiom
Onfi
Potiga
Fycompa
Central Nervous System Sleep Agents
Tier 1
eszopiclone
zolpidem
zolpidem ext-rel

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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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