Preferred Drug List - Tennessee - 2016 Page 5

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zaleplon
Tier 3
Rozerem
Central Nervous System Other
Tier 1
amantadine
gabapentin
pramipexole
aripiprazole
PA
galantamine
quetiapine
PA
benztropine
Glatopa
SPRx
risperidone
PA
carbidopa/levodopa
memantine
rivastigmine
modafinil
PA
carbidopa/levodopa/entacapone
ropinirole
clozapine
PA
olanzapine
PA
ziprasidone
PA
donepezil
olanzapine/fluoxetine
PA
Tier 2
Ampyra
PA SPRx
Latuda
PA
Savella
Avonex
SPRx
Lyrica
Seroquel XR
PA
Copaxone
SPRx
Namenda XR
Tecfidera
PA SPRx
Exelon Patch
Nuvigil
PA
Gilenya
PA SPRx
Rebif
SPRx
Tier 3
Abilify
PA
Fanapt
PA
Namzaric
Aubagio
PA SPRx
Fazaclo
PA
Nuedexta
Betaseron
ST SPRx
Geodon
PA
Plegridy
SPRx
Extavia
SPRx
Invega
PA
Saphris
PA
Dermatology
Tier 1
adapalene
desoximetasone
mometasone
Amnesteem
econazole
mupirocin
betamethasone
erythromycin topical
nystatin
Claravis
fluocinonide
nystatin/triamcinolone
clindamycin/benzoyl peroxide
fluticasone
Retin-A Micro
PA
clindamycin topical
hydrocortisone 2.5%
silver sulfadiazine
clobetasol
ketoconazole
tacrolimus
clotrimazole/betamethasone
lindane
triamcinolone
desonide
metronidazole topical
Tier 2
Acanya
Elidel
Atralin
Epiduo
Tier 3
Carac
Differin
Picato
Dermasorb HC
Fabior
PA
Tazorac
PA
Dermasorb TA
Finacea
Zyclara
Diabetes Blood Glucose Monitoring
Tier 2
Bayer Contour/Breeze2 products
QL
Lifescan OneTouch products
QL
Tier 3
Abbott Freestyle products
QL ST
Roche Accu-Chek products
QL ST

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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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