Preferred Drug List - Tennessee - 2016 Page 6

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Diabetes Diabetic Drugs
Tier 1
glimepiride
glyburide/metformin
pioglitazone
glipizide
metformin
pioglitazone/glimepiride
glipizide ext-rel
metformin ext-rel
pioglitazone/metformin
glyburide
nateglinide
repaglinide
Tier 2
Bydureon
Invokamet
Jentadueto
Byetta
Invokana
Tradjenta
Farxiga
Janumet
Victoza
Glucagon emergency kit
Janumet XR
V-Go
Glyxambi
Januvia
Xigduo XR
Diabetes Insulin
Tier 2
BD syringes
Novolin
Toujeo
Lantus vials/pens
Novolog
Levemir vials/pens
Novolog Mix
Tier 3
Afrezza
Humalog
ST
Humulin Kwikpen
ST
Apidra
ST
Humulin
ST
Eye/Ear
Tier 1
bimatoprost 0.03%
gentamicin ophthalmic
polymyxin B/bacitracin/neomycin ophth
brimonidine
ketotifen
polymyxin B/neomycin/hydrocortisone otic
bromfenac
latanoprost
polymyxin B/trimethoprim ophthalmic
carteolol solution
naphazoline
timolol maleate
ciprofloxacin otic
ofloxacin
tobramycin ophthalmic
diclofenac sodium ophthalmic
olopatadine
travoprost
Tier 2
Alrex
Lumigan
Tobradex Ointment
Azopt
Moxeza
TobraDex ST
Bepreve
Pataday
Travatan Z
Betimol
Patanol
Vigamox
Ciprodex
Pazeo
Zylet
Durezol
Prolensa
Lotemax
Restasis
Tier 3
Rescula
ST
Xalatan
ST
Simbrinza
Zioptan
ST
Gastrointestinal Agents
Tier 1
cimetidine
lansoprazole
ondansetron
diphenoxylate/atropine
metoclopramide
pantoprazole
famotidine
Nexium
promethazine
granisetron
nizatidine
ranitidine
lactulose
omeprazole
sulfasalazine

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Preferred Drug List Preferred Drug List Medical
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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
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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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