Preferred Drug List - Tennessee - 2016 Page 8

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Tier 2
Lo Loestrin FE
Tier 3
Ortho Tri-Cyclen Lo
Oral Contraceptives Other
Tier 1
all generic extended-cycle
Camila
Jolivette
all generic progestin
Camrese Lo
Xulane
Amethia Lo
Errin
Tier 2
NuvaRing
Osteoporosis/Bone Diseases
Tier 1
alendronate
calcitonin-salmon
raloxifene
alendronate plus OTC Vitamin D
ibandronate
risedronate
Tier 2
Forteo
SPRx
Tier 3
Actonel
Atelvia
Rheumatology
Tier 1
celecoxib
indomethacin
nabumetone
diclofenac
ketoprofen
naproxen
diclofenac/misoprostol
leflunomide
naproxen sodium
etodolac
meloxicam
piroxicam
ibuprofen
methotrexate
sulindac
Tier 3
Actemra SQ
PA ST SPRx
Humira
PA SPRx
Xeljanz
PA ST SPRx
Orencia SQ
PA ST SPRx
Enbrel
PA SPRx
Thyroid Medications
Tier 1
levothyroxine
Tier 3
Armour Thyroid
Synthroid
Urologic Disorders
Tier 1
alfuzosin
oxybutynin ext-rel
tolterodine
doxazosin
prazosin
trospium
finasteride
tamsulosin
oxybutynin
terazosin
Tier 2
Enablex
Myrbetriq
Gelnique
Vesicare
Tier 3
Avodart
Jalyn
Detrol LA
Rapaflo

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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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