Generic Label Name Drug Strength Dosage Form Example Product (s) MME/Unit ACETAMINOPHEN WITH CODEINE

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1 STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE 3 Great Circle Road NASHVILLE, TENNESSEE This notice is to advise you of information regarding the TennCare Pharmacy Program. Please forward or copy the information in this notice to all providers who may be affected by these processing changes. This notice is being sent to notify you of changes for the TennCare pharmacy program. We encourage you to read this notice thoroughly and contact Magellan s Pharmacy Support Center ( ) should you have additional questions. Effective September, 17, TennCare will begin implementation of a Morphine Milligram Equivalent (MME) edit. The MME edit will utilize morphine equivalent dosing for all agents in the Short-Acting Narcotic and Long-Acting Narcotic Classes of the PDL. The edit will accumulate MME for all short-acting narcotics and longacting narcotics a patient is currently receiving and will deny claims for patients prescribed a cumulative daily MME of greater than 0 MME. Prior authorization will be required for patients exceeding the daily MME limit. The chart below can be used as a reference for MME per unit. In addition, the following products, both brand and generic, will have a change in the daily quantity limit effective 9//17: hydrocodone/apap: 6/day hydrocodone/ibuprofen: 6/day oxycodone IR, 7., mg: 8/day oxycodone IR 1,, 30 mg: 4/day oxycodone/apap: 6/day oxycodone/ibuprofen: 6/day oxymorphone: 4/day Generic Label Name Drug Strength Dosage Form Example Product (s) MME/Unit ACETAMINOPHEN WITH CODEINE Suspension APAP-CODEINE, TYLENOL with 1-12MG/ML CODEINE /ML 0.36 BUPRENORPHINE BUPRENORPHINE HCL /12.ML MG-1MG MG-30MG MG-60MG 9 MCG/HR PATCH BUPRENORPHINE, BUTRANS MCG/HR 94. MCG/HR 126 MCG/HR 22 1 MCG/HR MCG FILM BELBUCA 2.2 MCG MCG 9 40 MCG MCG MCG MCG 27

2 CODEINE SULFATE FENTANYL HYDROCODONE BITARTRATE HYDROCODONE/ACETAMINOPHEN HYDROCODONE/IBUPROFEN HYDROMORPHONE HCL 1 MG CODEINE SULFATE 30 MG MG 9 12 MCG/HR PATCH DURAGESIC PATCH, FENTANYL PATCH MCG/HR MCG/HR 270 0MCG/HR MCG/HR 40 7MCG/HR MCG/HR MCG/HR 7 MG HYSINGLA 80 MG 80 1 MG 1 MG CAPSULE ZOHYDRO ER 1 MG 1 MG 0 MG MG NORCO, HYDROCODONE-APAP, 2. MG-32MG VICODIN, LORCET, LORTAB, XODOL MG-300MG MG MG 7. MG-32MG MG-300MG 2.-8/ ML SOLUTION HYDROCODONE-APAP, LORTAB, ZAMICET MG/ ML / /1 ML /1 ML / MG REPREXAIN, HYDROCODONE-IBU 2. MG-0MG MG-0MG 3 MG SUPPOSITORY HYDROMORPHONE, DILAUDID, EXALGO ER 12 1 MG/ML SOLUTION 4 2 MG 8 4 MG 16 8 MG MG MG 128 IBUPROFEN/OXYCODONE HCL 400MG-MG OXYCODONE-IBUPROFEN

3 LEVORPHANOL TARTRATE 2 MG LEVORPHANOL 22 MEPERIDINE HCL 0 MG MEPERIDINE METHADONE HCL MORPHINE SULFATE MORPHINE SULFATE/NALTREXONE OXYCODONE HCL 0 MG 0 MG/ ML SOLUTION 1 MG DOLOPHINE, METHADONE, METHADOSE MG MG DISPR 3 MG/ ML SOLUTION 8 MG/ML 80 MG SUPPOSITORY MORPHINE IR, MORPHINE ER, AVINZA, KADIAN MG MG MG/ ML SOLUTION 2 MG/ ML 4 0 MG/ML 1 MG 1 0 MG 0 MG CAPSULE MG 4 MG 4 0 MG 0 7 MG 7 80 MG MG 90 1 MG 1 0 MG 0 MG-0.8MG CAPSULE EMBEDA ER 30MG-1.2MG 30 0 MG-2 MG 0 60MG-2.4MG 60 80MG-3.2MG 80 0MG-4MG 0 MG/ ML SOLUTION OXYCODONE, OXAYDO, ROXICODONE, OXYCONTIN 1. MG/ML 30 MG MG 11.2 MG 1 1 MG 22. MG MG 4

4 OXYCODONE HCL/ACETAMINOPHEN OXYCODONE MYRISTATE OXYMORPHONE HCL TAPENTADOL HCL TRAMADOL HCL 40 MG MG MG 1 MG CAPSULE 7. OXYCODONE-APAP, ENDOCET, -32/ ML SOLUTION PRIMLEV, PERCOCET MG 3.7 MG-32MG 7. MG-300MG MG MG 11.2 MG-32MG 1 MG-300MG 1 9 MG CAPSULE XTAMPZA ER MG.2 18 MG MG MG 4 MG OXYMORPHONE, OPANA, OPANA ER 1 7. MG 22. MG 30 1 MG 4 MG MG MG 1 0 MG NUCYNTA, NUCYNTA ER 7 MG 30 0 MG 40 MG 60 0 MG 80 MG 0 0 MG ULTRAM, TRAMADOL, TRAMDOL ER, CONZIP 0 MG 0 MG 300 MG 30 0 MG CAPSULE MG 1 0 MG 300 MG 30 TRAMADOL HCL/ACETAMINOPHEN MG TRAMADOL-APAP 3.7 Important Phone Numbers: TennCare Family Assistance Service Center TennCare Fraud and Abuse Hotline TennCare Pharmacy Program Fax Magellan Pharmacy Support Center Magellan Clinical Call Center Magellan Call Center Fax Helpful TennCare Internet Links: Magellan: TennCare website: Please visit the Magellan TennCare website regularly to stay up-to-date on changes to the pharmacy program.

5 For additional information or updated payer specifications, please visit the Magellan website at: then click on pharmacy and choose program information from the drop down menu. Please forward or copy the information in this notice to all providers who may be affected by these processing changes. Thank you for your valued participation in the TennCare program. -Page of - 08/07/17

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