STATE OF TENNESSEE DIVISION OF TENNCARE 310 Great Circle Road NASHVILLE, TENNESSEE 37243 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 (866-434-5520) should you have additional questions. PREFERRED DRUG LIST (PDL) FOR TENNCARE EFFECTIVE 5-1-19 TennCare is continuing the process of reviewing all covered drug classes. Changes to the PDL may occur as new classes are reviewed and previously reviewed classes are revisited. As a result of these changes, some medications your patients are now taking may be considered non-preferred agents in the future. Please inform your patients who are on these medications that switching to preferred products will decrease delays in receiving their medications. We encourage you to share this information with other TennCare providers. The individual changes to the PDL are listed below. A copy of the new PDL will be posted May 1, 2019 for more details on clinical criteria, please visit: https://tenncare.magellanhealth.com Below is a summary of the PDL changes that will be effective May 1, 2019. All other agents in these classes will retain their current PDL listing. The following agents available in specific package sizes (e.g. - bottles, tubes, pumps, etc.) will have a quantity limit added: Changes to quantity limits (QL) for the preferred drug list (PDL) effective May 1, 2019: ACANYA GEL PUMP ACULAR LS 0.4% OPHTH SOL ACUVAIL 0.45% OPHTH SOLUTION ACZONE 5% GEL ACZONE 7.5% GEL PUMP ADAPALENE 0.1% CREAM ADAPALENE 0.1% GEL ADAPALENE 0.3% GEL ADAPALENE 0.3% GEL PUMP ADAPALENE-BNZYL PEROX 0.1-2.5% AK-POLY-BAC EYE OINTMENT ALA-SCALP 2% LOTION ALCLOMETASONE DIPR 0.05% OINT ALCLOMETASONE DIPRO 0.05% CRM ALOCRIL 2% EYE DROPS ALOMIDE 0.1% EYE DROPS ALPHAGAN P 0.1% DROPS ALPHAGAN P 0.15% EYE DROPS ALREX 0.2% EYE DROPS ALTRENO 0.05% LOTION AMCINONIDE 0.1% CREAM AMMONIUM LACTATE 12% CREAM AMMONIUM LACTATE 12% LOTION ANALPRAM HC 2.5%-1% CREAM ANALPRAM HC 2.5%-1% LOTION ANDROGEL 1%(2.5G) GEL PACKET ANDROGEL 1%(5G) GEL PACKET ANDROGEL 1.62% GEL PUMP ANDROGEL 1.62%(1.25G) GEL PCKT ANDROGEL 1.62%(2.5G) GEL PCKT ANUSOL-HC 2.5% CREAM APEXICON E 0.05% CREAM APRACLONIDINE HCL 0.5% DROPS ATOPICLAIR CREAM ATRALIN 0.05% GEL ATROPINE 1% EYE DROPS ATROPINE 1% EYE OINTMENT AVAGE 0.1% CREAM AVAR 9.5%-5% FOAM AVAR LS 10%-2% FOAM AVAR-E EMOLLIENT CREAM AVAR-E LS CREAM AVC 15% CREAM AVITA 0.025% CREAM -Page 1 of 5-
AVITA 0.025% GEL CLEOCIN T 1% LOTION AZASITE 1% EYE DROPS CLIND PH-BENZOYL PEROX 1.2-5% AZELASTINE HCL 0.05% DROPS CLINDAGEL 1% GEL AZELEX 20% CREAM CLINDAMYCIN PHOSPHATE 1% FOAM BACITRACIN 500 UNIT/GM OPHTH CLINDAMYCIN-BENZOYL PEROX 1-5% BACTROBAN 2% CREAM CLINDA-TRETINOIN 1.2 %-0.025 % BENSAL HP 3% OINTMENT CLINDESSE 2% VAGINAL CREAM BENZACLIN GEL 50G PUMP CLOBETASOL 0.05% CREAM BENZAMYCIN GEL CLOBETASOL 0.05% GEL BENZOYL PEROXIDE 5.3% FOAM CLOBETASOL 0.05% OINTMENT BENZOYL PEROXIDE 9.8% FOAM CLOBETASOL 0.05% TOPICAL LOTN BEPREVE 1.5% EYE DROPS CLOBETASOL EMOLLIENT 0.05% CRM BESIVANCE 0.6% SUSP CLOBETASOL EMULSION 0.05% FOAM BETAMETHASONE DP 0.05% CRM CLOBETASOL PROP 0.05% FOAM BETAMETHASONE DP 0.05% LOT CLOCORTOLONE PIVALATE 0.1% CRM BETAMETHASONE DP 0.05% OINT CLODAN 0.05% KIT BETAMETHASONE DP AUG 0.05% CRM CLOTRIMAZOLE 1% CREAM BETAMETHASONE DP AUG 0.05% GEL CLOTRIMAZOLE-BETAMETHASONE CRM BETAMETHASONE DP AUG 0.05% LOT CLOTRIMAZOLE-BETAMETHASONE LOT BETAMETHASONE DP AUG 0.05% OIN COLY-MYCIN S OTIC SUSP DROP BETAMETHASONE VA 0.1% CREAM COMBIGAN 0.2%-0.5% EYE DROPS BETAMETHASONE VA 0.1% LOTION CONDYLOX 0.5% GEL BETAMETHASONE VALER 0.1% OINTM CORTIFOAM 10% AEROSOL BETAMETHASONE VALER 0.12% FOAM CRINONE 4% GEL BETAXOLOL HCL 0.5% EYE DROP CRINONE 8% GEL BETOPTIC S 0.25% EYE DROPS CROMOLYN 4% EYE DROPS BIMATOPROST 0.03% EYE DROPS CROTAN 10% LOTION BIMATOPROST 0.03% EYELASH SOLN CUTIVATE 0.05% CREAM BLEPHAMIDE EYE DROPS CUTIVATE 0.05% LOTION BLEPHAMIDE EYE OINTMENT CYCLOGYL 0.5% EYE DROPS BPO 4% GEL CYCLOGYL 2% EYE DROPS BPO 8% GEL CYCLOMYDRIL EYE DROPS BRIMONIDINE 0.2% EYE DROP CYCLOPENTOLATE 1% EYE DROPS BROMFENAC SODIUM 0.09% EYE DRP CYSTARAN 0.44% EYE DROPS BROMSITE 0.075% EYE DROPS DENAVIR 1% CREAM BRYHALI 0.01% LOTION DENTA 5000 PLUS CREAM BUTENAFINE HCL 1% CREAM DENTAGEL 1.1% GEL CALCIPOTRIENE 0.005% CREAM DERMACINRX PHN PAK CALCIPOTRIENE 0.005% OINTMENT DERMATOP 0.1% OINTMENT CALCIPOTRIENE-BETAMETH DP OINT DERMOTIC OIL 0.01% EAR DROPS CALCITRIOL 3 MCG/G OINTMENT DESONATE 0.05% GEL CARAC 0.5% CREAM DESONIDE 0.05% CREAM CARTEOLOL HCL 1% EYE DROPS DESONIDE 0.05% LOTION CICLODAN 0.77% CREAM DESONIDE 0.05% OINTMENT CICLOPIROX 0.77% GEL DESOXIMETASONE 0.05% CREAM CILOXAN 0.3% OINTMENT DESOXIMETASONE 0.05% GEL CIPRO HC OTIC SUSPENSION DESOXIMETASONE 0.05% OINTMENT CIPROFLOXACIN 0.2% OTIC SOLN DESOXIMETASONE 0.25% CREAM CLEOCIN 2% VAGINAL CREAM DESOXIMETASONE 0.25% OINTMENT CLEOCIN T 1% GEL DEXAMETHASONE 0.1% EYE DROP -Page 2 of 5-
DICLOFENAC 0.1% EYE DROPS DICLOFENAC 1.5% TOPICAL SOLN DICLOFENAC SODIUM 3% GEL DIFFERIN 0.1% LOTION DIFLORASONE 0.05% CREAM DIFLORASONE 0.05% OINTMENT DIVIGEL 0.25 MG GEL PACKET DIVIGEL 0.5 MG GEL PACKET DIVIGEL 1 MG GEL PACKET DOXEPIN 5% CREAM DUREZOL 0.05% EYE DROPS ECONAZOLE NITRATE 1% CREAM EFUDEX 5% CREAM ELESTRIN 0.06% GEL ELIDEL 1% CREAM ELLZIA PAK ELOCON 0.1% CREAM ELOCON 0.1% OINTMENT EMADINE 0.05% EYE DROPS ENSTILAR 0.005%-0.064% FOAM EPIDUO FORTE 0.3-2.5% GEL PUMP EPIFOAM FOAM ERTACZO 2% CREAM ERYGEL 2% GEL ERYTHROMYCIN 0.5% EYE OINTMENT ESTRACE 0.01% CREAM EURAX 10% CREAM EXELDERM 1% CREAM EXTINA 2% FOAM FABIOR 0.1% FOAM FINACEA 15% FOAM FINACEA 15% GEL FLAREX 0.1% EYE DROPS FLUOCINOLONE 0.01% CREAM FLUOCINONIDE 0.05% CREAM FLUOCINONIDE 0.05% GEL FLUOCINONIDE 0.05% OINTMENT FLUOCINONIDE 0.1% CREAM FLUOCINONIDE-E 0.05% CREAM FLUOROMETHOLONE 0.1% DROPS FLURANDRENOLIDE 0.05% OINTMENT FLURBIPROFEN 0.03% EYE DROP FLUTICASONE PROP 0.005% OINT FML FORTE 0.25% EYE DROPS FML S.O.P. 0.1% OINTMENT FORTESTA 10 MG GEL PUMP GATIFLOXACIN 0.5% EYE DROPS GELNIQUE 10% GEL PUMP GENTAK 3 MG/GM EYE OINTMENT GENTAMICIN 0.1% CREAM GENTAMICIN 0.1% OINTMENT GYNAZOLE 1 2% CREAM HALOBETASOL PROP 0.05% CREAM HALOBETASOL PROP 0.05% OINTMNT HALOG 0.1% CREAM HALOG 0.1% OINTMENT HYDROCORT BUTY 0.1% LIPID CRM HYDROCORTISONE 1% CREAM HYDROCORTISONE 1% CREAM HYDROCORTISONE 2.5% CREAM HYDROCORTISONE 2.5% LOTION HYDROCORTISONE 2.5% OINTMENT HYDROCORTISONE BUTY 0.1% CREAM HYDROCORTISONE BUTYR 0.1% LOTN HYDROCORTISONE BUTYR 0.1% OINT HYDROCORTISONE VAL 0.2% CREAM HYDROCORTISONE VAL 0.2% OINTMT HYDROQUINONE 4% CREAM HYDROQUINONE TR 4% CREAM ILEVRO 0.3% OPHTH DROPS IMIQUIMOD 3.75% CREAM PUMP IMIQUIMOD 5% CREAM PACKET IODOQUINOL-HYDROCORT-ALOE GEL IOPIDINE 1% EYE DROPS ISOPTO CARPINE 1% EYE DROPS ISOPTO CARPINE 2% EYE DROPS ISOPTO CARPINE 4% EYE DROPS ISTALOL 0.5% EYE DROPS KERAFOAM 30% FOAM KERAFOAM 42% FOAM KETOCONAZOLE 2% CREAM KETOROLAC 0.5% OPHTH SOLUTION LASTACAFT 0.25% EYE DROPS LEVOBUNOLOL 0.5% EYE DROPS LEVOFLOXACIN 0.5% EYE DROPS LIDOCAINE-HC 2.8-0.55% GEL LIDOCAINE-HC 3-1% CREAM LIDOCAINE-HYDROCORT 3-2.5% GEL LIDOCAINE-PRILOCAINE CREAM LIDOTRAL 3.88% CREAM LIDOZION 3% LOTION LOPROX 0.77% SUSPENSION KIT LOTEMAX 0.5% EYE DROPS LOTEMAX 0.5% EYE OINTMENT LOTEMAX 0.5% OPHTHALMIC GEL LULICONAZOLE 1% CREAM MAXIDEX 0.1% EYE DROPS -Page 3 of 5-
MAXITROL EYE DROPS MAXITROL EYE OINTMENT METIPRANOLOL 0.3% EYE DROPS MICORT HC 2.5% CREAM MICORT-HC 2.5% CREAM MIRVASO 0.33% GEL MIRVASO 0.33% GEL PUMP MOXEZA 0.5% EYE DROPS MOXIFLOXACIN 0.5% EYE DROPS MYDRIACYL 1% EYE DROPS NAFTIFINE HCL 1% CREAM NAFTIFINE HCL 2% CREAM NAFTIN 1% GEL NAFTIN 2% GEL NATACYN EYE DROPS NEO-BACIT-POLY-HC EYE OINTMENT NEOMYC-BACIT-POLYMIX EYE OINT NEOMYCIN-POLY-HC EYE DROPS NEOMYCIN-POLYMYXIN-HC EAR SUSP NEOMYC-POLYM-GRAMICID EYE DROP NEVANAC 0.1% DROPTAINER NITRO-BID 2% OINTMENT NORITATE 1% CREAM NUVESSA VAGINAL 1.3% GEL NYSTATIN 100,000 UNIT/GM CREAM NYSTATIN 100,000 UNIT/GM OINT NYSTATIN-TRIAMCINOLONE CREAM NYSTATIN-TRIAMCINOLONE OINTM ONEXTON 1.2%-3.75% GEL ONEXTON GEL PUMP ORALONE 0.1% PASTE OVACE PLUS 10% CREAM OVACE PLUS 9.8% FOAM OVACE PLUS 9.8% LOTION OXICONAZOLE NITRATE 1% CREAM OXISTAT 1% LOTION PANDEL 0.1% CREAM PANRETIN 0.1% GEL PAREMYD EYE DROPS PHENYLEPHRINE 10% EYE DROPS PHENYLEPHRINE 2.5% EYE DROP PHOSPHOLINE IODIDE 0.125% PICATO 0.015% GEL PICATO 0.05% GEL PLIAGLIS 7%-7% CREAM POLYMYXIN B-TMP EYE DROPS PRAMOSONE 1%-1% OINTMENT PRAMOSONE 2.5%-1% OINTMENT PRED FORTE 1% EYE DROPS PRED MILD 0.12% EYE DROPS PRED-G 1% EYE DROPS PRED-G S.O.P. EYE OINTMENT PREDNICARBATE 0.1% CREAM PREDNISOLONE SOD 1% EYE DROP PROCTOCORT 1% CREAM PROCTOFOAM-HC 1%-1% FOAM PROLENSA 0.07% EYE DROPS PROPARACAINE 0.5% EYE DROPS PROTOPIC 0.03% OINTMENT PROTOPIC 0.1% OINTMENT RECTIV 0.4% OINTMENT REGRANEX 0.01% GEL RENOVA 0.02% CREAM RESTASIS MULTIDOSE 0.05% EYE RETIN-A 0.01% GEL RETIN-A 0.05% CREAM RETIN-A 0.1% CREAM RETIN-A MICRO 0.04% GEL RETIN-A MICRO 0.1% GEL RETIN-A MICRO PUMP 0.04% GEL RETIN-A MICRO PUMP 0.08% GEL RETIN-A MICRO PUMP 0.1% GEL ROSADAN 0.75% CREAM KIT ROSADAN 0.75% GEL KIT SALEX 6% CREAM KIT SALICYLIC ACID 27.5% LIQUID SALICYLIC ACID 6% CREAM SALICYLIC ACID 6% FOAM SALICYLIC ACID 6% GEL SALICYLIC ACID 6% LOTION SALKERA 6% FOAM SANTYL OINTMENT SB HYDROCORTISONE 1% OINTMENT SELENIUM SULFIDE 2.5% LOTION SILVADENE 1% CREAM SIMBRINZA 1%-0.2% EYE DROPS SOD SULFACETAMIDE-SULFUR LOTN SOD SULFACETAMIDE-SULFUR LOTN SORILUX 0.005% FOAM SSS 10-5 FOAM SULFACETAMIDE 10% EYE DROPS SULFACETAMIDE 10% EYE OINTMENT SULFAMYLON 8.5% CREAM SULF-PRED 10-0.23% EYE DROPS SYNALAR 0.025% CREAM SYNALAR 0.025% CREAM KIT SYNALAR 0.025% OINTMENT TARGRETIN 1% GEL TAZAROTENE 0.1% CREAM TAZORAC 0.05% CREAM -Page 4 of 5-
TAZORAC 0.05% GEL TAZORAC 0.1% GEL TERCONAZOLE 0.4% CREAM TERCONAZOLE 0.8% CREAM TESTIM 1% (50MG) GEL TESTOSTERONE 12.5 MG/1.25 GRAM TIMOLOL 0.25% EYE DROPS TIMOLOL 0.25% GEL-SOLUTION TIMOLOL 0.5% EYE DROPS TIMOLOL 0.5% GEL-SOLUTION TIMOPTIC 0.25% OCUDOSE DROP TIMOPTIC 0.5% OCUDOSE DROP TOBRADEX EYE DROPS TOBRADEX EYE OINTMENT TOBRADEX ST EYE DROPS TOBRAMYCIN 0.3% EYE DROP TOBREX 0.3% EYE OINTMENT TOLAK 4% CREAM TRIAMCINOLONE 0.025% CREAM TRIAMCINOLONE 0.025% LOTION TRIAMCINOLONE 0.025% OINT TRIAMCINOLONE 0.1% CREAM TRIAMCINOLONE 0.1% LOTION TRIAMCINOLONE 0.1% OINTMENT TRIAMCINOLONE 0.5% OINTMENT TRIANEX 0.05% OINTMENT TRIDERM 0.5% CREAM TRIFLURIDINE 1% EYE DROPS TRI-LUMA CREAM TROPICAMIDE 0.5% EYE DROPS ULTRAVATE 0.05% LOTION UMECTA 40% MOUSSE URAMAXIN 20% FOAM URAMAXIN 45% LOTION URAMAXIN GT 45% KIT URAMAXIN GT 45% PRE-FILLED APP UREA 35% FOAM UREA 40% LOTION UREA 45% NAIL GEL VALCHLOR 0.016% GEL VANIQA 13.9% CREAM VEREGEN 15% OINTMENT XERESE 5%-1% CREAM ZIOPTAN 0.0015% EYE DROPS ZIRGAN 0.15% OPHTHALMIC GEL ZOVIRAX 5% CREAM ZYCLARA 2.5% CREAM PUMP ZYCLARA 3.75% CREAM ZYLET EYE DROPS TRIANEX 0.05% OINTMENT All of the aforementioned changes, whether preferred or non-preferred, may have additional criteria that control their usage. Any agent noted above with a superscripted PA requires Prior Authorization and any agent noted above with a superscripted QL is subject to Quantity Limits. Please refer to the document Drug Criteria Listing located at: https://tenncare.magellanhealth.com for additional information. Important Phone Numbers: Tennessee Health Connection 855-259-0701 TennCare Fraud and Abuse Hotline 800-433-3982 TennCare Pharmacy Program Fax 888-298-4130 Magellan Pharmacy Support Center 866-434-5520 Magellan Clinical Call Center 866-434-5524 Magellan Call Center Fax 866-434-5523 Helpful TennCare Internet Links: Magellan: https://tenncare.magellanhealth.com TennCare website: www.tn.gov/tenncare/ Please visit the Magellan TennCare website regularly to stay up-to-date on changes to the pharmacy program. For additional information or updated payer specifications, please visit the Magellan website at: https://tenncare.magellanhealth.com 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 5 of 5-