This is a current list of the drugs and supplies that do not count toward an enrollee’s monthly drug limit

TennCare AutoExempt List
This is a current list of the drugs and supplies that do not count toward an enrollee’s monthly drug limit. This list will change. Go to https://tnm.providerportal.sxc.com/rxclaim/TNM/PREQS.htm to see the most current copy of this list. ANTINEOPLASTICS
leuprolide (Eligard, Lupron, Lupron Depot, Viadur) methotrexate (Mexate, Trexall, Abitrexate, Folex) cytarabine, conventional (Cytosar-U, Tarabine PFS) daunorubicin citrate liposomal (DaunoXome) tamoxifen citrate and oral solution (Nolvadex) etoposide (VP-16-213) (Toposar, VePesid, Etopophos) TennCare AutoExempt List
vorinostat (Zolinza) ziv-aflibercept (Zaltrap) ANTIPARKINSONIAN AGENT
ANTI-TUBERCULAR AGENTS
rifampin/pyrazinamide / isoniazid (Rifater) isoniazid (INH, Isohydrazide, Niazid, Nydrazid, Niazid-B6) rifapentine (Priftin) streptomycin sulfate ANTI-VIRALS
ganciclovir (DHPG) (Cytovene (PO), Cytovene (IV) ) abacavir/lamivudine/zidovudine (Trizivir) cobicistat/elvitegravir/emtricitabine/tenofovir (Stribild) efavirenz/emtricitabine/tenofovir (Atripla) emtricitabine/rilpivirine/tenofovir (Complera) CARDIOVASCULAR DISEASE (ORAL FORMULATIONS ONLY)
Note: Brand names in this category are provided for reference only. Only generic cardiovascular medications are exempt from the script limit.
If classified as a brand in Medi-span the product will not be exempt from the script limit.
lisinopril/hydrochlorothiazide (Prinzide, Zestoretic) amiloride/hydrochlorothiazide (Moduretic) metoprolol/hydrochlorothiazide (Lopressor HCT) benazepril/hydrochlorothiazide (Lotensin HCT) moexipril/hydrochlorothiazide (Uniretic) nifedipine ER/SA/XL (Adalat CC, Procardia XL) captopril/hydrochlorothiazide (Capozide) diltiazem ER/SR/XR (Cardizem CD, Cardizem LA, Cartia XT, Dilacor propranolol/hydrochlorothiazide (Inderide) quinapril/hydrochlorothiazide (Accuretic) enalapril/hydrochlorothiazide (Vasoretic) fosinopril/hydrochlorothiazide (Monopril-HCT) spironolactone/hydrochlorothiazide (Aldactazide) triamterene/hydrochlorothiazide (Dyazide, Maxzide) TennCare AutoExempt List
verapamil ER (Covera-HS, Isoptin SR, Verelan) CLOTTING FACTORS
antihemophilic factor, human (Alphanate, Hemofil-M, Humate-P, Koate, Melate, Monarc-M, Monoclate-P, Nybcen, Profilate) antihemophilic factor, human recombinant (Advate, Bioclate, Genarc, Helixate, Kogenate, Recombinate, Refacto, Xyntha) antihemophilic factor/Von Willebrand factor complex (Humate-P, Wilate) anti-inhibitor coagulant complex (Autoplex T, Feiba VH Immuno) factor VIIa, recombinant (NovoSeven, NovoSeven RT) factor IX (Alphanine, Mononine) factor IX complex human (Bebulin, Konyne, Profilnine, Proplex) factor IX human recombinant (Benefix) factor XIII (Corifact) DIABETES AGENTS - INSULINS
human insulin NPH (Humulin N, Novolin N®) human insulin NPH/Regular (Humulin 70/30, Novolin 70/30®) insulin lispro (Humalog and Novolog – all dosage forms) human insulin Regular (Humulin R, Novolin R®, Humulin R U-500) insulin lispro protamine/lispro (Humalog and Novolog mix– all dosage DIABETES AGENTS – ORAL HYPOGLYCEMICS
Note: Brand names in this category are provided for reference only. Only generic oral hypoglycemic medications are exempt from the script
limit. If classified as a brand in Medi-span the product will not be exempt from the script limit.
glyburide, micronized (Glynase, PresTab) DIALYSIS MEDICATIONS
calcium acetate/ magnesium carbonate (MagneBind) sodium polystyrene sulfonate (Kayexalate, Kionex, Marlexate, SPS) FA/vitamin B complex with C (B-Plex, Dialyvite, Folbee Plus, Nephronex, renal caps, Renal Multivitamin Formula, Renaphro) FLU VACCINE - INJECTABLE FORMULATIONS ONLY
influenza (Fluvirin, Fluzone, Fluarix, Influenza A H1N1) HEMATOPOIETIC AGENTS
epoetin alfa, recombinant (Epogen, Procrit) HEPATITIS C
ribavirin (Copegus, Rebetol, Ribasphere, Ribapak) ribivirin / interferon alfa-2b (Rebetron) IMMUNOSUPPRESSIVES
cyclosporine (Sandimmune, Gengraf, Neoral, Sangcya) IRON PREPARATIONS
iron dextran complex (DexFerrum, Imferon, Infed, Proferdex) sodium ferric gluconate complex/sucrose (Ferrlecit) TennCare AutoExempt List
LONG ACTING ANTIPSYCHOTICS
haloperidol decanoate (Haldol Decanoate) RESPIRATORY
Note: Brand names in this category, with the exception of Proventil HFA, are provided for reference only. Only generic respiratory medications
are exempt from the script limit. TennCare considers Proventil HFA a generic medication. All other medications classified as brand products
in Medi-span will not be exempt from the script limit.
ipratropium inhalation solution (Atrovent) albuterol sulfate inhalation solution (Accuneb, Proventil) TRANSPLANT
hepatitis B immune globulin (Bayhep-B, H-Big, Hyperhep, NABI-HB, HepaGam B)
Other covered items:
Diabetic Supplies – Test strips; Lancets; Lancet Devices; Acetone Urine Test (i.e. Ketostix®), Alcohol Pads; Glucose Control
Solution; Meters; Syringes: Pen Needles
Prenatal vitamins - Brands such as Prenate, Zenate, etc.
Asthma Supplies – Spacers, Peak Flow Meters, and NaCl for inhalation
Large Volume Parenterals - Coded by large volume fluid for quantities > 500mL, any additive will be covered. (Generic
Name: Dextrose; Lactated Ringers; Sodium Chloride; Sterile Water)
Total Parenteral Nutrition (TPN) - Coded by Amino Acid, all additives will be covered
Heplock - Heplock of 10u/mL or 100u/mL
Saline Flush - Coded up to 30mL vials

Source: https://tnm.providerportal.sxc.com/rxclaim/TNM/AutoExemptList.pdf