The TennCare Attestation List, updated on July 24, 2014, serves as a critical tool for healthcare providers navigating patient prescription limits under TennCare, Tennessee's Medicaid program. Managed by Magellan Health Services, it outlines a process whereby prescribing physicians or their agents can request approval for medications for patients who have already reached their monthly prescription ceiling but are at high risk of hospitalization or severe health decline without the necessary drugs. This list is distinct from the Preferred Drug List (PDL) and operates independently, though medications included are still subject to TennCare's existing conditions such as non-preferred status on the PDL, clinical criteria, and quantity limits. Covering a vast array of drugs from anti-infectives, antifungals, and antivirals to cardiovascular agents and beyond, it underscores the system's initiative to balance stringent prescription controls with the need to provide critical care for high-risk individuals. Its comprehensive enumeration of medications, including antibiotics, anticoagulants, diuretics, and more, reflects an effort to ensure that vulnerable patients receive the treatments they require, fostering a nuanced approach to prescription healthcare management.
| Question | Answer |
|---|---|
| Form Name | Tenncare Attestation Form |
| Form Length | 11 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 45 sec |
| Other names | tenncare attestation form pdf, attestatison for tncare, tncareattestionform, attestation tenncare form |
TennCare Attestation List
July 24, 2014
To initiate an attestation request for any agent on the attestation list, the prescribing physician or the prescribing physician’s agent must call the Magellan Health Services Call Center at
Medications on this list can be approved for patients currently at their monthly prescription limit (greater than 5 prescriptions or greater than 2 brand medications), who are at a high risk for adverse health consequences and could be hospitalized, institutionalized, or die within the next 90 days without the requested drug(s). This list is independent of the preferred drug list (PDL) and other criteria. All drugs on this list are still subject to existing TennCare edits, including
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Aminoglycosides |
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amikacin (Amikin) |
paromomycin |
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gentamicin (Garamycin) |
streptomycin |
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kanamycin |
tobramycin (Nebcin, Tobi) |
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neomycin |
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Cephalosporins, First Generation |
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cefadroxil (Duricef) |
cephalexin (Keflex) |
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cefazolin (Ancef) |
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Cephalosporins, Second Generation |
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cefaclor (Ceclor) |
cefprozil (Cefzil) |
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cefoxitin (Mefoxin) |
cefuroxime (Ceftin, Zinacef) |
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Cephalosporins, Third Generation |
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cefdinir |
ceftazidime (Fortaz, Tazicef) |
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cefditoren (Spectracef) |
ceftibuten (Cedax) |
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cefixime (Suprax) |
ceftizoxime (Cefizox) |
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cefotaxime (Claforan) |
ceftriaxone (Rocephin) |
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cefpodoxime (Vantin) |
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Cephalosporins, Fourth Generation |
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cefepime (Maxipime) |
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Ketolides |
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telithromycin (Ketek) |
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Lincosamides |
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clindamycin (Cleocin) |
lincomycin (Lincocin) |
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Proprietary & Confidential
© 2014, Magellan Health Services, Inc. All Rights Reserved.
Magellan Health ServicesTennCare Attestation List
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Macrolides |
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azithromycin (Zithromax, Zmax) |
erythromycin (E.E.S., Eryc, |
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clarithromycin (Biaxin, Biaxin XL) |
erythromycin/sulfisoxazole (Eryzole, Pediazole) |
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Nitrofurans |
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nitrofurantoin (Furadantin, Macrodantin, Macrobid) |
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Nitroimidazoles |
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metronidazole HCl (Flagyl) |
tinidazole (Tindamax) |
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Oxazolidinones |
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linezolid (Zyvox) |
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Penicillins |
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amoxicillin/potassium clavulanate (Augmentin) |
oxacillin |
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amoxicillin |
penicillin G (Bicillin |
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ampicillin |
penicillin V potassium (Veetids) |
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ampicillin/sulbactam (Unasyn) |
piperacillin |
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dicloxacillin |
piperacillin/tazobactam (Zosyn) |
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nafcillin |
ticarcillin/potassium clavulanate (Timentin) |
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Quinolones |
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ciprofloxacin (Cipro, Cipro XR, Proquin XR) |
moxifloxacin (Avelox) |
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gemifloxacin (Factive) |
norfloxacin (Noroxin) |
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levofloxacin (Levaquin) |
ofloxacin (Floxin) |
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Sulfonamides |
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sulfadiazine |
sulfasalazine (Azulfidine) |
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sulfamethoxazole/trimethoprim (Bactrim, Septra) |
trimethoprim |
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Tetracyclines |
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demeclocycline |
minocycline (Arestin, Dynacin, Minocin, Myrac) |
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doxycycline (Adoxa, Atridox, Doryx, Monodox, Oracea, |
tetracycline (Sumycin) |
Oraxyl, Periostat, Vibramycin) |
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Vancomycin and Derivatives
vancomycin (Vancocin)
Miscellaneous Antibiotics
fosfomycin (Monurol) |
methenamine (Hiprex, Urex) |
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Proprietary & Confidential |
Page 2 |
Revision Date: July 24, 2014
Magellan Health ServicesTennCare Attestation List
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Antifungals |
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amphotericin B (Abelcet, Ambisome, Amphocin, |
itraconazole (Sporanox) |
Amphotec) |
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anidulafungin (Cancidas) |
micafungin (Mycamine) |
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caspofungin (Eraxis) |
miconazole (Monistat) |
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fluconazole (Diflucan) |
posaconazole (Noxafil) |
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flucytosine (Ancobon) |
voriconazole (Vfend) |
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griseofulvin (Fulvicin U/F, |
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Antiparasitics |
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albendazole (Albenza) |
mefloquine |
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artemether/lumefantrine (Coartem) |
nitazoxanide (Alinia) |
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atovaqu one/proguanil (Malarone) |
paromomycin |
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atovaquone (Mepron) |
pentamidine (Nebupent, Pentam 300) |
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chloroquine (Aralen) |
praziquantel (Biltricide) |
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dapsone |
primaquine |
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iodoquinol (Yodoxin) |
pyrantel |
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ivermectin (Stromectol) |
pyrimethamine (Daraprim) |
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mebendazole |
quinine (Qualaquin) |
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Antivirals |
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acyclovir (Zovirax) |
penciclovir (Denavir) |
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famciclovir (Famvir) |
valacyclovir (Valtrex) |
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oseltamivir (Tamiflu) |
zanamivir (Relenza) |
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CARDIOVASCULAR
ranolazine (Ranexa)
Proprietary & Confidential |
Page 3 |
Revision Date: July 24, 2014
Magellan Health ServicesTennCare Attestation List
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CARDIOVASCULAR |
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Antiarryhthmics |
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adenosine (Adenocard) |
lidocaine (Xylocaine) |
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amiodarone (Cordarone, Pacerone) |
mexiletine (Mexitil) |
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bretylium |
procainamide |
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disopyramide IR/SA (Norpace/Norpace CR) |
propafenone (Rythmol/Rythmol SR) |
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dofetilide (Tikosyn) |
quinidine gluconate |
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dronedarone (Multaq) |
quinidine sulfate (Quinidex) |
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flecainide (Tambocor) |
sotalol/sotalol af (Betapace/Betapace AF) |
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ibutilide (Corvert) |
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Anticoagulants |
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apixaban (Eliquis) |
heparin (Heparin) |
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dalteparin (Fragmin) |
rivaroxaban (Xarelto) |
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dabigatran Etexilate (Pradaxa) |
tinzaparin (Innohep) |
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enoxaparin (Lovenox) |
warfarin (Coumadin, Jantoven) |
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fondaparinux (Arixtra) |
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Antifibrinolytics |
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aminocaproic acid (Amicar) |
tranexamic acid (Cyklokapron, Lysteda) |
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aprotinin (Trasylol) |
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Cardiac Glycosides
digoxin (Lanoxin)
Diuretics, Loop
ethacrynic acid (Edecrin)
Hyperkalemia Agents
sodium polystyrene sulfonate (Kayexalate, Kionex, SPS)
Hypotensives, ACE Inhibitors
perindopril (Aceon)
Proprietary & Confidential |
Page 4 |
Revision Date: July 24, 2014
Magellan Health ServicesTennCare Attestation List
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CARDIOVASCULAR |
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Hypotensives, Angiotensin Receptor Blockers |
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azilsartan (Edarbi) |
losartan/HCTZ (Hyzaar) |
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candesartan (Atacand) |
olmesartan (Benicar) |
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candesartan/HCTZ (Atacand HCT) |
olmesartan/HCTZ (Benicar HCT) |
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eprosartan (Teveten) |
telmisartan (Micardis) |
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eprosartan/HCTZ (Teveten HCT) |
telmisartan/HCTZ (Micardis HCT) |
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irbesartan (Avapro) |
valsartan (Diovan) |
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irbesartan/HCTZ (Avalide) |
valsartan/HCTZ (Diovan HCT) |
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losartan potassium (Cozaar) |
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Hypotensives, Direct Renin Inhibitors |
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aliskiren/valsartan (Valturna) |
aliskiren/HCTZ (Tekturna HC) |
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aliskiren (Tekturna) |
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Hypotensives, Sympatholytics |
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clonidine (Catapres, Catapres TTS, Nexiclon XR) |
methyldopa/HCTZ |
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guanabenz |
methyldopate |
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guanfacine (Tenex) |
reserpine |
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methyldopa (Aldomet) |
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Hypotensives, Vasodilators |
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diazoxide (Hyperstat I.V.) |
hydralazine HCl (Apresoline) |
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fenoldopam mesylate (Corlopam) |
minoxidil (Minoxidil) |
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Oral Thrombopoietic Agonists |
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eltrombopag (Promacta) |
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Pheochromocytoma Agents |
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metyrosine (Demser) |
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Platelet Aggregation Inhibitors/Intermittent Claudication |
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abciximab (Reopro) |
pentoxifylline (Trental) |
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aspirin/dipyridamole (Aggrenox) |
prasugrel (Effient) |
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cilostazol (Pletal) |
ticagrelor (Brilinta) |
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clopidogrel (Plavix) |
ticlopidine (Ticlid) |
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dipyridamole (Persantine) |
tirofiban (Aggrastat) |
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eptifibatide (Integrilin) |
vorapaxar (Zontivity) |
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Proprietary & Confidential |
Page 5 |
Revision Date: July 24, 2014
Magellan Health ServicesTennCare Attestation List
CARDIOVASCULAR |
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Pulmonary Hypertension Agents |
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ambrisentan (Letairis) |
riociguat (Adempas) |
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bosentan (Tracleer) |
sildenafil (Revatio) |
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epoprostenol (Flolan) |
tadalafil (Adcirca) |
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iloprost (Ventavis) |
treprostinil (Remodulin, Tyvaso, Orenitram) |
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macitentan (Opsumit) |
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Vasodilators |
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amyl nitrite |
isosorbide mononitrate (Imdur, Monoket) |
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isosorbide dinitrate |
nitroglycerin (Minitran, Nitrek, |
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Nitrolingual, Nitroquick, Nitrostat, Nitrotab, Nitro- |
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Time, Nitromist) |
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Vasopressors |
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midodrine |
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CNS |
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Anticonsulvants |
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carbamazepine (Tegretol, Tegretol XR) |
lacosamide (Vimpat) |
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clobazam (Onfi) |
methsuximide (Celontin) |
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clonazepam (Klonopin) |
oxcarbazepine (Trileptal) |
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clonazepam ODT (Klonopin Wafer) |
perampanel (Fycompa) |
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diazepam rectal gel (Diastat) |
phenobarbital |
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divalproex sodium (Depakote, Depakote ER, Depakote |
phenytoin (Dilantin, Dilantin Kapseals, Phenytek) |
Sprinkles) |
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eslicarbazepine (Aptiom) |
pregabalin (Lyrica) |
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ethosuximide (Zarontin) |
primidone (Mysoline) |
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ethotoin (Peganone) |
rufinamide (Banzel) |
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ezogabine (Potiga) |
tiagabine (Gabitril) |
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felbamate (Felbatol) |
topiramate (Topamax, Qudexy XR) |
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fosphenytoin (Cerebyx) |
valproate sodium (Depacon) |
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gabapentin (Neurontin) |
valproic acid (Depakene, Stavzor) |
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lamotrigine (Lamictal, Lamictal XR) |
vigabatrin (Sabril) |
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levetiracetam (Keppra, Keppra XR) |
zonisamide (Zonegran) |
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Proprietary & Confidential |
Page 6 |
Revision Date: July 24, 2014
Magellan Health ServicesTennCare Attestation List
CNS
Antidepressants, New Generation
bupropion HCl (Wellbutrin, Wellbutrin SR, |
nefazodone (Serzone) |
Wellbutrin XL) |
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maprotiline |
trazodone (Oleptro) |
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mirtazapine (Remeron, Remeron SolTab) |
vilazodone (Viibryd) |
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Antidepressants, SNRIs and SSRIs |
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citalopram (Celexa) |
fluvoxamine |
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desvenlafaxine (Pristiq, Khedezla) |
milnacipran (Savella) |
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duloxetine (Cymbalta) |
paroxetine (Paxil, Paxil CR, Pexeva) |
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escitalopram (Lexapro) |
sertraline HCl (Zoloft) |
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fluoxetine (Prozac, Prozac Weekly, Sarafem) |
venlafaxine (Effexor XR) |
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apomorphine (Apokyn) |
rasagiline (Azilect) |
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bromocriptine (Parlodel) |
ropinirole (Requip, Requip XL) |
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carbidopa/levodopa (Sinemet, Sinemet CR) |
selegiline (Zelapar, Eldepryl) |
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carbidopa/levodopa/entacapone (Stalevo) |
tolcapone (Tasmar) |
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pramipexole (Mirapex, Mirapex ER) |
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entacapone (Comtan) |
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Antipsychotics |
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chlorpromazine (Thorazine) |
perphenazine |
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droperidol (Inapsine) |
pimozide (Orap) |
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fluphenazine |
prochlorperazine (Compazine) |
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haloperidol (Haldol) |
thioridazine |
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loxapine (Loxitane) |
thiothixene (Navane) |
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molindone (Moban) |
trifluoperazine |
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Antipsychotics, Atypical |
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aripiprazole (Abilify, Abilify Discmelt, Abilify Maintena) |
olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) |
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asenapine (Saphris) |
paliperidone (Invega, Invega Sustenna) |
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clozapine (Clozaril, FazaClo) |
quetiapine (Seroquel, Seroquel XR) |
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iloperidone (Fanapt) |
risperidone (Risperdal, Risperdal Consta) |
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lurasidone (Latuda) |
ziprasidone (Geodon) |
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MAOIs |
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isocarboxazide (Marplan) |
selegiline (Eldepryl, Emsam, Zelapar) |
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phenelzine (Nardil) |
tranylcypromine (Parnate) |
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Proprietary & Confidential |
Page 7 |
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Revision Date: July 24, 2014 |
Magellan Health ServicesTennCare Attestation List
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CNS |
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Mood Stabilizers |
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lithium carbonate (Lithobid) |
lithium citrate |
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lithium carbonate ER |
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SSRI/Antipsychotic Combos |
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olanzapine/fluoxetine (Symbyax) |
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TCAs |
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amitriptyline |
imipramine (Tofranil, |
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amoxapine |
nortriptyline (Pamelor) |
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clomipramine (Anafranil) |
protriptyline (Vivactil) |
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desipramine (Norpramin) |
trimipramine (Surmontil) |
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doxepin |
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ENDOCRINE AGENTS |
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Glucocorticoids, Oral |
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cortisone |
hydrocortisone (Cortef) |
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betamethasone solution (Celestone) |
methylprednisolone (Medrol) |
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budesonide (Entocort EC) |
prednisolone (Millipred, Orapred, Pediapred, Prelone) |
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dexamethasone (Dexpak, Dekpak Jr.) |
prednisone |
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GASTROINTESTINAL AGENTS
Pancreatic Enzymes
6,000 L/19,000 P/30,000 A (Creon L 6,000 units) |
24,000 L/76,000 P/120,000 A (Creon L 24,000 units) |
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12,000 L/38,000 P/60,000 A (Creon L 12,000 units) |
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Pancreatic Enzymes |
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Pancreaze |
Viokace |
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Pertyze |
ZenPep |
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Ultresa |
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ondansetron (tabs, ODT, solution) |
Kytril® |
Zofran® (tabs, ODT, solution) |
Sancuso® |
Anzemet® |
Zuplenz® |
granisetron |
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Proprietary & Confidential |
Page 8 |
Revision Date: July 24, 2014
Magellan Health ServicesTennCare Attestation List
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IMMUNOGOLOGIC AGENTS |
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Immunomodulators |
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anakinra (Kineret) |
certolizumab pegol (Cimzia) |
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adalimumab (Humira) |
golimumab (Simponi) |
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etanercept (Enbrel) |
ustekinumab (Stelara) |
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Immune Globulins |
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Gammagard |
Hizentra |
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Vivaglobin |
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Multiple Sclerosis |
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Fingolimod (Gilenya) |
interferon |
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glatiramer acetate (Copaxone) |
teriflunomide (Aubagio) |
interferon
MISCELLANEOUS
epinephrine (TwinJect, EpiPen, EpiPen Jr., Adrenaclick)
OPHTHALMICS
Antibiotic/Corticoid Combinations
gentamicin/prednisolone |
neomycin/polymyxin B/prednisolone |
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neomycin/bacitracin/polymyxin/hydrocortisone |
tobramycin/dexamethasone (Tobradex ointment) |
(Cortisporin) |
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neomycin/polymyxin B/dexamethasone (Maxitrol) |
tobramycin/loteprednol (Zylet) |
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neomycin/polymyxin B/hydrocortisone (Cortisporin) |
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Antibiotics |
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azithromycin (AzaSite) |
levofloxacin (Iquix, Quixin) |
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bacitracin |
moxifloxacin (Vigamox) |
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bacitracin/polymyxin B |
neomycin/ polymyxin B/bacitracin (Neosporin) |
Polysporin) |
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besifloxacin (Besivance) |
neomycin/polymyxin B/gramicidin (Neosporin Eye |
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Drops) |
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chloramphenicol (Chloromycetin) |
ofloxacin (Ocuflox) |
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ciprofloxacin (Ciloxan) |
polymyxin B/trimethoprim (Polytrim) |
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erythromycin (Ilotycin, Romycin) |
sulfacetamide sodium |
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gatifloxacin (Zymar) |
tobramycin |
gentamicin (Garamycin, Genoptic, Gentak, Gentasol)
Proprietary & Confidential |
Page 9 |
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Revision Date: July 24, 2014 |
Magellan Health ServicesTennCare Attestation List
OPHTHALMICS
Antifungals |
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natamycin (Natacyn) |
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Antivirals |
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ganciclovir (Zirgan) |
trifluridine (Viroptic) |
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bromfenac (Xibrom) |
ketorolac (Acular, Acular LS, Acular PF) |
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diclofenac (Voltaren) |
loteprednol (Alrex, Lotemax) |
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fluorometholone (Flarex, FML Forte, FML Liquifilm, FML |
nepafenac (Nevanac) |
S.O.P.) |
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flurbiprofen (Ocufen) |
rimexolone (Vexol) |
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Miotics/IOP Reducers |
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acetylcholine chloride |
dorzolamide (Trusopt) |
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apraclonidine (Iopidine) |
latanoprost (Xalatan) |
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betaxolol |
levobunolol (Betagan) |
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bimatoprost (Lumigan) |
metipranolol (OptiPranolol) |
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brimonidine (Alphagan P) |
pilocarpine (Isopto Carpine, Pilopine HS, Piloptic) |
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brinzolamide (Azopt) |
timolol (Betimol, Istalol, Timoptic, |
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carbachol (Isopto Carbachol, Miostat) |
timolol/dorzolamide (Cosopt) |
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carteolol |
travoprost (Travatan Z) |
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Sulfonamides |
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sodium sulfacetamide/prednisolone (Blephamide S.O.P.) |
sulfacetamide sodium |
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Sulfamide) |
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OTICS
ciprofloxacin/dexamethasone (Ciprodex) |
neomycin/polymixin B/hydrocortisone (Cortisporin Otic) |
ciprofloxacin/hydrocortisone (Cipro HC Otic)
neomycin/colistin/hydrocortisone/thonzonium ofloxacin
neomycin/colistin/hydrocortisone
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RESPIRATORY |
|
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Anticholinergics |
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ipratropium (Atrovent HFA) |
tiotropium (Spiriva) |
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|
Proprietary & Confidential |
Page 10 |
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Revision Date: July 24, 2014 |
Magellan Health ServicesTennCare Attestation List
|
RESPIRATORY |
|
|
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Beta Agonist: |
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|
albuterol (ProAir HFA) |
levalbuterol (Xopenex, Xopenex HFA) |
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|
Beta Agonist/Anticholinergic Combinations |
|
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albuterol/ipratropium (Combivent) |
|
|
|
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Beta Agonists: Other |
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|
formoterol (Foradil, Perforomist) |
salmeterol (Serevent) |
|
|
metaproterenol |
terbutaline (Brethine) |
|
|
pirbuterol (Maxair Autohaler) |
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Beta Agonist/Corticosteroid Combinations |
|
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budesonide/formoterol (Symbicort) |
|
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fluticasone/salmeterol (Advair) |
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mometasone/formoterol (Dulera) |
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Inhaled Corticosteroids |
|
|
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beclomethasone (QVAR) |
fluticasone (Flovent Diskus, Flovent HFA) |
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|
budesonide (Pulmicort Respules, Pulmicort Flexhaler) |
mometasone (Asmanex Twisthaler) |
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flunisolide (Aerospan) |
|
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Monoclonal Antibody |
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omalizumab (Xolair) |
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Mucolytics |
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acetylcysteine |
dornase alfa (Pulmozyme) |
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Xanthines |
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aminophylline |
dyphylline (Dylix, Lufyllin) |
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caffeine citrated (Cafcit) |
theophylline anhydrous |
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caffeine/sodium benzoate |
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VITAMINS AND ELECTROLYTES
Potassium Supplements (Rx ONLY)
potassium chloride (Epiklor,
Proprietary & Confidential |
Page 11 |
Revision Date: July 24, 2014