Tenncare Attestation Form PDF Details

Accessing TennCare health plan benefits shouldn’t be hard – that’s why we’ve created this guide to help you navigate the TennCare attestation form. In this post, we'll explore what the attestation form is, when and why it should be used and anything else worth knowing before submitting your application. With the right information at hand, obtaining TennCare healthcare coverage can be an easy task, so let's dive in and take a look!

QuestionAnswer
Form NameTenncare Attestation Form
Form Length11 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 45 sec
Other namestenncare attestation form pdf, attestatison for tncare, tncareattestionform, attestation tenncare form

Form Preview Example

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 1-866-434-5524.

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 non-preferred status on the PDL, clinical criteria, step therapy criteria, and quantity limits.*

 

ANTI-INFECTIVES

 

 

 

Aminoglycosides

 

 

amikacin (Amikin)

paromomycin

 

 

gentamicin (Garamycin)

streptomycin

 

 

kanamycin

tobramycin (Nebcin, Tobi)

 

 

neomycin (Neo-Fradin)

 

 

 

 

Cephalosporins, First Generation

 

 

cefadroxil (Duricef)

cephalexin (Keflex)

 

 

cefazolin (Ancef)

 

 

 

 

Cephalosporins, Second Generation

 

 

cefaclor (Ceclor)

cefprozil (Cefzil)

 

 

cefoxitin (Mefoxin)

cefuroxime (Ceftin, Zinacef)

 

 

 

Cephalosporins, Third Generation

 

 

cefdinir

ceftazidime (Fortaz, Tazicef)

 

 

cefditoren (Spectracef)

ceftibuten (Cedax)

 

 

cefixime (Suprax)

ceftizoxime (Cefizox)

 

 

cefotaxime (Claforan)

ceftriaxone (Rocephin)

 

 

cefpodoxime (Vantin)

 

 

 

 

Cephalosporins, Fourth Generation

 

 

cefepime (Maxipime)

 

 

 

 

Ketolides

 

 

telithromycin (Ketek)

 

 

 

 

Lincosamides

 

 

clindamycin (Cleocin)

lincomycin (Lincocin)

 

 

Proprietary & Confidential

© 2014, Magellan Health Services, Inc. All Rights Reserved.

Magellan Health ServicesTennCare Attestation List

ANTI-INFECTIVES

 

Macrolides

 

 

azithromycin (Zithromax, Zmax)

erythromycin (E.E.S., Eryc, Ery-Tab, EryPed)

 

 

clarithromycin (Biaxin, Biaxin XL)

erythromycin/sulfisoxazole (Eryzole, Pediazole)

 

Nitrofurans

 

 

nitrofurantoin (Furadantin, Macrodantin, Macrobid)

 

 

Nitroimidazoles

 

 

metronidazole HCl (Flagyl)

tinidazole (Tindamax)

 

Oxazolidinones

 

 

linezolid (Zyvox)

 

 

Penicillins

 

 

amoxicillin/potassium clavulanate (Augmentin)

oxacillin

 

 

amoxicillin

penicillin G (Bicillin C-R, Bicillin L-A, Permapen)

 

 

ampicillin

penicillin V potassium (Veetids)

 

 

ampicillin/sulbactam (Unasyn)

piperacillin

 

 

dicloxacillin

piperacillin/tazobactam (Zosyn)

 

 

nafcillin

ticarcillin/potassium clavulanate (Timentin)

 

Quinolones

 

 

ciprofloxacin (Cipro, Cipro XR, Proquin XR)

moxifloxacin (Avelox)

 

 

gemifloxacin (Factive)

norfloxacin (Noroxin)

 

 

levofloxacin (Levaquin)

ofloxacin (Floxin)

 

Sulfonamides

 

 

sulfadiazine

sulfasalazine (Azulfidine)

 

 

sulfamethoxazole/trimethoprim (Bactrim, Septra)

trimethoprim

 

Tetracyclines

 

 

demeclocycline

minocycline (Arestin, Dynacin, Minocin, Myrac)

 

 

doxycycline (Adoxa, Atridox, Doryx, Monodox, Oracea,

tetracycline (Sumycin)

Oraxyl, Periostat, Vibramycin)

 

Vancomycin and Derivatives

vancomycin (Vancocin)

Miscellaneous Antibiotics

fosfomycin (Monurol)

methenamine (Hiprex, Urex)

 

 

Proprietary & Confidential

Page 2

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

 

ANTI-INFECTIVES

 

 

 

Antifungals

 

 

amphotericin B (Abelcet, Ambisome, Amphocin,

itraconazole (Sporanox)

Amphotec)

 

 

 

anidulafungin (Cancidas)

micafungin (Mycamine)

 

 

caspofungin (Eraxis)

miconazole (Monistat)

 

 

fluconazole (Diflucan)

posaconazole (Noxafil)

 

 

flucytosine (Ancobon)

voriconazole (Vfend)

 

 

griseofulvin (Fulvicin U/F, Gris-Peg, Grifulvin V)

 

 

 

 

Antiparasitics

 

 

albendazole (Albenza)

mefloquine

 

 

artemether/lumefantrine (Coartem)

nitazoxanide (Alinia)

 

 

atovaqu one/proguanil (Malarone)

paromomycin

 

 

atovaquone (Mepron)

pentamidine (Nebupent, Pentam 300)

 

 

chloroquine (Aralen)

praziquantel (Biltricide)

 

 

dapsone

primaquine

 

 

iodoquinol (Yodoxin)

pyrantel (Pin-X, Reese Pinworm)

 

 

ivermectin (Stromectol)

pyrimethamine (Daraprim)

 

 

mebendazole

quinine (Qualaquin)

 

 

 

Antivirals

 

 

acyclovir (Zovirax)

penciclovir (Denavir)

 

 

famciclovir (Famvir)

valacyclovir (Valtrex)

 

 

oseltamivir (Tamiflu)

zanamivir (Relenza)

 

 

 

 

CARDIOVASCULAR

Anti-Anginal Agents, Miscellaneous

ranolazine (Ranexa)

Proprietary & Confidential

Page 3

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

 

CARDIOVASCULAR

 

 

 

Antiarryhthmics

 

 

adenosine (Adenocard)

lidocaine (Xylocaine)

 

 

amiodarone (Cordarone, Pacerone)

mexiletine (Mexitil)

 

 

bretylium

procainamide

 

 

disopyramide IR/SA (Norpace/Norpace CR)

propafenone (Rythmol/Rythmol SR)

 

 

dofetilide (Tikosyn)

quinidine gluconate

 

 

dronedarone (Multaq)

quinidine sulfate (Quinidex)

 

 

flecainide (Tambocor)

sotalol/sotalol af (Betapace/Betapace AF)

 

 

ibutilide (Corvert)

 

 

 

 

Anticoagulants

 

 

apixaban (Eliquis)

heparin (Heparin)

 

 

dalteparin (Fragmin)

rivaroxaban (Xarelto)

 

 

dabigatran Etexilate (Pradaxa)

tinzaparin (Innohep)

 

 

enoxaparin (Lovenox)

warfarin (Coumadin, Jantoven)

 

 

fondaparinux (Arixtra)

 

 

 

 

Antifibrinolytics

 

 

aminocaproic acid (Amicar)

tranexamic acid (Cyklokapron, Lysteda)

 

 

aprotinin (Trasylol)

 

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

 

CARDIOVASCULAR

 

Hypotensives, Angiotensin Receptor Blockers

 

 

azilsartan (Edarbi)

losartan/HCTZ (Hyzaar)

 

 

candesartan (Atacand)

olmesartan (Benicar)

 

 

candesartan/HCTZ (Atacand HCT)

olmesartan/HCTZ (Benicar HCT)

 

 

eprosartan (Teveten)

telmisartan (Micardis)

 

 

eprosartan/HCTZ (Teveten HCT)

telmisartan/HCTZ (Micardis HCT)

 

 

irbesartan (Avapro)

valsartan (Diovan)

 

 

irbesartan/HCTZ (Avalide)

valsartan/HCTZ (Diovan HCT)

 

 

losartan potassium (Cozaar)

 

 

Hypotensives, Direct Renin Inhibitors

 

 

aliskiren/valsartan (Valturna)

aliskiren/HCTZ (Tekturna HC)

 

 

aliskiren (Tekturna)

 

 

Hypotensives, Sympatholytics

 

 

clonidine (Catapres, Catapres TTS, Nexiclon XR)

methyldopa/HCTZ

 

 

guanabenz

methyldopate

 

 

guanfacine (Tenex)

reserpine

 

 

methyldopa (Aldomet)

 

 

Hypotensives, Vasodilators

 

 

diazoxide (Hyperstat I.V.)

hydralazine HCl (Apresoline)

 

 

fenoldopam mesylate (Corlopam)

minoxidil (Minoxidil)

 

Oral Thrombopoietic Agonists

 

 

eltrombopag (Promacta)

 

 

 

 

Pheochromocytoma Agents

 

 

metyrosine (Demser)

 

 

Platelet Aggregation Inhibitors/Intermittent Claudication

 

 

abciximab (Reopro)

pentoxifylline (Trental)

 

 

aspirin/dipyridamole (Aggrenox)

prasugrel (Effient)

 

 

cilostazol (Pletal)

ticagrelor (Brilinta)

 

 

clopidogrel (Plavix)

ticlopidine (Ticlid)

 

 

dipyridamole (Persantine)

tirofiban (Aggrastat)

 

 

eptifibatide (Integrilin)

vorapaxar (Zontivity)

 

 

Proprietary & Confidential

Page 5

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

CARDIOVASCULAR

 

Pulmonary Hypertension Agents

 

 

ambrisentan (Letairis)

riociguat (Adempas)

 

 

bosentan (Tracleer)

sildenafil (Revatio)

 

 

epoprostenol (Flolan)

tadalafil (Adcirca)

 

 

iloprost (Ventavis)

treprostinil (Remodulin, Tyvaso, Orenitram)

 

 

macitentan (Opsumit)

 

 

Vasodilators

 

 

amyl nitrite

isosorbide mononitrate (Imdur, Monoket)

 

 

isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil)

nitroglycerin (Minitran, Nitrek, Nitro-Bid, Nitro-Dur,

 

Nitrolingual, Nitroquick, Nitrostat, Nitrotab, Nitro-

 

Time, Nitromist)

 

Vasopressors

 

 

midodrine

 

 

 

 

 

 

CNS

 

Anticonsulvants

 

 

carbamazepine (Tegretol, Tegretol XR)

lacosamide (Vimpat)

 

 

clobazam (Onfi)

methsuximide (Celontin)

 

 

clonazepam (Klonopin)

oxcarbazepine (Trileptal)

 

 

clonazepam ODT (Klonopin Wafer)

perampanel (Fycompa)

 

 

diazepam rectal gel (Diastat)

phenobarbital

 

 

divalproex sodium (Depakote, Depakote ER, Depakote

phenytoin (Dilantin, Dilantin Kapseals, Phenytek)

Sprinkles)

 

 

 

eslicarbazepine (Aptiom)

pregabalin (Lyrica)

 

 

ethosuximide (Zarontin)

primidone (Mysoline)

 

 

ethotoin (Peganone)

rufinamide (Banzel)

 

 

ezogabine (Potiga)

tiagabine (Gabitril)

 

 

felbamate (Felbatol)

topiramate (Topamax, Qudexy XR)

 

 

fosphenytoin (Cerebyx)

valproate sodium (Depacon)

 

 

gabapentin (Neurontin)

valproic acid (Depakene, Stavzor)

 

 

lamotrigine (Lamictal, Lamictal XR)

vigabatrin (Sabril)

 

 

levetiracetam (Keppra, Keppra XR)

zonisamide (Zonegran)

 

 

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)

 

 

 

maprotiline

trazodone (Oleptro)

 

 

mirtazapine (Remeron, Remeron SolTab)

vilazodone (Viibryd)

 

Antidepressants, SNRIs and SSRIs

 

 

citalopram (Celexa)

fluvoxamine

 

 

desvenlafaxine (Pristiq, Khedezla)

milnacipran (Savella)

 

 

duloxetine (Cymbalta)

paroxetine (Paxil, Paxil CR, Pexeva)

 

 

escitalopram (Lexapro)

sertraline HCl (Zoloft)

 

 

fluoxetine (Prozac, Prozac Weekly, Sarafem)

venlafaxine (Effexor XR)

 

Anti-Parkinson Agents

 

 

apomorphine (Apokyn)

rasagiline (Azilect)

 

 

bromocriptine (Parlodel)

ropinirole (Requip, Requip XL)

 

 

carbidopa/levodopa (Sinemet, Sinemet CR)

selegiline (Zelapar, Eldepryl)

 

 

carbidopa/levodopa/entacapone (Stalevo)

tolcapone (Tasmar)

 

 

pramipexole (Mirapex, Mirapex ER)

 

 

 

entacapone (Comtan)

 

 

Antipsychotics

 

 

chlorpromazine (Thorazine)

perphenazine

 

 

droperidol (Inapsine)

pimozide (Orap)

 

 

fluphenazine

prochlorperazine (Compazine)

 

 

haloperidol (Haldol)

thioridazine

 

 

loxapine (Loxitane)

thiothixene (Navane)

 

 

molindone (Moban)

trifluoperazine

 

Antipsychotics, Atypical

 

 

aripiprazole (Abilify, Abilify Discmelt, Abilify Maintena)

olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv)

 

 

asenapine (Saphris)

paliperidone (Invega, Invega Sustenna)

 

 

clozapine (Clozaril, FazaClo)

quetiapine (Seroquel, Seroquel XR)

 

 

iloperidone (Fanapt)

risperidone (Risperdal, Risperdal Consta)

 

 

lurasidone (Latuda)

ziprasidone (Geodon)

 

MAOIs

 

 

isocarboxazide (Marplan)

selegiline (Eldepryl, Emsam, Zelapar)

 

 

phenelzine (Nardil)

tranylcypromine (Parnate)

 

 

 

 

Proprietary & Confidential

Page 7

 

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

 

CNS

 

 

 

Mood Stabilizers

 

 

lithium carbonate (Lithobid)

lithium citrate

 

 

lithium carbonate ER

 

 

 

 

SSRI/Antipsychotic Combos

 

 

olanzapine/fluoxetine (Symbyax)

 

 

 

 

TCAs

 

 

amitriptyline

imipramine (Tofranil, Tofranil-PM)

 

 

amoxapine

nortriptyline (Pamelor)

 

 

clomipramine (Anafranil)

protriptyline (Vivactil)

 

 

desipramine (Norpramin)

trimipramine (Surmontil)

 

 

doxepin

 

 

 

 

ENDOCRINE AGENTS

 

 

 

Glucocorticoids, Oral

 

 

cortisone

hydrocortisone (Cortef)

 

 

betamethasone solution (Celestone)

methylprednisolone (Medrol)

 

 

budesonide (Entocort EC)

prednisolone (Millipred, Orapred, Pediapred, Prelone)

 

 

dexamethasone (Dexpak, Dekpak Jr.)

prednisone

 

 

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)

 

 

12,000 L/38,000 P/60,000 A (Creon L 12,000 units)

 

 

Pancreatic Enzymes

 

 

Pancreaze

Viokace

 

 

Pertyze

ZenPep

 

 

Ultresa

 

 

 

 

Anti-Emetics

 

 

ondansetron (tabs, ODT, solution)

Kytril®

Zofran® (tabs, ODT, solution)

Sancuso®

Anzemet®

Zuplenz®

granisetron

 

 

 

Proprietary & Confidential

Page 8

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

 

IMMUNOGOLOGIC AGENTS

 

 

 

Immunomodulators

 

 

anakinra (Kineret)

certolizumab pegol (Cimzia)

 

 

adalimumab (Humira)

golimumab (Simponi)

 

 

etanercept (Enbrel)

ustekinumab (Stelara)

 

 

 

Immune Globulins

 

 

Gammagard

Hizentra

 

 

Gamunex-C

Vivaglobin

 

 

 

Multiple Sclerosis

 

 

Fingolimod (Gilenya)

interferon beta-1b (Betaseron, Extavia)

 

 

glatiramer acetate (Copaxone)

teriflunomide (Aubagio)

interferon beta-1a (Avonex, Avonex Administration Pack, Rebif)

MISCELLANEOUS

epinephrine (TwinJect, EpiPen, EpiPen Jr., Adrenaclick)

OPHTHALMICS

Antibiotic/Corticoid Combinations

gentamicin/prednisolone (Pred-G)

neomycin/polymyxin B/prednisolone (Poly-Pred)

 

 

neomycin/bacitracin/polymyxin/hydrocortisone

tobramycin/dexamethasone (Tobradex ointment)

(Cortisporin)

 

 

 

neomycin/polymyxin B/dexamethasone (Maxitrol)

tobramycin/loteprednol (Zylet)

 

neomycin/polymyxin B/hydrocortisone (Cortisporin)

 

 

 

Antibiotics

 

 

azithromycin (AzaSite)

levofloxacin (Iquix, Quixin)

 

 

bacitracin

moxifloxacin (Vigamox)

 

 

bacitracin/polymyxin B (AK-Poly-BAC, Polycin-B,

neomycin/ polymyxin B/bacitracin (Neosporin)

Polysporin)

 

 

 

besifloxacin (Besivance)

neomycin/polymyxin B/gramicidin (Neosporin Eye

 

Drops)

 

 

chloramphenicol (Chloromycetin)

ofloxacin (Ocuflox)

 

 

ciprofloxacin (Ciloxan)

polymyxin B/trimethoprim (Polytrim)

 

 

erythromycin (Ilotycin, Romycin)

sulfacetamide sodium (Bleph-10)

 

 

gatifloxacin (Zymar)

tobramycin (AK-Tob, Tobrasol, Tobrex)

gentamicin (Garamycin, Genoptic, Gentak, Gentasol)

Proprietary & Confidential

Page 9

 

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

OPHTHALMICS

Antifungals

 

 

natamycin (Natacyn)

 

 

Antivirals

 

 

ganciclovir (Zirgan)

trifluridine (Viroptic)

 

Anti-inflammatory Agents

 

 

bromfenac (Xibrom)

ketorolac (Acular, Acular LS, Acular PF)

 

 

diclofenac (Voltaren)

loteprednol (Alrex, Lotemax)

 

 

fluorometholone (Flarex, FML Forte, FML Liquifilm, FML

nepafenac (Nevanac)

S.O.P.)

 

 

 

flurbiprofen (Ocufen)

rimexolone (Vexol)

 

Miotics/IOP Reducers

 

 

acetylcholine chloride (Miochol-E)

dorzolamide (Trusopt)

 

 

apraclonidine (Iopidine)

latanoprost (Xalatan)

 

 

betaxolol (Betoptic-S)

levobunolol (Betagan)

 

 

bimatoprost (Lumigan)

metipranolol (OptiPranolol)

 

 

brimonidine (Alphagan P)

pilocarpine (Isopto Carpine, Pilopine HS, Piloptic)

 

 

brinzolamide (Azopt)

timolol (Betimol, Istalol, Timoptic, Timoptic-XE GFS)

 

 

carbachol (Isopto Carbachol, Miostat)

timolol/dorzolamide (Cosopt)

 

 

carteolol

travoprost (Travatan Z)

 

Sulfonamides

 

 

sodium sulfacetamide/prednisolone (Blephamide S.O.P.)

sulfacetamide sodium (Bleph-10, Ocusulf-10, Sulfac,

 

Sulfamide)

 

 

OTICS

Antibiotics/Anti-inflammatory Agents

ciprofloxacin/dexamethasone (Ciprodex)

neomycin/polymixin B/hydrocortisone (Cortisporin Otic)

ciprofloxacin/hydrocortisone (Cipro HC Otic)

Antibiotics/Anti-inflammatory Agents

neomycin/colistin/hydrocortisone/thonzonium ofloxacin (Cortisporin-TC Otic)

neomycin/colistin/hydrocortisone (Colymycin-S)

 

RESPIRATORY

 

 

 

Anticholinergics

 

 

ipratropium (Atrovent HFA)

tiotropium (Spiriva)

 

 

 

 

Proprietary & Confidential

Page 10

 

Revision Date: July 24, 2014

Magellan Health ServicesTennCare Attestation List

 

RESPIRATORY

 

 

 

Beta Agonist: Short-Acting

 

 

albuterol (ProAir HFA)

levalbuterol (Xopenex, Xopenex HFA)

 

 

 

Beta Agonist/Anticholinergic Combinations

 

albuterol/ipratropium (Combivent)

 

 

 

Beta Agonists: Other

 

 

formoterol (Foradil, Perforomist)

salmeterol (Serevent)

 

 

metaproterenol

terbutaline (Brethine)

 

 

pirbuterol (Maxair Autohaler)

 

Beta Agonist/Corticosteroid Combinations

 

 

budesonide/formoterol (Symbicort)

 

 

 

fluticasone/salmeterol (Advair)

 

 

 

mometasone/formoterol (Dulera)

 

 

Inhaled Corticosteroids

 

 

beclomethasone (QVAR)

fluticasone (Flovent Diskus, Flovent HFA)

 

 

budesonide (Pulmicort Respules, Pulmicort Flexhaler)

mometasone (Asmanex Twisthaler)

 

 

flunisolide (Aerospan)

 

 

Monoclonal Antibody

 

 

omalizumab (Xolair)

 

 

Mucolytics

 

 

acetylcysteine

dornase alfa (Pulmozyme)

 

Xanthines

 

 

aminophylline

dyphylline (Dylix, Lufyllin)

 

 

caffeine citrated (Cafcit)

theophylline anhydrous (Theo-24, Theochron, Uniphyl)

 

 

caffeine/sodium benzoate

 

 

 

VITAMINS AND ELECTROLYTES

Potassium Supplements (Rx ONLY)

potassium chloride (Epiklor, Kaon-CL, Klor-Con, K-tabs, potassium chloride, microencapsulated (Klor-Con M) K-Vescent, Micro K)

Proprietary & Confidential

Page 11

Revision Date: July 24, 2014