Bluecare.bcbst.com

STATE OF TENNESSEE
BUREAU OF TENNCARE
DEPARTMENT OF FINANCE AND ADMINISTRATION
310 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 summarize the upcoming PDL changes for the TennCare pharmacy program. We encourage you to
read this notice thoroughly and contact SXC’s Technical Call Center (866-434-5520) should you have additional questions.

PREFERRED DRUG LIST (PDL) FOR TENNCARE EFFECTIVE 7/1/10
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. For medications with existing prior
authorizations in place, each PA will remain active through the current expiration date. A copy of the new PDL will be posted
July 1, 2010 to
We encourage you to share this information with other TennCare providers. The individual changes to the PDL are listed below.
For more details on clinical criteria, please visit:
Below is a summary of the PDL changes that will be effective July 1, 2010.

Oral Thrombopoietin Receptor Agonist
The following agent will be added as non-preferred: Promacta® CC, QL. Anti-Diarrheals
The following agents will remain as preferred: diphenoxylate/atropine, Lofene®, Lonox®, and loperamide. The following agents will be added as non-preferred: opium tincture and paregoric. Additionally, the following agents will remain as non-preferred: Lomotil® and Motofen®. Current users of opium tincture and paregoric will be indefinitely grandfathered. 5-ASA Derivatives, Oral Preparations
The following agents will become preferred: balsalazide QL, Dipentum® QL, and Pentasa® QL. Additionally, the following agents will remain preferred: Asacol® QL, Lialda® QL, sulfasalazine ECQL, sulfasalazineQL, Sulfazine EC® QL, and Sulfazine® QL. The following agents will remain non-preferred: Apriso® QL, Asacol HD® QL, Azulfidine® QL,
Azulfidine EN® QL, and Colazal® QL.
5-ASA Derivatives, Rectal Preparations
The following agents will remain preferred: Canasa® and mesalamine enema. The following agents will be added as non-preferred: mesalamine kit, Rowasa kit®, and sfRowasa®. Mucosal Protectants
The following agents will remain as preferred: misoprostol and sucralfate tablets. The following agent will become non-preferred: sucralfate suspension CC. Additionally, the following agents will remain as non-preferred: Carafate® and Cytotec®. Saliva Stimulating Agents
The following agent will become preferred: pilocarpineCC, QL. The following agents will remain as non-preferred: Evoxac® CC, QL and Salagen® CC, QL.
NOTE:
All of the aforementioned changes, whether preferred or non-preferred, may have additional criteria which control their usage.
Any clinical criteria associated with an agent are noted with a superscripted “CC” and any step therapy criteria associated with an
agent are noted with a superscripted “ST.” Please refer to the document “Drug Criteria Listing” located at:
for additional information.


CC = Subject to specific clinical criteria ST = Subject to specific step therapy criteria Changes to Prior Authorization Criteria (CC, ST, QL) for the PDL (effective 7-1-10)
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GUIDE FOR TENNCARE PHARMACIES: OVERRIDE CODES
OVERRIDE TYPE
OVERRIDE NCPDP FIELD
Emergency 3-Day Supply of Non-PDL Product Patient Location Field (NCPDP field 307-C7) Pregnancy Indicator Field (NCPDP field 335-2C) Titration Dose Override for the following select drugs/drug classes: anticonvulsants, warfarin, low molecular weight heparins, theophylline, Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Norepinephrine Reuptake Inhibitors (SNRIs), atypical antipsychotics (except clozapine/Clozaril®), Hizentra®, Vivaglobin® - process second Rx for the same drug within 21 days of initial Rx with an override code to avoid the second Rx counting as another prescription against the limit. Two co-pays will apply. Titration Dose Override for the following select drugs/drug classes: clozapine/Clozaril®, Suboxone®, and Subutex®- will allow up to four prescription fills to process for the same drug within a month of the initial prescription without the subsequent fills counting against the enrollee’s monthly RX limit. Two-co pays will apply.
Important Phone Numbers:
TennCare Family Assistance Service Center
Express Scripts Health Options Hotline (RxOutreach PAP) TennCare Pharmacy Program (providers only) 888-816-1680
TennCare Pharmacy Program Fax

Helpful TennCare Internet Links:
SXC:
TennCare website: Please visit the SXC / TennCare website regularly to stay up-to-date on changes to the pharmacy program. For additional information or updated payer specifications, please visit the SXC website at: under “Pharmacist and Prescriber,” then “Program Requirements.” 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.
CC = Subject to specific clinical criteria ST = Subject to specific step therapy criteria

Source: http://bluecare.bcbst.com/providers/Formulary_Changes.pdf