PDF File
|
|
For Prescription Drug Benefits |
319 KB |
PDF File
|
Quantity Limit or High Dose Exceptions Only
|
|
39 KB |
PDF File
|
|
TEKAMLO 150 MG-5 MG TABLET, TEKAMLO 150 MG-10 MG TABLET, TEKTURNA 150 MG TABLET, TEKTURNA HCT 150-12.5 MG TAB, TEKTURNA HCT 150-25 MG TABLET |
67 KB |
PDF File
|
|
AMTURNIDE 300-5-25 MG TAB, TEKTURNA 300 MG TABLET, TEKTURNA HCT 300-12.5 MG TAB, TEKTURNA HCT 300-25 MG TABLET |
67 KB |
PDF File
|
|
zafirlukast (ACCOLATE) |
59 KB |
PDF File
|
STAR and STAR KID Members Only
|
ABSORICA cap |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CLEOCIN-T LOTION, clindamycin gel (CLINDAGEL), clindamycin lotion, dapsone gel, erythromycin pads (ERY PADS), EVOCLIN FOAM, sulfacetamide lotion |
21 KB |
PDF File
|
|
tocilizumab (ACTEMRA) |
66 KB |
PDF File
|
|
pioglitazone (ACTOS), pioglitazone/metformin (ACTOPLUS MET), pioglitazone/glimepiride (DUETACT) |
148 KB |
PDF File
|
|
tralokinumab-ldrm (ADBRY) |
214 KB |
PDF File
|
|
atomoxetine (STRATTERA) |
212 KB |
PDF File
|
|
guanfacine extended-release (INTUNIV ER) |
205 KB |
PDF File
|
|
viloxazine (QELBREE) |
214 KB |
PDF File
|
|
clonidine ER |
27 KB |
PDF File
|
|
amphetamine salts (MYDAYIS), amphetamine/dextroamphetamine salts (ADDERALL XR, DYANAVEL XR, ADZENYS ER, ADZENYS XR-ODT), AZSTARYS, dexmethylphenidate (FOCALIN XR), dextroamphetamine (DEXEDRINE SPANSULE), methylphenidate (ADHANSIA XR, APTENSIO XR, CONCERTA, COTEMPLA XR-ODT, DAYTRANA TD, JORNAY PM, QUILLICHEW ER, QUILLIVANT XR, RITALIN LA), lisdexamfetamine (VYVANSE capsule, VYVANSE chewable tablet) |
195 KB |
PDF File
|
NOTE: Drugs listed are a representative list, only. See plan formulary to verify coverage status. Formulary available at www.txvendordrug.com
|
amphetamine/dextroamphetamine salts (ADDERALL), amphetamine sulfate (EVEKEO, EVEKEO ODT), dexmethylphenidate (FOCALIN), dextroamphetamine (DEXEDRINE, PROCENTRA, ZENZEDI), methamphetamine (DESOXYN), methylphenidate (METHYLIN, RITALIN) |
196 KB |
PDF File
|
|
CERDELGA, CEREZYME, ELELYSO, miglustat (ZAVESCA), VPRIV |
20 KB |
PDF File
|
|
imiquimod 5% cream (ALDARA) |
52 KB |
PDF File
|
|
laronidase (ALDURAZYME) |
166 KB |
PDF File
|
|
nitazoxanide (ALINIA) tablets |
60 KB |
PDF File
|
|
grass pollen allergen extract (ORALAIR) |
216 KB |
PDF File
|
|
peanut allergen powder (PALFORZIA) |
198 KB |
PDF File
|
STAR and STAR KID Members Only
|
ADLARITY, donepezil (ARICEPT), galantamine (RAZADYNE ER), memantine (NAMENDA), memantine extended-release (NAMENDA XR), NAMZARIC, NAMZARIC PACK, rivastigmine |
22 KB |
PDF File
|
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Osmolex ER, Gocovri |
66 KB |
PDF File
|
|
lubiprostone (AMITIZA) |
203 KB |
PDF File
|
|
testosterone (ANDRODERM, ANDROGEL, FORTESTA, TESTIM, VOGELXO), testosterone solution |
198 KB |
PDF File
|
STAR and STAR KID Members Only
|
amlodipine/olmesartan (AZOR), amlodipine/valsartan/hydrochlorothiazide (EXFORGE), LOTREL, olmesartan medoxomil/amlodipine/hydrochlorothiazide (TRIBENZOR), telmisartan/amlodipine, trandolapril/verapamil (TARKA) |
126 KB |
PDF File
|
STAR and STAR KID Members Only
|
ACCUPRIL, ALTACE, AVALIDE, AVAPRO, benazepril/hydrochlorothiazide, candesartan (ATACAND), candesartan/hydrochlorothiazide (ATACAND HCT), captopril, COZAAR, EDARBI, EDARBYCLOR, enalapril (VASOTEC), fosinopril/hydrochlorothiazide, HYZAAR, moexipril, olmesartan (BENICAR), olmesartan/hydrochlorothiazide (BENICAR HCT), perindopril, QBRELIS, quinapril/hydrochlorothiazide (ACCURETIC), telmisartan (MICARDIS), telmisartan/hydrochlorothiazide (MICARDIS HCT), trandolapril, valsartan, valsartan/hydrochlorothiazide (DIOVAN HCT), VASERETIC, ZESTORETIC |
55 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
COUMADIN, dabigatran etexilate mesylate (PRADAXA), fondaparinux (ARIXTRA), FRAGMIN, FRAGMIN INJ, LOVENOX, SAVAYSA |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
APLENZIN, AUVELITY, BUPROPION ER, desvenlafaxine ER, EMSAM, FETZIMA, MARPLAN, NARDIL, NEFAZODONE, REMERON, tranylcypromine, TRINTELLIX, venlafaxine (EFFEXOR XR), VIIBRYD, VILAZODONE, WELLBUTRIN |
22 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CELEXA, escitalopram solution, fluoxetine tablets, fluoxetine capsules (PROZAC), fluvoxamine, LEXAPRO tablets, paroxetine (PAXIL), paroxetine ER, ZOLOFT |
22 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
amoxapine, clomipramine (ANAFRANIL), desipramine, imipramine pamoate (TOFRANIL), maprotiline, nortriptyline (PAMELOR), protriptyline, trimipramine |
127 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
meclizine (ANTIVERT), GIMOTI, dronabinol (MARINOL), metoclopramide (REGLAN), prochlorperazine (COMPRO), scopolamine |
21 KB |
PDF File
|
|
AKYNZEO, ANZEMET, aprepitant (EMEND), EMEND SUSPENSION, GRANISETRON, SANCUSO |
28 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
BREXAFEMME, CRESEMBA, DIFLUCAN, flucytosine (ANCOBON), griseofulvin, itraconazole (SPORANOX, TOLSURA), ORAVIG, posaconazole (NOXAFIL), VIVJOA, voriconazole tab (VFEND), voriconazole susp |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
athletes foot spray, ciclopirox (LOPROX), clotrimazole/betamethasone, CLOTRIMAZOLE SOL, econazole, FUNGOID TINCTURE, ketoconazole (EXTINA), luliconazole, miconazole/petrolatum/zinc oxide, naftifine, nystatin/triamcinolone, oxiconazole (OXISTAT), TM-TOLNAFTATE LIQ, VUSION |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
24-Hour Allergy, Allergy D, Allergy Relief, Allergy Relief-D, antihistamine, cetirizine/pseudoephedrine, cetirizine, desloratadine (CLARINEX), fexofenadine/pseudoephedrine, fexofenadine, levocetirizine, loratadine-D, loratadine ODT, SEMPREX-D |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
colchicine cap/tab, febuxostat (ULORIC), MITIGARE |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
diclofenac pow (CAMBIA), dihydroergotamine (D.H.E. 45, MIGRANAL), REYVOW, TRUDHESA AER |
21 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
almotriptan, diclofenac powder, eletriptan (RELPAX), frovatriptan (FROVA), MAXALT, naratriptan, sumatriptan (ZEMBRACE), sumatriptan/naproxen, zolmitriptan tab/ODT (ZOMIG), sumatriptan inj (IMITREX) |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
EURAX, LINDANE shampoo, malathion lotion (OVIDE), ivermectin (SKLICE) lotion |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
carbidopa/levodopa tab (SINEMET), bromocriptine, carbidopa tab (LODOSYN), entacapone (COMTAN), DUOPA susp, GOCOVRI, INBRIJA CAP 42MG, NEUPRO, ONGENTYS CAP, OSMOLEX ER, pramipexole ER (MIRAPEX ER), rasagiline (AZILECT), ropinirole ER (REQUIP XL 6mg and 12mg), RYTARY, selegiline, STALEVO, tolcapone (TASMAR), ZELAPAR |
212 KB |
PDF File
|
NOTE: Drugs listed are a representative list, only. See plan formulary to verify coverage status. Formulary available at www.txvendordrug.com
|
ABILIFY, ABILIFY DISCMELT, ABILIFY MAINTENA, ABILIFY MYCITE, aripiprazole, asenapine, CAPLYTA, chlorpromazine, chlorpromazine inj, clozapine, FANAPT, fluphenazine, fluphenazine inj, GEODON, GEODON inj, haloperidol lactate injection, haloperidol tablet, INVEGA, loxapine, lurasidone (LATUDA), LYBALVI, MOLINDONE, olanzapine, olanzapine inj, olanzapine/fluoxetine, paliperidone, perphenazine, pimozide, quetiapine (SEROQUEL & SEROQUEL XR), REXULTI, RISPERDAL, risperidone, SAPHRIS, SECUADO, SYMBYAX, thioridazine, thiothixene, trifluoperazine VRAYLAR, ziprasidone, ZYPREXA, ZYPREXA ZYDIS |
198 KB |
PDF File
|
|
stiripentol (DIACOMIT) |
177 KB |
PDF File
|
|
cannabidiol (EPIDIOLEX) |
179 KB |
PDF File
|
|
fenfluramine (FINTEPLA) |
185 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
LIVTENCITY TAB, valganciclovir soln, valganciclovir tab |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
RELENZA, rimantadine, SITAVIG, TAMIFLU, VALTREX, XOFLUZA |
126 KB |
PDF File
|
|
alprazolam (XANAX) |
199 KB |
PDF File
|
|
clonazepam (KLONOPIN), diazepam |
231 KB |
PDF File
|
|
clorazepate |
205 KB |
PDF File
|
|
lorazepam |
216 KB |
PDF File
|
|
chlordiazepoxide, meprobamate, oxazepam |
217 KB |
PDF File
|
|
rilonacept (ARCALYST) |
201 KB |
PDF File
|
|
amikacin (ARIKAYCE) |
70 KB |
PDF File
|
|
rosiglitazone (AVANDIA) |
137 KB |
PDF File
|
STAR and STAR KID Members Only
|
doxazosin (CARDURA), dutasteride-tamsulosin (JALYN), dutasteride (AVODART), ENTADFI, PROSCAR, silodosin (RAPAFLO), FLOMAX, tadalafil |
22 KB |
PDF File
|
|
belimumab (BENLYSTA) |
63 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ALBUTEROL AEROSOL HFA, ALBUTEROL TABLETS, ARCAPTA CAPSULES, arformoterol nebulizer (BROVANA), formoterol nebulizer (PERFOROMIST), levalbuterol nebulizer, metaproterenol syrup, PROAIR DIGIHALER, PROAIR RESPICLICK, STRIVERDI RESPIMAT, terbutaline tablets |
23 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
betaxolol, carvedilol ER, COREG, metoprolol/hydrochlorothiazide, nadolol, nevivolol (BYSTOLIC), pindolol, propranolol/hydrochlorothiazide, propranolol ER (INDERAL LA, INDERAL XL, INNOPRAN XL), SOTYLIZE, timolol maleate tab, TENORMIN, TENORETIC, TOPROL XL, ZIAC |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CHENODAL, CHOLBAM, OCALIVA, URSO, URSO FORTE, ursodiol 300mg cap |
126 KB |
PDF File
|
STAR and STAR KID Members Only
|
darifenacin (ENABLEX), tolterodine (DETROL), tolterodine ER (DETROL LA), oxybutynin (DITROPAN XL), fesoterodine, flavoxate, GELNIQUE, GEMTESA, OXYTROL, solifenacin, trospium, trospium ER, VESICARE LS |
21 KB |
PDF File
|
|
|
22 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
risedronate (ACTONEL), alendronate soln, ATELVIA, ibandronate (BONIVA), calcitonin, raloxifene, FOSAMAX, FOSAMAX+D, TERIPARATIDE, TYMLOS |
126 KB |
PDF File
|
|
doxylamine/pyridoxine (BONJESTA, DICLEGIS) |
60 KB |
PDF File
|
|
buprenorphine/naloxone (BUNAVAIL, SUBOXONE, ZUBSOLV) |
179 KB |
PDF File
|
|
buprenorphine |
176 KB |
PDF File
|
|
odevixibat (BYLVAY) |
206 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CALAN SR, CARDIZEM, CARDIZEM CD, diltiazem (CARDIZEM LA), isradipine capsule, KATERZIA, matzim la tablet, nicardipine capule, nifedipine capsule, nimodipine, nisoldipine, NORVASC, PROCARDIA XL, verapamil (VERELAN), VERELAN PM |
21 KB |
PDF File
|
|
CARISOPRODOL, CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND TAB, SOMA |
68 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
amoxicillin/potassium clavulanate, amoxicillin and clavulanate potassium chewable, cefaclor, cefaclor ER, cefadroxil, cefixime (SUPRAX), cefpodoxime tablet, cefpodoxime proxetil oral suspension, cephalexin tablet |
126 KB |
PDF File
|
|
protein C concentrate human (CEPROTIN) |
166 KB |
PDF File
|
|
ubrogepant (UBRELVY) |
201 KB |
PDF File
|
|
rimegepant (NURTEC) |
222 KB |
PDF File
|
|
erenumab (AIMOVIG), fremanezumab (AJOVY), galcanezumab (EMGALITY), atogepant (QULIPTA) |
262 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
FULPHILA, GRANIX, LEUKINE, NEULASTA, NIVESTYM, UDENYCA, ZARXIO, ZIEXTENZO |
126 KB |
PDF File
|
Compound Drugs over $200
|
|
30 KB |
PDF File
|
|
|
18 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
BEVESPI, DALIRESP, DUAKLIR, INCRUSE, LONHALA, roflumilast, TUDORZA, UTIBRON, YUPELRI |
126 KB |
PDF File
|
Table A
|
ALAHIST PE TAB 2-7.5MG, APRODINE TAB, CHEST CONGESTION SYRUP 100/5ML, CHEST CONGESTION TAB 400MG, CHEST CONGESTION TAB 400MG, CHEST CONGESTION TAB RELIEF PE, CHEST CONGESTION TAB RELIEF PE, CHLO TUSS LIQUID, COLD AND ALLERGY CHILDRENS LIQUID, DECONEX IR TAB 10-385MG, DEXBROMPHENIRAMINE/PHENYLEPHRINE TAB 2-10MG, ED BRON GP LIQUID, HISTEX-PE LIQUID, MUCUS AND CHEST LIQUID 100MG/5ML, MUCUS RELIEF TAB 10-400MG, MUCUS/CHEST LIQUID 100/5ML, MUCUS/CHEST LIQUID 100/5ML, POLY-VENT IR TAB 60-380MG, RESCON-GG LIQUID, RESCON-GG LIQUID, ROBAFEN LIQUID 200MG/10ML, RU-HIST D TAB, RYNEX PE ELIXIR, RYNEX PSE ELIXIR |
179 KB |
PDF File
|
Table B
|
12 HOUR NASAL SPRAY, ALAHIST, ALA-HIST IR TAB, BPM-PSE-DM LIQ, BROM/PSE/DM SYRUP, BROTAPP DM LIQ, CHEST CONGESTION RELIEF DM SYRUP, CHLOR/DEXCH/PSE LIQ, COLD RELIEF CHILDRENS LIQ, COUGH DM SUSP, COUGH/CHEST DM SYRUP, DECONEX DMX TAB, DEXTROMETHORPHAN LIQ, DM/GG/PHENYL, DOXYLAMINE/PHENYLEPHRINE TAB, ED A-HIST, ENDACOF-DM LIQ, FLU/COLD DAYTIME POWDER, GNP TUSSIN DM LIQ, HISTEX-DM SYRUP, LOHIST-D LIQ, LOHIST-DM SYRUP, M-END DMX LIQ, MUCUS RELIEF LIQ, MUCUS/COUGH RELIEF, NASAL DECONGESTANT SPRAY, NASAL NO DRIP SPRAY, NASAL RELIEF SPRAY, NASOPEN PE LIQ, NINJACOF LIQ, NOHIST-DM LIQ, NOHIST-LQ LIQ, OXYMETAZOLINE NASAL SOLN, PEDIATRIC COUGH/COLD LIQ, PHENYLEPHRINE/BROMPHENIRAMINE/DM LIQ, POLY HIST FORTE TAB, POLY-HIST DM LIQ, POLYTUSSIN DM, POLY-VENT DM TAB, PROMETHAZINE DM SOLN, PROMETHAZINE DM SYRUP, PSEUDOEPHEDRINE-GUAIFENESIN TAB, RESCON DM SYRUP, ROBAFEN, RYMED TAB, RYNEX DM LIQ, SILTUSSIN DM DAS LIQ, SM TUSSIN, TUSSIN, VANACOF, VANATAB DM TAB, WESTUSSIN DM SYRUP |
180 KB |
PDF File
|
Table C
|
BENZONATATE |
163 KB |
PDF File
|
Table D
|
CHEST CONGESTION RELIEF D TAB 20-400MG, COUGH AND COLD TAB 4-30MG, DEXTROMETHORPHAN CAP 15MG, GUAIFENESIN/PSE ER TAB 120/1200, GUAIFENESIN/PSEUDOEPHEDRINE ER TAB 600-60MG, MUCUS RELIEF D TAB 60-600MG, MUCUS RELIEF DM COUGH TAB, MUCUS RELIEF DM ER TAB 30-600MG, MUCUS RELIEF ER TAB 30-600, MUCUS RELIEF ER TAB 600MG, MUCUS RELIEF TAB 1200MG, MUCUS RELIEF TAB 60-1200, NIGHTTIME LIQUID COUGH, PSEUDOEPHEDRINE/GUAIFENESIN ER TAB 60-600MG, PSEUDOEPHEDRINE/GUAIFENESIN TAB 60-600MG, RESCON TAB |
179 KB |
PDF File
|
STAR and STAR KID Members Only
|
ALLERGY MULTI SYMPTOM TAB, ALL-NITE COLD AND FLU LIQUID, COLD AND FLU DAYTIME LIQUID, COLD AND FLU NIGHTTIME CAP, COLD AND FLU RELIEF NIGHTTIME CAP, COLD AND SINUS CAP 30-200MG, COLD AND SINUS TAB 30-200MG, COLD/FLU CAP DAYTIME, COLD/FLU REL CAP NITETIME, COLD/FLU RELIEF DAYTIME CAP, DAYTIME COLD/FLU LIQUID 10-5-325, DAYTIME COLD/FLU RELIEF LIQUID 10/5/325, FLU HBP TAB 10-325-2, HEAD CONGESTION/MUCUS TAB, MAPAP COLD FORMULA TAB, NIGHTTIME COLD/FLU LIQUID, SEVERE COLD AND FLU TAB, SEVERE COLD/COUGH PAK, SEVERE COLD/FLU TAB, SINUS CONGESTION/PAIN TAB 5-325MG, SINUS RELIEF SEVERE TAB, SINUS RELIEF SOLN 1%, SINUS RELIEF TAB 5-325MG, SINUS/COLD-D TAB 120-220MG, SINUS+HEADACHE TAB 5-325MG, TUSSIN CF COUGH/FLU LIQUID |
21 KB |
PDF File
|
|
ivacaftor (KALYDECO) |
213 KB |
PDF File
|
|
lumacaftor / ivacaftor (ORKAMBI) |
199 KB |
PDF File
|
|
tezacaftor/ivacaftor and ivacaftor (SYMDEKO) |
205 KB |
PDF File
|
|
elexcaftor/tezacaftor/ivacaftor (TRIKAFTA) |
207 KB |
PDF File
|
|
adalimumab-atto (AMJEVITA), adalimumab (HUMIRA) |
258 KB |
PDF File
|
|
abrocitinib (CIBINQO) |
226 KB |
PDF File
|
|
certolizumab pegol (CIMZIA) |
213 KB |
PDF File
|
|
secukinumab (COSENTYX) |
211 KB |
PDF File
|
|
etanercept (ENBREL) |
200 KB |
PDF File
|
|
satralizumab-mwge (ENSPRYNG) |
204 KB |
PDF File
|
|
canakinumab (ILARIS) |
203 KB |
PDF File
|
|
tildrakizumab (ILUMYA) |
192 KB |
PDF File
|
|
sarilumab (KEVZARA) |
206 KB |
PDF File
|
|
anakinra (KINERET) |
205 KB |
PDF File
|
|
abatacept (ORENCIA) |
207 KB |
PDF File
|
|
apremilast (OTEZLA) |
189 KB |
PDF File
|
|
upadacitinib (RINVOQ) |
241 KB |
PDF File
|
|
brodalumab (SILIQ) |
205 KB |
PDF File
|
|
golimumab (SIMPONI) |
218 KB |
PDF File
|
|
risankizumab (SKYRIZI) |
193 KB |
PDF File
|
|
ustekinumab (STELARA) |
205 KB |
PDF File
|
|
ixekizumab (TALTZ) |
207 KB |
PDF File
|
|
guselkumab (TREMFYA) |
211 KB |
PDF File
|
|
tofacitinib citrate (XELJANZ / XELJANZ XR) |
232 KB |
PDF File
|
|
desmopressin injectable (DDAVP) |
175 KB |
PDF File
|
|
desmopressin oral (DDAVP) |
172 KB |
PDF File
|
|
|
19 KB |
PDF File
|
|
diclofenac 1.5% topical solution, diclofenac 2% topical solution (PENNSAID 2% PUMP) |
59 KB |
PDF File
|
|
diclofenac 3% gel (SOLARAZE 3% GEL) |
53 KB |
PDF File
|
|
apomorphine (APOKYN) inj & apomorphine (KYNMOBI) film |
197 KB |
PDF File
|
|
alogliptin 6.25 mg (NESINA 6.25 MG), JANUVIA 25 MG, ONGLYZA 2.5 MG, TRADJENTA 5 MG |
136 KB |
PDF File
|
|
alogliptin 12.5 mg (NESINA 12.5 MG), JANUVIA 50 MG |
61 KB |
PDF File
|
|
alogliptin 25 mg (NESINA 25 MG), JANUVIA 100 MG, ONGLYZA 5 MG |
139 KB |
PDF File
|
|
alogliptin-metformin (KAZANO), alogliptin-pioglitazone (OSENI), GLYXAMBI, JANUMET (XR), JENTADUETO (XR), KOMBIGLYZE XR, QTERN, STEGLUJAN |
137 KB |
PDF File
|
|
dupilumab (DUPIXENT) |
250 KB |
PDF File
|
For Cook Children’s Health Plans Only
|
idursulfase (ELAPRASE) |
196 KB |
PDF File
|
|
idursulfase (ELAPRASE) |
165 KB |
PDF File
|
|
deflazacort (EMFLAZA) |
76 KB |
PDF File
|
|
deflazacort (EMFLAZA) |
26 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
AUVI-Q ,epinephrine inj |
126 KB |
PDF File
|
|
darbepoetin alfa (ARANESP) |
26 KB |
PDF File
|
|
epoetin alfa (EPOGEN) |
29 KB |
PDF File
|
|
epoetin alfa (PROCRIT) |
36 KB |
PDF File
|
|
epoetin alfa (RETACRIT) |
28 KB |
PDF File
|
|
risdiplam (EVRYSDI) |
54 KB |
PDF File
|
|
risdiplam (EVRYSDI) |
55 KB |
PDF File
|
|
agalsidase beta (FABRAZYME) |
170 KB |
PDF File
|
|
benralizumab (FASENRA) |
193 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ALLERGY RELI CHW 25MG, clemastine, ed chlorped jr syrup, KARBINAL ER, RYVENT, triprolidine, VISTARIL |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
BAXDELA, CIPRO TAB, ciprofloxacin susp, levofloxacin soln, moxifloxacin tab, OFLOXACIN TAB |
126 KB |
PDF File
|
|
gabapentin (NEURONTIN) |
74 KB |
PDF File
|
|
migalastat (GALAFOLD) |
167 KB |
PDF File
|
|
teduglutide (GATTEX) |
195 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
DIFICID, DIFICID SUSP, metronidazole (FLAGYL), paromomycin, vancomycin (VANCOCIN HCL) |
21 KB |
PDF File
|
|
ADLYXIN, BYDUREON BCISE, BYETTA, MOUNJARO, OZEMPIC, RYBELSUS, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY |
218 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
DIAZOXIDE SUS, GLUCAGON EMERGENCY SOLN, GVOKE KIT SOLN, GVOKE PFS , ZEGALOGUE |
21 KB |
PDF File
|
|
relugolix-estradiol-norethindrone (MYFEMBREE), elagolix-estradiol-norethindrone acetate (ORIHANN) |
217 KB |
PDF File
|
|
gabapentin extended release (GRALISE) |
61 KB |
PDF File
|
|
somatropin (SEROSTIM) |
67 KB |
PDF File
|
|
somatropin (ZORBITIVE) |
137 KB |
PDF File
|
All Plans Except Cook Children’s Health Plan, Driscoll Children’s Health Plan & Texas Children’s Health Plan
|
GENOTROPIN, NORDITROPIN |
132 KB |
PDF File
|
For Cook Children’s Health Plan Only
|
GENOTROPIN, NORDITROPIN |
132 KB |
PDF File
|
Driscoll Children’s Health Plan Only
|
GENOTROPIN & NORDITROPIN |
133 KB |
PDF File
|
For Texas Children’s Health Plan Only
|
GENOTROPIN, NORDITROPIN |
132 KB |
PDF File
|
|
HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN, SKYTROFA |
138 KB |
PDF File
|
|
BERINERT, CINRYZE, icatibant (FIRAZYR), HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO |
241 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
HELIDAC, lansoprazole/amoxicillin/clarithromycin, omeprazole/clarithromycin/amoxicillin (listed as "omeclamox"), TALICIA CAP |
21 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
PEGASYS, EPCULSA, HARVONI, SOVALDI, VIEKIRA, VOSEVI, ZEPATIER |
22 KB |
PDF File
|
|
gabapentin enacarbil (HORIZANT) |
64 KB |
PDF File
|
|
corticotropin (HP ACTHAR) |
66 KB |
PDF File
|
|
alirocumab (PRALUENT) |
221 KB |
PDF File
|
STAR and STAR KID Members Only
|
ADMELOG, AFREZZA, APIDRA, BASAGLAR, BASAGLAR TEMPO, FIASP, HUMULIN N KWIKPEN, HUMALOG KWIKPEN, HUMALOG TEMPO, LYUMJEV, INSULIN GLARGINE, INSULIN LISPRO, INSULIN DEGLUDEC, NOVOLIN, NOVOLIN N, NOVOLIN R, SEMGLEE, TOUJEO, TRESIBA |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
repaglinide/metformin |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
glipizide/metformin 2.5-250MG, glipizide/metformin 5-500MG, metformin soln 500/5ML, metformin ER 500mg tab, metformin ER 1000mg tab, metformin ER osmotic tab 500mg, metformin ER osmotic tab 1000mg, RIOMET soln |
126 KB |
PDF File
|
|
tenapanor (IBSRELA) |
199 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CUTAQUIG, CUVITRU, FLEBOGAMMA, HYQVIA, OCTAGAM, PRIVIGEN, XEMBIFY |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ASTAGRAF XL, cyclosporine (SANDIMMUNE), ENVARSUS XR, everolimus (ZORTRESS), mycophenolate, mycophenolic (MYFORTIC, CELLCEPT), NEORAL, PROGRAF, sirolimus tab, sirolimus soln, REZUROCK, TAVNEOS |
126 KB |
PDF File
|
|
mecasermin (INCRELEX) |
67 KB |
PDF File
|
|
BETHKIS, CAYSTON, KITABIS, tobramycin (TOBI, TOBI PODHALER) |
62 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
AIRDUO, ALVESCO, ARMONAIR, ARNUITY, ASMANEX HFA (Twisthaler is PDL), BREO, BREZTRI, budesonide/formoterol, FLUTICASONE HFA AER, FLUTICASONE FUROATE/VILAN, budesonide, PULMICORT SUSP, QVAR, TRELEGY, fluticasone/salmeterol (WIXELA) |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
allergy relief spray, azelastine-fluticasone (DYMISTA), azelastine, BECONASE AQ, budesonide, flunisolide, ipratropium, fluticasone, mometasone (NASONEX), nasal allergy spray, olopatadine (PATANASE), OMNARIS, QNASL CHILD, QNASL, RYALTRIS, triamcinolone acetonide, XHANCE |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CITRANATAL, CORVITE, CORVITE FE, FERIVA, FERIVAFA, FERRAPLUS, FUSION PLUS, IROSPAN, TARON FORTE CAP |
21 KB |
PDF File
|
|
lomitapide (JUXTAPID) |
69 KB |
PDF File
|
|
injectable/nasal ketorolac (TORADOL equiv) |
201 KB |
PDF File
|
|
oral ketorolac (TORADOL) |
178 KB |
PDF File
|
|
dichlorphenamide (KEVEYIS) |
56 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
montelukast granules (SINGULAIR), SINGULAIR chewable 4mg/5mg, SINGULAIR tablets 10mg |
21 KB |
PDF File
|
|
lidocaine (LIDODERM) 5% patch, LIDOPURE 5% patch, ZILACAINE 5% patch, ZTLIDO 1.8% |
60 KB |
PDF File
|
STAR and STAR KIDS Only Members
|
CLEOCIN, LINCOCIN, linezolid susp, SIVEXTRO |
126 KB |
PDF File
|
|
linaclotide (LINZESS) |
183 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
colesevelam, colestipol (COLESTID), ezetimibe, fenofibrate (FENOGLIDE, LIPOFEN, TRICOR, TRILIPIX), fenofibric acid, FENOFIB MICR CAP 90MG, LOPID, icosapent (VASCEPA), niacin extended-release (NIASPAN ER), NEXLETOL, NEXLIZET, QUESTRAN |
21 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
amlodipine/atorvastatin (CADUET), CRESTOR, ezetimibe/simvastatin (VYTORIN), fluvastatin, fluvastatin ER (LESCOL XL), LIVALO, ZOCOR, ZYPITAMAG |
21 KB |
PDF File
|
|
maralixibat (LIVMARLI) |
205 KB |
PDF File
|
|
ABILIFY MAINTENA, ARISTADA, ARISTADA INITIO, fluphenazine decanoate inj, HALDOL DECANOATE INJ, haloperidol decanoate inj, INVEGA HAFYERA, INVEGA SUSTENNA, INVEGA TRINZA, PERSERIS, RISPERDAL CONSTA, ZYPREXA RELPREVV |
196 KB |
PDF File
|
|
alosetron (LOTRONEX) |
196 KB |
PDF File
|
|
voclosporin (LUPKYNIS) |
63 KB |
PDF File
|
|
pregabalin (LYRICA) |
189 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CLARITHROMYCIN, E.E.S. GRANULES, E.E.S. tab, erythromycin suspension, ZITHROMAX |
23 KB |
PDF File
|
|
prucalopride (MOTEGRITY) |
194 KB |
PDF File
|
|
naloxegol (MOVANTIK) & naldemedine (SYMPROIC) |
207 KB |
PDF File
|
|
dalfampridine (AMPYRA) |
177 KB |
PDF File
|
|
teriflunomide (AUBAGIO) |
189 KB |
PDF File
|
|
cladribine (MAVENCLAD) |
187 KB |
PDF File
|
|
siponimod (MAYZENT) |
191 KB |
PDF File
|
|
ponesimod (PONVORY) |
192 KB |
PDF File
|
|
fingolimod (TASCENSO) ODT |
193 KB |
PDF File
|
|
ozanimod (ZEPOSIA) |
197 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
chlorzoxazone (LORZONE), cyclobenzaprine ER (AMRIX), dantrolene (DANTRIUM), FEXMID, FLEQSUVY, LYVISPAH, metaxalone (SKELAXIN), orphenadrine extended-release, orphenadine/aspirin/caffeine tablet (ORPHENGESIC FORTE), tizanidine |
21 KB |
PDF File
|
|
galsulfase (NAGLAZYME) |
170 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
duloxetine (CYMBALTA) |
126 KB |
PDF File
|
|
nitisinone (NITYR & ORFADIN) |
166 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
celecoxib (CELEBREX), diclofenac sodium/misoprostol (ARTHROTEC), diclofenac (FLECTOR), diflunisal, DUEXIS, EC-NAPROXEN, etodolac, etodolac extended-release, fenoprofen (NALFON), flurbiprofen, indomethacin (INDOCIN), ketoprofen, meclofenamic, meloxicam capsules (VIVLODEX), MOBIC, nabumetone (RELAFEN), naproxen suspension, naproxen/esomeprazole (VIMOVO), oxaprozin (DAYPRO), piroxicam (FELDENE), tolmetin |
21 KB |
PDF File
|
|
mepolizumab (NUCALA) |
249 KB |
PDF File
|
|
pimavanserin (NUPLAZID) |
61 KB |
PDF File
|
|
armodafinil (NUVIGIL) |
195 KB |
PDF File
|
|
baricitinib (OLUMIANT) |
204 KB |
PDF File
|
|
omega-3-acid ethyl esters (LOVAZA), icosapent ethyl (VASCEPA) |
221 KB |
PDF File
|
|
EYSUVIS, RESTASIS, TYRVAYA, XIIDRA |
81 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
apraclonidine, betaxolol (BETOPTIC-S), bimatiprost (LUMIGAN), brimonidine (ALPHAGAN P), brimonidine / timolol sol, brinzolomide (AZOPT equiv), dorzolamide-timolol (COSOPT, COSOPT PF) , PHOSPHOLINE, tafluprost (ZIOPTAN), timolol maleate (ISTALOL), TIMOPTIC, TIMOPTIC XE, TRAVOPROST, TRUSOPT, VUITY, VYZULTA, XALATAN |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ALOCRIL, ALOMIDE, ALREX, azelastine, bepotastine, BEPREVE, epinastine, eye itch relief drops/soln, LASTACAFT, olopatadine 0.1%, olopatadine 0.2%, PATADAY 0.2%, ZERVIATE |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ACUVAIL, bromfenac, difluprednate (DUREZOL), dexamethason sodium phosphate (MAXIDEX), FLAREX, fluoromethol (FML FORTE, FML), FML LIQUIFLM, flurbiprofen 0.03% sol, ILEVRO, INVELTYS, ketorolac (ACULAR, ACULAR LS), loteprednol (LOTEMAX 0.5% SUSP, LOTEMAX GEL, LOTEMAX SM), NEVANAC 0.1% SUSP, prednisolone sodium acetate (PRED MILD, PRED FORTE) |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
BLEPHAMIDE, MAXITROL, neomycin-bacitracin-poly-HC, neomycin-bacitracin-polymyxin, PRED-G, TIOBRADEX ST, tobramycin-dexamethasone (TOBRADEX), ZYLET |
212 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
AZASITE, bacitracin, BESIVANCE, BLEPH-10, CILOXAN, gatofloxacin, levofloxacin, MOXEZA, NATACYN, neomycin-bacitracin-polymyxin (NEO-POLYCIN), neo-poly-gramicidin, OCUFLOX, POLYTRIM, sodium sulfacetamide (SULFACET), TOBREX, moxifloxacin (VIGAMOX) |
126 KB |
PDF File
|
|
CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE |
91 KB |
PDF File
|
Table E
|
codeine-guaifenesin, guaiatussin, hydrocodone-homatropin, hydrocodone-chlorpheniramine polistirex |
223 KB |
PDF File
|
|
oral transmucosal fentanyl (ACTIQ) |
234 KB |
PDF File
|
|
buccal fentanyl citrate (FENTORA) |
243 KB |
PDF File
|
|
transdermal fentanyl (DURAGESIC) |
228 KB |
PDF File
|
|
oxycodone extended-release (OXYCONTIN) 60mg & 80mg |
228 KB |
PDF File
|
|
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE, ACETAMINOPHEN/CODEINE, BELBUCA, BELLADONNA/OPIUM, BENZHYDROCODONE/ACETAMINOPHEN, BUPRENORPHINE PATCH, BUTALBITAL/CAFFEINE/ACETAMINOPHEN/CODEINE, BUTALBITAL/CAFFEINE/ASPIRIN/CODEINE, BUTORPHANOL, BUTRANS, CODEINE SULFATE, DEMEROL, DILAUDID, ENDOCET, HYDROCODONE/ACETAMINOPHEN, HYDROCODONE/IBUPROFEN, HYDROMORPHONE, HYSINGLA ER, LEVORPHANOL, LORCET, MEPERIDINE, METHADONE, METHADOSE, MORPHABOND, MORPHINE SULFATE, MS CONTIN, NALBUPHINE, NUCYNTA (ER), OPIUM TINCTURE, OXYCODONE, OXYCODONE/ACETAMINOPHEN, OXYCODONE/ASPIRIN, OXYCODONE/IBUPROFEN, OXYMORPHONE, PENTAZOCINE/NALOXONE, PERCOCET, ROXICODONE, TRAMADOL/ACETAMINOPHEN, TRAMADOL HYDROCHLORIDE, ULTRACET, ULTRAM |
74 KB |
PDF File
|
|
oxycodone extended-release (OXYCONTIN) 10mg, 15mg, 20mg, 30mg, 40mg; oxycodone extended-release (XTAMPZA ER) |
217 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ALKINDI SPRINKLE CAP, CORTEF, dexamethasone, methylprednisolone (MEDROL), MILLIPRED, prednisolone soln, PREDNISOLONE ODT TAB, prednisone pak, PREDNISONE INTENSOL CONC, TAPERDEX, TARPEYO CAP |
126 KB |
PDF File
|
|
elagolix (ORILISSA) |
64 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
hydrocortisone/acetic acid, PINNACAINE |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CIPRO HC, ciprofloxacin/dexamethasone (CIPRODEX), CORTISPORIN, OTOVEL |
126 KB |
PDF File
|
|
voxelotor (OXBRYTA) |
63 KB |
PDF File
|
|
cenegermin-bkbj (OXERVATE) |
54 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
PERTZYE, VIOKACE |
126 KB |
PDF File
|
|
sildenafil (REVATIO), tadalafil (ADCIRCA), tadalafil (ALYQ), TADLIQ suspension |
208 KB |
PDF File
|
STAR and STAR KID Members Only
|
ivermectin cream, METROGEL, METROCREAM, MIRVASO GEL |
21 KB |
PDF File
|
STAR and STAR KID Members Only
|
GRASTEK SUBLINGUAL, RAGWITEK SUBLINGUAL |
170 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
ANIMAL SHAPE CHW + IRON, FLORIVA, POLY-VI-FLOR, QUFLORA, TRI-VI-FLOR suspension, TRI-VIT/FLUO drops, vitamin A/C/D fluoride drops |
134 KB |
PDF File
|
|
AURYXIA, calcium acetate (PHOSLYRA), lanthanum (FOSRENOL), sevelamer (RENAGEL), sevelamer carbonate (RENVELA), VELPHORO |
128 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
dipyridamole (PERSANTINE), prasugrel (EFFIENT), clopidogrel (PLAVIX) |
126 KB |
PDF File
|
|
VELTASSA |
21 KB |
PDF File
|
|
alirocumab (PRALUENT) |
68 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
CITRANATAL, COMPLETENATE, ELITE-OB, NESTABS DHA, NESTABS, OB COMPLETE, PNV-DHA, PNV-OMEGA, PNV-SELECT, PRENAISSANCE, PRENATE AM, PRENATE, PRENATE DHA, PRENATE ELITE, PRENATE ESSENTIAL, PRENATE MINI, PRENATE PIXIE, PRENATE RESTORE, PRENATE STAR, SELECT-OB, SE-NATAL 19, TARON-C DHA, TRISTART DHA, WESTGEL DHA C, ZATEAN-PN |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
megestrol ES 625mg/5ml susp |
126 KB |
PDF File
|
|
PHENERGAN, PROMETHAZINE |
57 KB |
PDF File
|
|
propylthiouracil |
18 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
DEXILANT, DEXLANSOPRAZOLE DR, esomeprazole, lansoprazole, NEXIUM cap, omeprazole/bicarbonate (ZEGERID), omeprazole cap 20.6mg, omeprazole tab, PREVACID cap/solutab, PROTONIX tab, rabeprazole (ACIPHEX) |
21 KB |
PDF File
|
|
modafinil (PROVIGIL) |
195 KB |
PDF File
|
|
ADEMPAS, ambrisentan (LETAIRIS), bosentan (TRACLEER), OPSUMIT, ORENITRAM, TYVASO inhalation solution, UPTRAVI, VENTAVIS inhalation solution |
192 KB |
PDF File
|
|
dornase alfa (PULMOZYME) |
53 KB |
PDF File
|
|
ranolazine (RANEXA) |
60 KB |
PDF File
|
|
levoketoconazole (RECORLEV) |
58 KB |
PDF File
|
|
methylnaltrexone (RELISTOR) |
194 KB |
PDF File
|
|
evolocumab (REPATHA) |
221 KB |
PDF File
|
|
elapegademase (REVCOVI) |
169 KB |
PDF File
|
|
oteseconazole (VIVJOA) |
200 KB |
PDF File
|
|
milnacipran (SAVELLA) |
141 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
doxepin (SILENOR), DORAL, QUAZEPAM |
126 KB |
PDF File
|
|
tasimelteon (HETLIOZ) capsules |
206 KB |
PDF File
|
|
tasimelteon (HETLIOZ LQ) suspension |
198 KB |
PDF File
|
|
ramelteon (ROZEREM) |
226 KB |
PDF File
|
|
BELSOMRA, DAYVIGO, EDLUAR, estazolam, eszopiclone (LUNESTA), QUVIVIQ, temazepam (RESTORIL), triazolam, zaleplon, zolpidem (AMBIEN, AMBIEN CR, EDLUAR) |
193 KB |
PDF File
|
|
canagliflozin/metformin (INVOKAMET, INVOKAMET XR), ertugliflozin/metformin (SEGLUROMET), empagliflozin/metformin (SYNJARDY, SYNJARDY XR), dapagliflozin/metformin (XIGDUO XR) |
202 KB |
PDF File
|
|
FARXIGA, INVOKANA, JARDIANCE, STEGLATRO |
215 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
NICOTROL INHALER, NICOTROL NS |
126 KB |
PDF File
|
|
deucravacitinib (SOTYKTU) |
208 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
alclometason, amcinonide, betamethsone dipropionate (DIPROLENE, SERNIVO), betamethasone valerate (LUXIQ), BRYHALI, clobetasol (CLOBEX, OLUX, OLUX-E, TEMOVATE), CLODERM, desonide, desoximetasone (TOPICORT, TOPICORT LP), diflorasone (APEXICON E), fluocinolone, fluocinolone acetate oil, fluocinonide (VANOS), flurandrenolide, fluticasone, halcinonide (HALOG), hydrocortisone butyrate, hydrocortisone valerate, hydrocortisone (TEXACORT), LEXETTE, PANDEL CREAM, prednicarbate, triamcinolone acetate (TRIANEX), triamcinolone dental paste |
126 KB |
PDF File
|
|
asfotase alfa (STRENSIQ) |
167 KB |
PDF File
|
|
solriamfetol (SUNOSI) |
202 KB |
PDF File
|
|
pramlintide (SYMLIN) |
132 KB |
PDF File
|
|
naldemedine (SYMPROIC) |
139 KB |
PDF File
|
For Community First Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
306 KB |
PDF File
|
For Community Health Choice Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
283 KB |
PDF File
|
For Cook Children's Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
283 KB |
PDF File
|
For Dell Children's Health (Seton) Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
283 KB |
PDF File
|
For Driscoll Children's Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
284 KB |
PDF File
|
For El Paso First Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
283 KB |
PDF File
|
For FirstCare Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
296 KB |
PDF File
|
For Parkland Community Health Plans Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
289 KB |
PDF File
|
For Scott & White Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
296 KB |
PDF File
|
For Texas Children's Health Plan Only - RSV Season Dates 2023-2024
|
palivizumab (SYNAGIS) |
283 KB |
PDF File
|
|
inotersen (TEGSEDI) |
59 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
demeclocycline, DORYX, doxycycline, doxycycline hyclate, doxycycline monohydrate (ORACEA), doxycycline suspension (VIBRAMYCIN), minocycline (SOLODYN, MINOLIRA), NUZYRA, tetracycline, XIMINO |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
DOPTELET, MULPLETA, PROMACTA POW, TAVALISSE |
126 KB |
PDF File
|
|
AMZEEQ FOAM 4%, BENZACLIN GEL, BENZACLIN GEL PUMP, clindamycin 1% foam, clindamycin/benzoyl peroxide gel 1-5%, clindamycin/benzoyl peroxide gel 1.2-2.5%, clindamycin/benzoyl peroxide gel 1.2-5%, erythromycin/benzoyl peroxide gel 5-3% |
26 KB |
PDF File
|
|
salicylic acid 3% (BENSAL HP) ointment |
26 KB |
PDF File
|
|
azelaic acid gel 15% (FINACEA 15% GEL), metronidazole lotion 0.75% |
26 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
NATESTO GEL |
126 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
bacitracin zinc, CENTANY, gentamicin, mupirocin cream |
126 KB |
PDF File
|
|
CICLOPIROX 8% SOLUTION, JUBLIA 10% TOPICAL SOLUTION, KERYDIN (TAVABOROLE) 5% TOPICAL SOLUTION, OXISTAT LOTION 1%, TM-TOLNAFTAT LIQUID 1% |
66 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
acyclovir cream, acyclovir ointment, docosanol cream, penciclovir cream, XERESE |
126 KB |
PDF File
|
|
pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%) |
227 KB |
PDF File
|
|
crisaborole (EUCRISA) |
176 KB |
PDF File
|
|
ruxolitinib phosphate cream (OPZELURA) |
213 KB |
PDF File
|
|
tacrolimus (PROTOPIC) 0.1% |
227 KB |
PDF File
|
|
ADAPALENE, ADAPALENE-BENZYL PEROXIDE, ALTRENO, ARAZLO, ATRALIN, AVITA, CLINDAMYCIN-TRETINOIN, DIFFERIN, EPIDUO FORTE, FABIOR, RETIN-A MICRO GEL, TAZAROTENE, TRETINOIN, ZIANA |
26 KB |
PDF File
|
|
plecanatide (TRULANCE) |
195 KB |
PDF File
|
STAR and STAR KIDS Members Only
|
APRISO, azulfidine, balsalazide (COLAZAL), budesonide ER, DIPENTUM, mesalamine cap 400mg, mesalamine tab 800mg (ASACOL HD), mesalamine cap 0.375gm, mesalamine ER cap 0.375gm, mesalamine 1.2 gm, mesalamine ENE 4gm, mesalamine supp, UCERIS |
21 KB |
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CARBAGLU, RAVICTI, sodium phenylbutyrate (BUPHENYL) |
189 KB |
PDF File
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STAR and STAR KIDS Members Only
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clindamycin (CLEOCIN), metronidazole 0.75% vaginal gel, SOLOSEC, VANDAZOLE |
126 KB |
PDF File
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eluxadoline (VIBERZI) |
203 KB |
PDF File
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For Cook Children’s Health Plans Only
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elosulfase alfa (VIMIZIM) |
200 KB |
PDF File
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elosulfase alfa (VIMIZIM) |
168 KB |
PDF File
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STAR and STAR KIDS Members Only
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CITRANATAL, CORVITE 150, CORVITE FE, EZFE 200, ferrous sulfate (FEOSOL, FER-IN-SOL, SLOW FE), ferrous gluconate (FERATE, FERGON), FERIVA, FERIVAFA, FERRAPLUS 90, FERREX 150, ferrous fumarate (FERRIMIN 150, HEMOCYTE), FOLITAB 500, FUSION PLUS, GNP IRON, HEMOCYTE, ICAR PEDS, ICAR-C, INTEGRA, Iron 100/C, Iron Supplement Drops, polysaccharide iron complex (FEOSOL bifera, POLY-IRON, NU-IRON 150), IROSPAN, TARON FORTE, WEE CARE |
135 KB |
PDF File
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STAR and STAR KIDS Members Only
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antacids - calcium salts, antacids - magnesium salts, antidotes, b-complex vitamins, b-complex w/ c, b-complex w/ folic acid, b-complex w/ iron, b-complex w/ minerals, bioflavonoid products, calcium, cobalamins, dietary management products, fluoride, folic acid/folates, hematopoietic mixtures, iron, magnesium, mineral combinations, misc. nutritional substances, multiple vitamins w/ calcium, multiple vitamins w/ iron, multiple vitamins w/ minerals, multivitamins, oil soluble vitamins, ped multiple vitamins w/ minerals, ped mv w/ fluoride, ped mv w/ iron, pediatric multiple vitamins, phosphate, saline laxatives, specialty vitamins products, trace minerals, vitamin mixtures, vitamins w/ lipotropics, water soluble vitamins, zinc |
124 KB |
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All Plans Except Texas Children’s Health Plan
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deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE) |
223 KB |
PDF File
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Texas Children’s Health Plan Only
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deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE) |
227 KB |
PDF File
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valbenazine (INGREZZA) |
208 KB |
PDF File
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vosoritide (VOXZOGO) |
59 KB |
PDF File
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tafamidis (VYNDAMAX) and tafamidis meglumine (VYNDAQEL) |
58 KB |
PDF File
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pitolisant (WAKIX) |
201 KB |
PDF File
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rifaximin 200mg (XIFAXAN 200mg) |
135 KB |
PDF File
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rifaximin 550mg (XIFAXAN 550mg) |
139 KB |
PDF File
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omalizumab (XOLAIR) |
285 KB |
PDF File
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sodium oxybate (XYREM) / XYWAV |
56 KB |
PDF File
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ganaxolone (ZTALMY) |
173 KB |
PDF File
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imiquimod 3.75 % cream (ZYCLARA) |
52 KB |
PDF File
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zileuton (ZYFLO) |
60 KB |