Prior Authorization Forms

The Texas Managed Medicaid STAR/CHIP/STAR Kids formulary, including the Preferred Drug List and any clinical edits, is defined by the Texas Vendor Drug Program.

Please click on the link(s) below to view the prior authorization forms.

For more information, visit the Synagis page on this site.

For Clinical Edit information, click here.

For more information about prior authorizations, click here for frequently asked questions.

Type	Name	Drug Name	File Size
PDF File	**TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM	PRESCRIPTION DRUG BENEFITS	233 KB
PDF File	*EXCEPTION TO COVERAGE REQUEST Quantity Limit or High Dose Exceptions Only		39 KB
PDF File	150MG ALISKIREN-CONTAINING AGENTS	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	64 KB
PDF File	300MG ALISKIREN-CONTAINING AGENTS	AMTURNIDE 300-5-25 MG TAB, TEKTURNA 300 MG TABLET, TEKTURNA HCT 300-12.5 MG TAB, TEKTURNA HCT 300-25 MG TABLET	64 KB
PDF File	ACCOLATE	zafirlukast (ACCOLATE)	59 KB
PDF File	ACNE AGENTS ORAL (PDL) STAR and STAR KID Members Only	ABSORICA	126 KB
PDF File	ACTEMRA	tocilizumab (ACTEMRA)	63 KB
PDF File	ACTOS / DUETACT	pioglitazone (ACTOS), pioglitazone/metformin (ACTOPLUS MET), pioglitazone/glimepiride (DUETACT)	148 KB
PDF File	ADHD - CLONIDINE ER	clonidine ER	58 KB
PDF File	ADHD ER FORMULATIONS (DRO - PDL) NOTE: Drugs listed are a representative list, only. See plan formulary to verify coverage status. Formulary available at www.txvendordrug.com	amphetamine salts (MYDAYIS), amphetamine/dextroamphetamine salts (ADDERALL XR, DYANAVEL XR, ADZENYS ER, ADZENYS XR-ODT), 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)	199 KB
PDF File	ADHD IR FORMULATIONS 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)	197 KB
PDF File	ADHD NON-STIMULANTS NOTE: Drugs listed are a representative list, only. See plan formulary to verify coverage status. Formulary available at www.txvendordrug.com	guanfacine SR (INTUNIV), atomoxetine (STRATTERA)	59 KB
PDF File	AGENTS FOR GAUCHER’S DISEASE	CERDELGA, CEREZYME, ELELYSO, miglustat (ZAVESCA), VPRIV	20 KB
PDF File	ALDARA	imiquimod 5% cream (ALDARA)	45 KB
PDF File	ALINIA	nitazoxanide (ALINIA) tablets	59 KB
PDF File	ALTACE / DIOVAN (DRO - PDL)	ramipril (ALTACE), valsartan (DIOVAN)	62 KB
PDF File	ALZHEIMER’S AGENTS (DRO - PDL)	donepezil (ARICEPT), galantamine (RAZADYNE ER), titration pack (NAMENDA), memantine extended-release (NAMENDA XR), NAMZARIC, NAMZARIC PACK, rivastigmine patch	30 KB
PDF File	AMANTADINE ER AGENTS	Osmolex ER, Gocovri	64 KB
PDF File	AMITIZA	lubiprostone (AMITIZA)	64 KB
PDF File	AMPYRA	dalfampridine (AMPYRA)	53 KB
PDF File	ANGIOTENSIN MODULATOR COMBOS (PDL) 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	ANGIOTENSIN MODULATORS (DRO - PDL)	azilsartan (EDARBI), azilsartan/chlorthalidone (EDARBYCLOR), benazepril/hydrochlorothiazide (LOTENSIN HCT), candesartan/hydrochlorothiazide (ATACAND HCT), candesartan (ATACAND), captopril/hydrochlorothiazide (CAPOZIDE), captopril (CAPOTEN), enalapril/hctz (VASERETIC), enalapril (VASOTEC), fosinopril/hydrochlorothiazide (MONOPRIL HCT), irbesartan/hctz (AVALIDE), irbesartan (AVAPRO), losartan (COZAAR), moexipril (UNIVASC), olmesartan/hydrochlorothiazide (BENICAR HCT), olmesartan (BENICAR), perindopril (ACEON), lisinopril (PRINIVIL), lisinopril (QBRELIS), lisinopril/hctz (ZESTORETIC), quinapril (ACCUPRIL), quinapril/hydrochlorothiazide (ACCURETIC), telmisartan/hydrochlorothiazide (MICARDIS HCT), telmisartan (MICARDIS), trandolapril (MAVIK), valsartan/hydrochlorothiazide (DIOVAN HCT), valsartan (DIOVAN)	63 KB
PDF File	ANTICOAGULANTS (PDL) STAR and STAR KIDS Members Only	COUMADIN, fondaparinux (ARIXTRA), FRAGMIN, FRAGMIN INJ, LOVENOX, SAVAYSA	126 KB
PDF File	ANTIDEPRESSANTS (OTHER) (DRO - PDL)	bupropion (APLENZIN, FORFIVO XL, WELLBUTRIN), desvenlafaxine (PRISTIQ), EMSAM, FETZIMA, MARPLAN, mirtazapine (REMERON), NARDIL, nefazodone, tranylcypromine, TRINTELLIX, venlafaxine (EFFEXOR XR), VIIBRYD	30 KB
PDF File	ANTIDEPRESSANTS (SSRI) (DRO - PDL)	citalopram (CELEXA), escitalopram (LEXAPRO), fluoxetine (PROZAC), fluvoxamine, paroxetine (PAXIL), sertraline (ZOLOFT)	30 KB
PDF File	ANTIDEPRESSANTS (TRICYCLIC) (PDL) STAR and STAR KIDS Members Only	amoxapine, clomipramine (ANAFRANIL), desipramine, imipramine pamoate (TOFRANIL), maprotiline, nortriptyline (PAMELOR), protriptyline, trimipramine	127 KB
PDF File	ANTIEMETIC-ANTIVERTIGO AGENTS (PDL) STAR and STAR KIDS Members Only	dronabinol (MARINOL), metoclopramide (REGLAN), prochlorperazine (COMPRO), scopolamine, TRANSDERM-SC, trimethobenzamide, ZUPLENZ	21 KB
PDF File	ANTIEMETICS	AKYNZEO, ANZEMET, aprepitant (EMEND), EMEND SUSPENSION, GRANISETRON, SANCUSO	28 KB
PDF File	ANTIFUNGALS (PDL) STAR and STAR KIDS Members Only	clotrimazole 1% topical solution, CRESEMBA, DIFLUCAN, flucytosine (ANCOBON), griseofulvin, itraconazole (SPORANOX, TOLSURA), ORAVIG, posaconazole (NOXAFIL), voriconazole (VFEND)	126 KB
PDF File	ANTIHISTAMINES (MINIMALLY SEDATING) 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, SEMPREX-D	126 KB
PDF File	ANTIHYPERTENSIVES, SYMPATHOLYTICS (PDL) STAR and STAR KIDS Members Only	CATAPRES tab, clonidine patch, methyldopa/hydrochlorothiazide	126 KB
PDF File	ANTIHYPERURICEMICS (PDL) STAR and STAR KIDS Members Only	colchicine cap/tab (COLCRYS), febuxostat (ULORIC), GLOPERBA, ZYLOPRIM	126 KB
PDF File	ANTIMIGRAINE AGENTS (PDL) STAR and STAR KIDS Members Only	CAMBIA, dihydroergotamine (D.H.E. 45, MIGRANAL), REYVOW	21 KB
PDF File	ANTIMIGRAINE AGENTS (TRIPTANS) (PDL) STAR and STAR KIDS Members Only	almotriptan, naratriptan (AMERGE), eletriptan (RELPAX), frovatriptan (FROVA), sumatriptan (ONZETRA, ZEMBRACE), MAXALT, sumatriptan/naproxen (TREXIMET), zolmitriptan tab/ODT (ZOMIG**)	126 KB
PDF File	ANTIPARASITICS (TOPICAL) (PDL) STAR and STAR KIDS Members Only	EURAX, LINDANE shampoo, malathion lotion (OVIDE), ivermectin (SKLICE) lotion	126 KB
PDF File	ANTIPARKINSON’S AGENTS (PDL) STAR and STAR KIDS Members Only	carbidopa/levodopa tab (SINEMET), bromocriptine, carbidopa tab (LODOSYN), entacapone (COMTAN), DUOPA susp, GOCOVRI, pramipexole ER (MIRAPEX ER), NEUPRO, ONGENTYS CAP, OSMOLEX ER, rasagiline (AZILECT), ropinirole ER (REQUIP XL 6mg and 12mg), RYTARY, selegiline, STALEVO, tolcapone (TASMAR), ZELAPAR	212 KB
PDF File	ANTIPSYCHOTICS (DRO - PDL) 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 MYCITE, amitriptyline/perphenazine, aripiprazole, CAPLYTA, chlorpromazine, chlorpromazine inj, clozapine, CLOZARIL, FANAPT, FAZACLO, fluphenazine, fluphenazine inj, GEODON, GEODON inj, haloperidol lactate injection, haloperidol tablet, INVEGA, LATUDA, loxapine, loxitane, MOLINDONE, NUPLAZID, olanzapine, olanzapine inj, olanzapine/fluoxetine, ORAP, paliperidone, perphenazine, pimozide, quetiapine, quetiapine ER, REXULTI, RISPERDAL, risperidone, SAPHRIS, SECUADO, SEROQUEL, SEROQUEL XR, SYMBYAX, thioridazine, thiothixene, trifluoperazine, VERSACLOZ, VRAYLAR, ziprasidone, ZYPREXA, ZYPREXA ZYDIS	37 KB
PDF File	ANTIVIRALS (PDL) STAR and STAR KIDS Members Only	RELENZA, rimantadine, SITAVIG, TAMIFLU, VALTREX, XOFLUZA	126 KB
PDF File	ANXIOLYTICS (alprazolam)	alprazolam (XANAX)	64 KB
PDF File	ANXIOLYTICS (chlordiaz., meprobamate, oxazepam)	chlordiazepoxide, meprobamate, oxazepam	72 KB
PDF File	ANXIOLYTICS (clonazepam, diazepam)	clonazepam (KLONOPIN), diazepam	75 KB
PDF File	ANXIOLYTICS (clorazepate)	clorazepate (TRANXENE)	74 KB
PDF File	ANXIOLYTICS (lorazepam)	lorazepam	69 KB
PDF File	ARANESP	darbepoetin alfa (ARANESP)	26 KB
PDF File	ARIKAYCE	amikacin (ARIKAYCE)	70 KB
PDF File	AUBAGIO	teriflunomide (AUBAGIO)	75 KB
PDF File	AUSTEDO & XENAZINE All Plans Except Texas Children’s Health Plan	deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE)	71 KB
PDF File	AUSTEDO & XENAZINE Texas Children’s Health Plan Only	deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE)	84 KB
PDF File	AVANDIA	rosiglitazone (AVANDIA)	137 KB
PDF File	BENIGN PROSTATIC HYPERPLASIA (DRO - PDL)	doxazosin (CARDURA), terazosin, dutasteride-tamsulosin (JALYN), dutasteride (AVODART), PROSCAR, silodosin (RAPAFLO), FLOMAX	30 KB
PDF File	BETA AGONIST BRONCHODILATORS (PDL) STAR and STAR KIDS Members Only	ALBUTEROL AEROSOL HFA, ALBUTEROL TABLETS, ARCAPTA CAPSULES, BROVANA, levalbuterol nebulizer (XOPENEX), metaproterenol syrup, PERFOROMIST, PROAIR RESPICLICK, SEREVENT DISKUS, STRIVERDI RESPIMAT, terbutaline tablets	22 KB
PDF File	BETA BLOCKERS (ORAL) (PDL) STAR and STAR KIDS Members Only	betaxolol, BYSTOLIC, carvedilol ER (COREG CR), COREG, metoprolol/hydrochlorothiazide, nadolol, pindolol, propranolol/hydrochlorothiazide, propranolol ER (INDERAL LA, INDERAL XL, INNOPRAN XL), SOTYLIZE, timolol maleate tab, TENORMIN, TENORETIC, TOPROL XL, ZIAC	126 KB
PDF File	BILE SALTS (PDL) STAR and STAR KIDS Members Only	CHENODAL, CHOLBAM, OCALIVA, URSO, URSO FORTE, ursodiol 300mg cap	126 KB
PDF File	BLADDER RELAXANTS (DRO - PDL)	darifenacin (ENABLEX), tolterodine (DETROL), tolterodine ER (DETROL LA), DITROPAN XL, flavoxate, GELNIQUE, MYRBETRIQ, OXYTROL, solifenacin, trospium, trospium ER	29 KB
PDF File	Blood Glucose Monitors with Special Features		22 KB
PDF File	BONE RESORPTION (PDL) STAR and STAR KIDS Members Only	risedronate (ACTONEL), alendronate soln, ATELVIA, BINOSTO, ibandronate (BONIVA), calcitonin, raloxifene (EVISTA), FORTEO, FOSAMAX, FOSAMAX+D, TERIPARATIDE, TYMLOS	126 KB
PDF File	BONJESTA & DICLEGIS	doxylamine/pyridoxine (BONJESTA, DICLEGIS)	58 KB
PDF File	BUNAVAIL / SUBOXONE / ZUBSOLV	buprenorphine/naloxone (BUNAVAIL, SUBOXONE, ZUBSOLV)	55 KB
PDF File	BUPRENORPHINE	buprenorphine	55 KB
PDF File	CALCIUM CHANNEL BLOCKERS (DRO - PDL)	CALAN SR, CARDIZEM, CARDIZEM CD, CARDIZEM LA, isradipine capsule, KATERZIA, matzim la tablet, nicardipine capule, nifedipine capsule (ADALAT CC), nimodipine, nisoldipine, NORVASC, NYMALIZE, PROCARDIA, PROCARDIA XL, verapamil (VERELAN), VERELAN PM	30 KB
PDF File	CARISOPRODOL-CONTAINING AGENTS	CARISOPRODOL, CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND TAB, SOMA	143 KB
PDF File	CEPHALOSPORINS (ORAL) (PDL) 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	CETIRIZINE 5 MG (DRO)	cetirizine 5mg	23 KB
PDF File	CGRP ANTAGONISTS	erenumab (AIMOVIG), fremanezumab (AJOVY), galcanezumab (EMGALITY)	201 KB
PDF File	CIMZIA	certolizumab pegol (CIMZIA)	64 KB
PDF File	COLONY STIMULATING FACTORS (PDL) STAR and STAR KIDS Members Only	FULPHILA inj, GRANIX, LEUKINE, NEULASTA, ZARXIO, ZIEXTENZO	126 KB
PDF File	COMPOUND DRUGS Compound Drugs over $200		30 KB
PDF File	CONTRACEPTIVES - CHIP PLANS ONLY		18 KB
PDF File	CONTRACEPTIVES - DELL CHILDREN HEALTH PLAN (SETON)		18 KB
PDF File	COPD AGENTS (PDL) STAR and STAR KIDS Members Only	BEVESPI, DALIRESP, DUAKLIR, INCRUSE, LONHALA, SEEBRI, SPIRIVA Respimat (Handihaler is PDL), TUDORZA, UTIBRON, YUPELRI	126 KB
PDF File	COREG CR (DRO - PDL)	carvedilol ER (COREG CR) capsules	29 KB
PDF File	COSENTYX	secukinumab (COSENTYX)	135 KB
PDF File	COUGH & COLD (TABLE A - DECONGESTANTS) Table A (Decongestant-containing products and others)	ALA-HIST PE TABLET, APRODINE TABLET, BROTAPP LIQUID, CHEST CONGESTION RELIEF PE, CHEST CONGESTION RELIEF TABLET, CHL MUCINEX CHEST CONGEST LIQ, CHLD MUCINEX STUFFY NOSE-COLD, CHLO TUSS LIQUID, COUGH SYRUP 200 MG/10 ML, DECONEX IR TABLET, DIMAPHEN ELIXIR, ED BRON GP LIQUID, ED CHLORPED D PEDIATRIC DROPS, ED-A-HIST PSE TABLET, GUAIFENESIN 100 MG/5 ML SYRUP, HISTEX-PE SYRUP, IOPHEN NR LIQUID, KID'S MUCINEX MINI-MELTS PACK, LODRANE D CAPSULE, LORTUSS LQ LIQUID, MAXIPHEN TABLET, MUCUS RELIEF 400 MG TABLET, MUCUS RELIEF SINUS TABLET, NOSE DROPS, ORGAN-I NR 200 MG TABLET, POLY-HIST PD LIQUID, POLY-VENT IR TABLET, PROMETHAZINE VC SYRUP, Q-TUSSIN 100 MG/5 ML SOLUTION, RESCON-GG LIQUID, RESPAIRE-30 CAPSULE, ROBAFEN 100 MG/5 ML SYRUP, RU-HIST D 10-4 MG TABLET, RYNEX PE LIQUID, RYNEX PSE LIQUID, SILTUSSIN SA 100 MG/5 ML SYR, STAHIST AD LIQUID, STAHIST AD TABLET, TUSSIN 100 MG/5 ML SYRUP	131 KB
PDF File	COUGH & COLD (TABLE B - DEXTROMETHORPHAN) Table B (Dextromethorphan-containing products and others)	ALAHIST, ALA-HIST DM LIQUID, ALLFEN DM TABLET, AP-HIST DM LIQUID, BROMFED DM COUGH SYRUP, BROMPHENIR-PSEUDOEPHED-DM SYR, BROTAPP DM LIQUID, CHILD DELSYM, CHILD MUCINEX, CHILDREN COLD & COUGH DM ELIXI, COUGH DM 30 MG/5 ML SUSPENSION, DALLERGY, DECONEX DMX TABLET, DELSYM 30 MG/5 ML SUSPENSION, DEXTROMETHORPHAN ER 30 MG/5 ML, DIMAPHEN DM ELIXIR, ED A-HIST, ENDACOF-DM LIQUID, EXTRA ACTION COUGH SYRUP, HISTEX-DM SYRUP, IOPHEN DM-NR LIQUID, KIDKARE COUGH & COLD LIQUID, LOHIST, LORTUSS DM LIQUID, MAXIPHEN DM TABLET, M-END DMX LIQUID, M-HIST DM LIQUID, MUCINEX, NASAL DECONGESTANT 0.05% SPRAY, NASOPEN PE LIQUID, NINJACOF LIQUID, NOHIST, PEDIATRIC COUGH-COLD LIQUID, PHENYLEPHRINE-PYRILAMINE 10-25, POLY HIST, POLYTUSSIN DM SYRUP, POLY-VENT DM TABLET, PROMETHAZINE-DM SYRUP, Q-TUSSIN DM SYRUP, RESCON-DM LIQUID, ROBAFEN, RYMED TABLET, RYNEX DM LIQUID, SILTUSSIN, SM NASAL SPRAY 0.05%, SM TUSSIN, TUSSIN, VANACOF, VANATAB	120 KB
PDF File	COUGH & COLD (TABLE C - BENZONATATE) Table C (Benzonatate-containing products)	BENZONATATE	96 KB
PDF File	COUGH & COLD (TABLE D - GUAIFENESIN ER & OTHERS) Table D (Guaifenesin ER Tablets and Others)	DELSYM COUGH + CHEST CONGST DM LQ, GUAIFENESIN ER 1,200 MG TABLET, GUAIFENESIN/PSE ER 600-60 MG, MUCINEX D ER 1,200-120 MG TABLET, MUCINEX D ER 600-60 MG TABLET, MUCINEX DM ER 1,200-60 MG TAB, MUCINEX DM ER 600-30 MG TABLET, MUCINEX ER 1,200 MG TABLET, MUCINEX ER 600 MG TABLET, MUCINEX FAST-MAX CONGEST-COUGH, MUCINEX FAST-MAX DM MAX LIQUID, RESCON TABLET, ROBAFEN COUGH 15 MG LIQUIDGEL, SUDOGEST SINUS & ALLERGY TAB	252 KB
PDF File	COX-2 INHIBITORS (CELEBREX)	celecoxib (CELEBREX)	68 KB
PDF File	COX-2 INHIBITORS (MOBIC 15MG)	meloxicam 15mg (MOBIC)	66 KB
PDF File	COX-2 INHIBITORS (MOBIC 7.5MG) (DRO)	meloxicam 7.5mg (MOBIC)	71 KB
PDF File	CYCLOBENZAPRINE	cyclobenzaprine (FLEXERIL / AMRIX)	138 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (PDL) STAR and STAR KIDS Members Only	ENSPRYNG INJ, ARCALYST	21 KB
PDF File	DDAVP INJECTABLE	desmopressin injectable (DDAVP)	21 KB
PDF File	DDAVP ORAL	desmopressin oral (DDAVP)	51 KB
PDF File	DIABETIC SUPPLIES		19 KB
PDF File	DIACOMIT	stiripentol (DIACOMIT)	49 KB
PDF File	DICLOFENAC 1.5% & 2% SOLUTION	diclofenac 1.5% topical solution, diclofenac 2% topical solution (PENNSAID 2% PUMP)	57 KB
PDF File	DICLOFENAC 3% GEL	diclofenac 3% gel (SOLARAZE 3% GEL)	53 KB
PDF File	DIVALPROEX (DRO)	divalproex 250mg (DEPAKOTE ER)	23 KB
PDF File	DOPAMINE AGONISTS	apomorphine hydrochloride (KYNMOBI)	74 KB
PDF File	DPP-4 INHIBITORS: CRITERIA A	alogliptin 6.25 mg (NESINA 6.25 MG), JANUVIA 25 MG, ONGLYZA 2.5 MG, TRADJENTA 5 MG	136 KB
PDF File	DPP-4 INHIBITORS: CRITERIA B	alogliptin 12.5 mg (NESINA 12.5 MG), JANUVIA 50 MG	61 KB
PDF File	DPP-4 INHIBITORS: CRITERIA C	alogliptin 25 mg (NESINA 25 MG), JANUVIA 100 MG, ONGLYZA 5 MG	139 KB
PDF File	DPP-4 INHIBITORS: CRITERIA D	alogliptin-metformin (KAZANO), alogliptin-pioglitazone (OSENI), GLYXAMBI, JANUMET (XR), JENTADUETO (XR), KOMBIGLYZE XR, QTERN, STEGLUJAN	137 KB
PDF File	DUPIXENT - INITIAL REQUESTS	dupilumab (DUPIXENT)	76 KB
PDF File	DUPIXENT - RENEWAL REQUESTS	dupilumab (DUPIXENT)	30 KB
PDF File	ELIDEL & PROTOPIC 0.03%	pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%)	70 KB
PDF File	EMFLAZA - INITIAL REQUESTS	deflazacort (EMFLAZA)	76 KB
PDF File	EMFLAZA - RENEWAL REQUESTS	deflazacort (EMFLAZA)	26 KB
PDF File	ENBREL	etanercept (ENBREL)	138 KB
PDF File	ENZYMES NOTE: Drugs listed are a representative list, only. See plan formulary to verify coverage status. Formulary available at www.txvendordrug.com	ALDURAZYME, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, REVCOVI, VIMIZIM	67 KB
PDF File	ENZYMES - COOK For Cook Children’s Health Plans Only	ALDURAZYME, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, REVCOVI, VIMIZIM	67 KB
PDF File	EPIDIOLEX	cannabidiol (EPIDIOLEX)	49 KB
PDF File	EPINEPHRINE (PDL) STAR and STAR KIDS Members Only	EPIPEN, EPIPEN-JR	126 KB
PDF File	EPOGEN	epoetin alfa (EPOGEN)	35 KB
PDF File	EUCRISA	crisaborole (EUCRISA)	21 KB
PDF File	EVRYSD I- RENEWAL REQUEST	risdiplam (EVRYSDI)	54 KB
PDF File	EVRYSDI - INITIAL REQUEST	risdiplam (EVRYSDI)	54 KB
PDF File	FASENRA	benralizumab (FASENRA)	57 KB
PDF File	FIRST GENERATION ANTIHISTAMINES (PDL) STAR and STAR KIDS Members Only	carbinoxamine (KARBINAL ER, RYVENT), clemastine, ED CHLORPED, triprolidine (M-HIST PD), VANACLEAR, VANAMINE, VISTARIL	126 KB
PDF File	FLUOROQUINOLONES (PDL) STAR and STAR KIDS Members Only	BAXDELA, CIPRO, levofloxacin soln, moxifloxacin tab	126 KB
PDF File	GABAPENTIN	gabapentin (NEURONTIN)	74 KB
PDF File	GI ANTIBIOTICS (PDL) STAR and STAR KIDS Members Only	DIFICID, DIFICID SUSP, metronidazole (FLAGYL), paromomycin, vancomycin (VANCOCIN HCL)	21 KB
PDF File	GLP-1 RECEPTOR AGONISTS	ADLYXIN, BYDUREON, BYDUREON BCISE, BYETTA, OZEMPIC, RYBELSUS, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY	76 KB
PDF File	GLUCAGON AGENTS (PDL) STAR and STAR KIDS Members Only	DIAZOXIDE SUS, GVOKE, GLUCAGON EMR SOL	126 KB
PDF File	GLUCOTROL XL (DRO)	glipizide XL (GLUCOTROL XL)	23 KB
PDF File	GRALISE	gabapentin extended release (GRALISE)	135 KB
PDF File	GROWTH HORMONE - SEROSTIM	somatropin (SEROSTIM)	143 KB
PDF File	GROWTH HORMONE - ZORBTIVE	somatropin (ZORBITIVE)	137 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN All Plans Except Cook Children’s Health Plan & Texas Children’s Health Plan	GENOTROPIN, NORDITROPIN	271 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN - COOK For Cook Children’s Health Plan Only	GENOTROPIN, NORDITROPIN	279 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN - TCHP For Texas Children’s Health Plan Only	GENOTROPIN, NORDITROPIN	271 KB
PDF File	GROWTH HORMONES - OTHER PRODUCTS	HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN	272 KB
PDF File	HELICOBACTER PYLORI TREATMENT (PDL) STAR and STAR KIDS Members Only	HELIDAC, lansoprazole/amoxicillin/clarithromycin, omeprazole/clarithromycin/amoxicillin (listed as "omeclamox"), TALICIA CAP	21 KB
PDF File	HEP C AGENTS (PDL) STAR and STAR KIDS Members Only	PEGASYS	22 KB
PDF File	HEPATITIS C - INITIAL REQUEST	sofosbuvir/velpatasvir (EPCLUSA), ledipasvir/sofosbuvir (HARVONI), glecaprevir/pibrentasvir (MAVYRET), sofosbuvir (SOVALDI), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA PAK), sofosbuvir/velpatasvir/voxilaprevir (VOSEVI), elbasvir/grazoprevir (ZEPATIER)	87 KB
PDF File	HEREDITARY ANGIOEDEMA (HAE) AGENTS	BERINERT, CINRYZE, icatibant (FIRAZYR), HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO	71 KB
PDF File	HETLIOZ CAPSULES	tasimelteon (HETLIOZ) capsules	65 KB
PDF File	HETLIOZ SUSPENSION	tasimelteon (HETLIOZ) suspension	60 KB
PDF File	HORIZANT	gabapentin enacarbil (HORIZANT)	138 KB
PDF File	HP ACTHAR	corticotropin (HP ACTHAR)	66 KB
PDF File	HUMIRA	adalimumab (HUMIRA)	71 KB
PDF File	HYPOGLYCEMICS, INCRETIN MIMETICS / ENHANCERS STAR and STAR KID Members Only	TRIJARDY XR	21 KB
PDF File	HYPOGLYCEMICS, INSULIN (PDL) STAR and STAR KID Members Only	AFREZZA, APIDRA, BASAGLAR, FIASP, HUMULIN N KWIKPEN, insulin lispro (HUMALOG, ADMELOG), NOVOLIN, NOVOLIN N, NOVOLIN R, TOUJEO, TRESIBA	126 KB
PDF File	HYPOGLYCEMICS, MEGLITINIDES (PDL) STAR and STAR KIDS Members Only	repaglinide/metformin, STARLIX	126 KB
PDF File	HYPOGLYCEMICS, METFORMIN (PDL) STAR and STAR KIDS Members Only	FORTAMET, glipizide/metformin, GLUCOPHAGE, GLUCOPHAGE XR, GLUMETZA, RIOMET soln, metformin soln, metformin ER 1000mg tab	126 KB
PDF File	ILARIS	canakinumab (ILARIS)	72 KB
PDF File	ILUMYA	tildrakizumab (ILUMYA)	134 KB
PDF File	IMMUNE GLOBULINS (PDL) STAR and STAR KIDS Members Only	BIVIGAM, CUVITRU, FLEBOGAMMA, HYQVIA, OCTAGAM, PRIVIGEN, XEMBIFY	126 KB
PDF File	IMMUNOSUPPRESSIVES, ORAL (PDL) STAR and STAR KIDS Members Only	ASTAGRAF XL, cyclosporine (SANDIMMUNE), ENVARSUS XR, everolimus (ZORTRESS), mycophenolic (MYFORTIC, CELLCEPT), NEORAL, sirolimus (RAPAMUNE)	126 KB
PDF File	INCRELEX	mecasermin (INCRELEX)	60 KB
PDF File	INGREZZA	valbenazine (INGREZZA)	62 KB
PDF File	INHALED ANTIBIOTICS	BETHKIS, CAYSTON, KITABIS, tobramycin (TOBI, TOBI PODHALER)	140 KB
PDF File	INHALED GLUCOCORTICOIDS (PDL) STAR and STAR KIDS Members Only	AIRDUO, ALVESCO, ARMONAIR, ARNUITY, ASMANEX HFA (Twisthaler is PDL), BREO, BREZTRI, budesonide/formoterol, FLOVENT Diskus (HFA is PDL), budesonide (PULMICORT), QVAR, TRELEGY, fluticasone/salmeterol (WIXELA)	126 KB
PDF File	INTRANASAL RHINITIS AGENTS (PDL) 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, triamcinolone acetonide, XHANCE	126 KB
PDF File	IRON (ORAL) (PDL) STAR and STAR KIDS Members Only	CITRANATAL, CORVITE, CORVITE FE, FERIVA, FERIVAFA, FERRAPLUS, FUSION PLUS, IROSPAN, TARON FORTE CAP	21 KB
PDF File	JUXTAPID	lomitapide (JUXTAPID)	71 KB
PDF File	KALYDECO	ivacaftor (KALYDECO)	58 KB
PDF File	KETOROLAC (INJECTION / NASAL)	ketorolac (TORADOL equiv) injection, ketorolac nasal spray	160 KB
PDF File	KETOROLAC (ORAL)	oral ketorolac (TORADOL equiv)	76 KB
PDF File	KEVEYIS	dichlorphenamide (KEVEYIS)	50 KB
PDF File	KEVZARA	sarilumab (KEVZARA)	60 KB
PDF File	KINERET	anakinra (KINERET)	62 KB
PDF File	LEUKOTRIENE MODIFIERS (PDL) STAR and STAR KIDS Members Only	montelukast granules (SINGULAIR), SINGULAIR chewable 4mg/5mg, SINGULAIR tablets 10mg	21 KB
PDF File	LIDOCAINE	lidocaine (LIDODERM) 5% patch, ZTLIDO 1.8%	136 KB
PDF File	LINCOSAMIDE & RELATED ANTIBIOTICS (PDL) STAR and STAR KIDS Only Members	CLEOCIN, LINCOCIN, SIVEXTRO, ZYVOX	126 KB
PDF File	LINZESS	linaclotide (LINZESS)	125 KB
PDF File	LIPOTROPICS (DRO - PDL)	colesevelam (WELCHOL), colestipol (COLESTID), ezetimibe, fenofibrate (FENOGLIDE, LIPOFEN, TRICOR, TRILIPIX), fenofibric acid , LOPID, niacin extended-release (NIASPAN ER), NEXLETOL, NEXLIZET, QUESTRAN	29 KB
PDF File	LIPOTROPICS (STATINS) (DRO - PDL)	amlodipine/atorvastatin (CADUET), rosuvastatin (CRESTOR), ezetimibe/simvastatin (VYTORIN), fluvastatin, fluvastatin ER (LESCOL XL), lovastatin, atorvastatin (LIPITOR), LIVALO, pravastatin (PRAVACHOL), simvastatin (ZOCOR), ZYPITAMAG	30 KB
PDF File	LONG-ACTING INJECTABLE ANTIPSYCHOTICS (DRO - PDL)	ABILIFY MAINTENA, ARISTADA, ARISTADA INITIO, fluphenazine decanoate inj, HALDOL DECANOATE INJ, haloperidol decanoate inj, INVEGA SUSTENNA, INVEGA TRINZA, PERSERIS, RISPERDAL CONSTA, ZYPREXA RELPREVV	36 KB
PDF File	LOTRONEX	alosetron (LOTRONEX)	136 KB
PDF File	LOVAZA & VASCEPA	omega-3-acid ethyl esters (LOVAZA), icosapent ethyl (VASCEPA)	61 KB
PDF File	MACROLIDES (PDL) STAR and STAR KIDS Members Only	CLARITHROMYCIN, E.E.S., ERY-TAB, ERYTHROCIN, ERYTHROMYCIN, ERYTHROMYCIN ETHYLSUCCINATE, ZITHROMAX	23 KB
PDF File	MAKENA For Community First Health Plan (CFHP), Dell Children's (Seton), Driscoll Children's, El Paso, FirstCare Parkland, and Baylor Scott & White Health Plans	hydroxyprogesterone caproate injection (MAKENA)	45 KB
PDF File	MAKENA - CHC / COOK / TCHP For Community Health Choice, Cook Children’s Health Plans, and Texas Children’s Health Plans	hydroxyprogesterone caproate injection (MAKENA)	47 KB
PDF File	MAVENCLAD	cladribine (MAVENCLAD)	58 KB
PDF File	MAYZENT	siponimod (MAYZENT)	69 KB
PDF File	MOTEGRITY	prucalopride (MOTEGRITY)	135 KB
PDF File	MOVANTIK	naloxegol (MOVANTIK)	132 KB
PDF File	MUSCLE RELAXERS (PDL) STAR and STAR KIDS Members Only	chlorzoxazone (LORZONE), dantrolene (DANTRIUM), metaxalone (SKELAXIN), orphenadrine extended-release, ROBAXIN-750, tizanidine	21 KB
PDF File	NEUROPATHIC PAIN (PDL) STAR and STAR KIDS Members Only	duloxetine (CYMBALTA), pregabalin (LYRICA, LYRICA CR)	126 KB
PDF File	NSAIDs (PDL) STAR and STAR KIDS Members Only	diclofenac sodium/misoprostol (ARTHROTEC), diclofenac (FLECTOR), diflunisal, DUEXIS, EC-NAPROXEN, etodolac, etodolac extended-release, fenoprofen (NALFON), flurbiprofen, indomethacin (INDOCIN), ketoprofen, meclofenamic, meloxicam capsules (VIVLODEX), nabumetone (RELAFEN), naproxen/esomeprazole (VIMOVO), oxaprozin (DAYPRO), piroxicam (FELDENE), sulindac, tolmetin	21 KB
PDF File	NUCALA	mepolizumab (NUCALA)	67 KB
PDF File	NUPLAZID	pimavanserin (NUPLAZID)	61 KB
PDF File	NURTEC	rimegepant (NURTEC)	62 KB
PDF File	NUVIGIL	armodafinil (NUVIGIL)	63 KB
PDF File	OLUMIANT	baricitinib (OLUMIANT)	146 KB
PDF File	OPHTHALMIC IMMUNOMODULATORS	CEQUA, RESTASIS, XIIDRA	67 KB
PDF File	OPHTHALMICS, ALLERGIC CONJUNCTIVITIS (PDL) STAR and STAR KIDS Members Only	ALOCRIL, ALOMIDE, ALREX, azelastine, BEPREVE, epinastine, LASTACAFT, olopatadine 0.1%, 0.2%, (PATANOL, PATADAY)	126 KB
PDF File	OPHTHALMICS, ANTI-INFLAMMATORIES (PDL) STAR and STAR KIDS Members Only	ACUVAIL, bromfenac, 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	OPHTHALMICS, ANTIBIOTIC - STEROID COMBO (PDL) 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	OPHTHALMICS, ANTIBIOTICS (PDL) 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	OPHTHALMICS, GLAUCOMA AGENTS (PDL) STAR and STAR KIDS Members Only	apraclonidine, betaxolol (BETOPTIC-S), bimatiprost (LUMIGAN), brimonidine (ALPHAGAN P), dorzolamide-timolol (COSOPT, COSOPT PF) , PHOSPHOLINE, timolol maleate (ISTALOL), TIMOPTIC, TIMOPTIC XE, TRAVOPROST, TRUSOPT, VYZULTA, XALATAN, ZIOPTAN	126 KB
PDF File	OPIOID - CARISOPRODOL CODEINE	CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE	168 KB
PDF File	OPIOID - COUGH & COLD	codeine-guaifenesin (GUAIATUSSIN, NINJACOF-XG, VIRTUSSIN AC), hydrocodone-homatropine (HYDROMET), hydrocodone-chlorpheniramine polistirex (TUSSIONEX), pseudoephedrine/codeine/guaifenesin (VIRTUSSIN DAC)	154 KB
PDF File	OPIOID - FENTANYL AGENTS - ACTIQ	oral transmucosal fentanyl (ACTIQ)	92 KB
PDF File	OPIOID - FENTANYL AGENTS - FENTORA	buccal fentanyl (FENTORA)	92 KB
PDF File	OPIOID - FENTANYL AGENTS: DURAGESIC	transdermal fentanyl (DURAGESIC)	88 KB
PDF File	OPIOID - OXYCONTIN ER - HIGH DOSE	oxycodone (OXYCONTIN) 60mg & 80mg	165 KB
PDF File	OPIOID - OXYCONTIN ER - LOW DOSE	oxycodone (OXYCONTIN) 10mg, 15mg, 20mg, 30mg, 40mg / XTAMPZA	165 KB
PDF File	OPIOID - PROMETHAZINE CODEINE	PROMETHAZINE VC-CODEINE SYRUP, PROMETHAZINE-CODEINE SYRUP	150 KB
PDF File	OPIOID POLICY	ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE, ACETAMINOPHEN/CODEINE, ASCOMP WITH 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, KADIAN, LEVORPHANOL, LORCET, MEPERIDINE, METHADONE, METHADOSE, MORPHABOND, MORPHINE SULFATE, MS CONTIN, NALBUPHINE, NALOCET, NORCO, NUCYNTA (ER), OPIUM TINCTURE, OXYCODONE, OXYCODONE/ACETAMINOPHEN, OXYCODONE/ASPIRIN, OXYCODONE/IBUPROFEN, OXYMORPHONE, PENTAZOCINE/NALOXONE, PERCOCET, ROXICODONE, TRAMADOL/ACETAMINOPHEN, TRAMADOL HYDROCHLORIDE, ULTRACET, ULTRAM	154 KB
PDF File	ORAL GLUCOCORTICOIDS (PDL) STAR and STAR KIDS Members Only	CORTEF, CORTISONE, dexamethasone, ENTOCORT, methylprednisolone (MEDROL), prednisolone (MILLIPRED), prednisone, TAPERDEX	126 KB
PDF File	ORAL/NASAL ANTIVIRALS (PDL) STAR and STAR KIDS Members Only	valganciclovir soln/tab	126 KB
PDF File	ORALAIR	Grass Pollen Allergen Extract (ORALAIR)	57 KB
PDF File	ORENCIA	abatacept (ORENCIA)	139 KB
PDF File	ORIAHNN	elagolix, estradiol and norethindrone (ORIAHNN)	142 KB
PDF File	ORILISSA	elagolix (ORILISSA)	64 KB
PDF File	ORKAMBI	lumacaftor / ivacaftor (ORKAMBI)	59 KB
PDF File	OTEZLA	apremilast (OTEZLA)	58 KB
PDF File	OTIC ANTI-INFECTIVES/ANESTHETICS (PDL) STAR and STAR KIDS Members Only	hydrocortisone/acetic acid, PINNACAINE	126 KB
PDF File	OTIC ANTIBIOTICS (PDL) STAR and STAR KIDS Members Only	CIPRO HC, ciprofloxacin/dexamethasone (CIPRODEX), CORTISPORIN, OTOVEL	126 KB
PDF File	OXBRYTA	voxelotor (OXBRYTA)	58 KB
PDF File	OXERVATE	cenegermin-bkbj (OXERVATE)	52 KB
PDF File	PALFORZIA	peanut allergen powder (PALFORZIA)	61 KB
PDF File	PANCREATIC ENZYMES (PDL) STAR and STAR KIDS Members Only	PANCREAZE, PERTZYE, VIOKACE	126 KB
PDF File	PDE5-INHIBITORS	sildenafil (REVATIO), tadalafil (ADCIRCA)	68 KB
PDF File	PEDIATRIC VITAMIN PREPARATIONS STAR and STAR KIDS Members Only	ANIMAL SHAPE CHW + IRON, mulitvitamin with fluoride (FLORIVA, POLY-VI-FLOR, QUFLORA, TRI-VI-FLOR suspension, TRI-VIT/FLUO drops), vitamin A, C, D and fluroide drops	134 KB
PDF File	PHOSPHATE BINDERS	AURYXIA, calcium acetate (PHOSLYRA), lanthanum (FOSRENOL), VELPHORO	70 KB
PDF File	PHOSPHATE BINDERS (PDL) STAR and STAR KIDS Members Only	sevelamer (RENVELA)	29 KB
PDF File	PLATELET AGGREGATION INHIBITORS (PDL) STAR and STAR KIDS Members Only	dipyridamole, EFFIENT, PLAVIX, ZONTIVITY	126 KB
PDF File	PONVORY	ponesimod (PONVORY)	69 KB
PDF File	PRALUENT	alirocumab (PRALUENT)	66 KB
PDF File	PRENATAL VITAMINS (PDL) STAR and STAR KIDS Members Only	CITRANATAL, COMPLETENATE, CONCEPT DHA, CONCEPT OB, ELITE-OB, FOLIVANE-OB, NESTABS, NESTABS DHA, OB COMPLETE, PNV-DHA, PNV-OMEGA, PNV-SELECT, PRENAISSANCE, PRENATE, PRENATE AM, PRENATE DHA, PRENATE MINI, PRENATE STAR, SELECT-OB, SE-NATAL 19, TARON-C DHA, THRIVITE 19, THRIVITE RX, TRISTART DHA, VP-CH-PNV, VP-PNV-DHA, ZATEAN-PN	126 KB
PDF File	PROCRIT	epoetin alfa (PROCRIT)	34 KB
PDF File	PROGESTINS FOR CACHEXIA (PDL) STAR and STAR KIDS Members Only	megestrol ES 625mg/5ml susp	126 KB
PDF File	PROMETHAZINE & PROMETHAZINE CONTAINING PRODUCTS	PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE VC SYRUP, PROMETHAZINE-DM SYRUP, PROMETHEGAN	57 KB
PDF File	PROPYLTHIOURACIL	propylthiouracil	18 KB
PDF File	PROTON PUMP INHIBITORS (DRO - PDL)	ACIPHEX/rabeprazole, DEXILANT, esomeprazole, lansoprazole, NEXIUM cap, ZEGERID/omepra/bicar (omeprazole/bicarbonate), omeprazole cap 20.6mg, omeprazole tab, PREVACID cap/solutab, PROTONIX tab.	30 KB
PDF File	PROTOPIC 0.1%	tacrolimus (PROTOPIC) 0.1%	65 KB
PDF File	PROVIGIL	modafinil (PROVIGIL)	63 KB
PDF File	Pulmonary Arterial Hypertension Agents (PDL) STAR and STAR KIDS Members Only	ADEMPAS, bosentan, LETAIRIS, OPSUMIT, ORENITRAM, TRACLEER, TYVASO solution, TYVASO refill solution, TYVASO start solution, UPTRAVI, VENTAVIS solution	126 KB
PDF File	QELBREE	viloxazine (QELBREE)	58 KB
PDF File	RANEXA	ranolazine (RANEXA)	93 KB
PDF File	RELISTOR	methylnaltrexone (RELISTOR)	135 KB
PDF File	REPATHA	evolocumab (REPATHA)	71 KB
PDF File	RETACRIT	epoetin alfa (RETACRIT)	28 KB
PDF File	RINVOQ	upadacitinib (RINVOQ)	147 KB
PDF File	ROZEREM	ramelteon (ROZEREM)	66 KB
PDF File	SAVELLA	milnacipran (SAVELLA)	141 KB
PDF File	SEDATIVES / HYPNOTICS (PDL) STAR and STAR KIDS Members Only	doxepin (SILENOR)	126 KB
PDF File	SEDATIVES / HYPNOTICS - ADULTS	AMBIEN, AMBIEN CR, BELSOMRA, DAYVIGO, EDLUAR, ESTAZOLAM, ESZOPICLONE, INTERMEZZO, LUNESTA, RESTORIL, SONATA, TEMAZEPAM, TRIAZOLAM, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER	64 KB
PDF File	SEDATIVES / HYPNOTICS - FLURAZEPAM	flurazepam	64 KB
PDF File	SGLT2 INHIBITOR COMBINATION AGENTS	INVOKAMET (XR), SEGLUROMET, SYNJARDY (XR), XIGDUO XR	139 KB
PDF File	SGLT2 INHIBITOR SINGLE AGENTS	FARXIGA, INVOKANA, JARDIANCE, STEGLATRO	66 KB
PDF File	SILIQ	brodalumab (SILIQ)	61 KB
PDF File	SIMPONI	golimumab (SIMPONI)	67 KB
PDF File	SKYRIZI	risankizumab (SKYRIZI)	62 KB
PDF File	SMOKING CESSATION (PDL) STAR and STAR KIDS Members Only	NICOTROL	126 KB
PDF File	STELARA	ustekinumab (STELARA)	62 KB
PDF File	STEROIDS, TOPICAL (PDL) STAR and STAR KIDS Members Only	alclometason, amcinonide, betamethsone dipropionate (DIPROLENE, SERNIVO), betamethasone valerate, BRYHALI, clobetasol (CLOBEX, OLUX, OLUX-E, TEMOVATE), desonide, desoximetas (TOPICORT, TOPICORT LP), diflorasone (APEXICON E), fluocinolone acetate oil, fluocinonide (VANOS), halcinonide (HALOG), hydrocortisone butyrate, hydrocortisone valerate, hydrocortisone (TEXACORT), LEXETTE, prednicarbate, triamcinolone acetate (TRIANEX)	126 KB
PDF File	SUNOSI	solriamfetol (SUNOSI)	62 KB
PDF File	SYMDEKO	tezacaftor/ivacaftor and ivacaftor (SYMDEKO)	54 KB
PDF File	SYMLIN	pramlintide (SYMLIN)	132 KB
PDF File	SYMPROIC	naldemedine (SYMPROIC)	139 KB
PDF File	SYNAGIS - COMMUNITY FIRST HEALTH PLANS For Community First Health Plan Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	315 KB
PDF File	SYNAGIS - COMMUNITY HEALTH CHOICE For Community Health Choice Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	299 KB
PDF File	SYNAGIS - COOK CHILDREN'S HEALTH PLANS For Cook Children's Health Plan Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	299 KB
PDF File	SYNAGIS - DELL CHILDREN'S (SETON) HEALTH PLANS For Dell Children's Health (Seton) Plan Only - RSV Dates 2021-2022	palivizumab (SYNAGIS)	299 KB
PDF File	SYNAGIS - DRISCOLL CHILDREN'S HEALTH PLANS For Driscoll Children's Health Plan Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	300 KB
PDF File	SYNAGIS - EL PASO FIRST HEALTH PLANS For El Paso First Health Plan Only - RVS Season Dates 2021-2022	palivizumab (SYNAGIS)	299 KB
PDF File	SYNAGIS - FIRSTCARE HEALTH PLANS For FirstCare Health Plan Only - RSV Dates 2021-2022	palivizumab (SYNAGIS)	301 KB
PDF File	SYNAGIS - PARKLAND COMMUNITY HEALTH PLANS For Parkland Community Health Plans Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	299 KB
PDF File	SYNAGIS - RENEWAL		27 KB
PDF File	SYNAGIS - SCOTT & WHITE HEALTH PLANS For Scott & White Health Plan Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	301 KB
PDF File	SYNAGIS - TEXAS CHILDREN'S HEALTH PLANS For Texas Children's Health Plan Only - RSV Season Dates 2021-2022	palivizumab (SYNAGIS)	289 KB
PDF File	TALTZ	ixekizumab (TALTZ)	140 KB
PDF File	TEGSEDI	inotersen (TEGSEDI)	59 KB
PDF File	TETRACYCLINES (PDL) STAR and STAR KIDS Members Only	demeclocycline, doxycycline monohydrate (ORACEA), doxycycline suspension (VIBRAMYCIN), minocycline (SOLODYN, MINOLIRA), NUZYRA, tetracycline	126 KB
PDF File	THROMBOPOIESIS STIMULATING PROTEINS (PDL) STAR and STAR KIDS Members Only	DOPTELET, MULPLETA, PROMACTA POW, TAVALISSE	126 KB
PDF File	TOPICAL ACNE AGENTS	BENZACLIN GEL, BENZACLIN PUMP GEL, BENZEFOAM, ERYTHROMYCIN-BENZOYL GEL, CLINDAMYCIN-BENZOYL PEROXIDE GEL 1.2-5%, CLINDAMYCIN-BENZOYL PEROXIDE GEL, DUAC 1.2-5% GEL	26 KB
PDF File	TOPICAL ACNE AGENTS (PDL) STAR and STAR KIDS Members Only	AMZEEQ, ARAZLO LOT, AZELEX, CLEOCIN-T, CLINDAMYCIN AEROSOL, CLINDAMYCIN GEL, CLINDAMYCIN LOTION, dapsone (ACZONE), erythromycin (ERY) pads, EVOCLIN, RETIN-A MICRO GEL, sulfacetamide lotion.	21 KB
PDF File	TOPICAL ANDROGENIC AGENTS (PDL) STAR and STAR KIDS Members Only	testosterone (ANDRODERM, ANDROGEL, FORTESTA, TESTIM, VOGELXO)	126 KB
PDF File	TOPICAL ANTIBIOTICS (PDL) STAR and STAR KIDS Members Only	bacitracin zinc, gentamicin, mupirocin (CENTANY)	126 KB
PDF File	TOPICAL ANTIFUNGALS (PDL) STAR and STAR KIDS Members Only	athletes foot spray, BENSAL HP, ciclopirox (LOPROX), clotrimazole/betamethasone, econazole, FUNGOID TINCTURE, JUBLIA, KERYDIN, ketoconazole (EXTINA), luliconazole, MENTAX, miconazole/petrolatum/zinc oxide, naftifine, nystatin/triamcinolone, oxiconazole (OXISTAT), VUSION	126 KB
PDF File	TOPICAL ANTIVIRALS (PDL) STAR and STAR KIDS Members Only	acyclovir cream, XERESE, ZOVIRAX cream/oint	126 KB
PDF File	TOPICAL RETINOIDS	ADAPALENE, ADAPALENE-BENZYL PEROXIDE, ALTRENO, ATRALIN, AVITA, CLINDAMYCIN-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, ZIANA	26 KB
PDF File	TOPICAL ROSACEA AGENTS STAR and STAR KID Members Only	AZELAIC ACID GEL, METRONIDAZOL LOT, METROGEL, METROCREAM, MIRVASO GEL, IVERMECTIN CRE, FINACEA AER	21 KB
PDF File	TREMFYA	guselkumab (TREMFYA)	57 KB
PDF File	TRIKAFTA	elexcaftor/tezacaftor/ivacaftor (TRIKAFTA)	56 KB
PDF File	TRULANCE	plecanatide (TRULANCE)	135 KB
PDF File	TYVASO STARTER KIT - CHIP PLANS ONLY	treprostinil (TYVASO STARTER KIT)	16 KB
PDF File	UBRELVY	ubrogepant (UBRELVY)	57 KB
PDF File	ULCERATIVE COLITIS AGENTS (PDL) STAR and STAR KIDS Members Only	azulfidine, balsalazide (COLAZAL), budesonide ER, CANASA, DIPENTUM, mesalamine 800mg (ASACOL HD), mesalamine 0.375gm (APRISO, PENTASA), mesalamine 1.2 gm, mesalamine ENE 4gm, UCERIS	21 KB
PDF File	UREA CYCLE DISORDER AGENTS	CARBAGLU, RAVICTI, sodium phenylbutyrate (BUPHENYL)	25 KB
PDF File	VAGINAL ANTIBIOTICS (PDL) STAR and STAR KIDS Members Only	clindamycin (CLEOCIN), metronidazole 0.75% vaginal gel, SOLOSEC, VANDAZOLE	126 KB
PDF File	VIBERZI	eluxadoline (VIBERZI)	139 KB
PDF File	VITAMINS & MINERALS - IRON STAR and STAR KIDS Members Only	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	VITAMINS AND MINERALS STAR and STAR KIDS Members Only	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
PDF File	VYNDAMAX & VYNDAQEL	tafamidis (VYNDAMAX) and tafamidis meglumine (VYNDAQEL)	58 KB
PDF File	WAKIX	pitolisant (WAKIX)	68 KB
PDF File	XELJANZ / XELJANZ XR	tofacitinib citrate (XELJANZ / XELJANZ XR)	67 KB
PDF File	XENICAL	orlistat (XENICAL)	44 KB
PDF File	XIFAXAN 200 MG	rifaximin 200mg (XIFAXAN 200mg)	135 KB
PDF File	XIFAXAN 550 MG	rifaximin 550mg (XIFAXAN 550mg)	139 KB
PDF File	XYREM / XYWAV	sodium oxybate (XYREM) / XYWAV	56 KB
PDF File	ZELBORAF	vemurafenib (ZELBORAF)	21 KB
PDF File	ZEPOSIA	ozanimod (ZEPOSIA)	72 KB
PDF File	ZYCLARA	imiquimod 3.75 % cream (ZYCLARA)	45 KB
PDF File	ZYFLO	zileuton (ZYFLO)	57 KB

Type

Date

Name

File Size

.txt

10/25/2021

Texas-CHIP-Formulary-10-25-21

2.4 MB

.txt

10/25/2021

Texas-STAR-Formulary-10-25-21

3.5 MB

.txt

10/25/2021

Texas-STAR-Kids-Dual-Formulary-10-25-21

850 kB