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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.

Click here for additional Synagis information.

Click here for Clinical Edit information.

Type Name Drug Name File Size
PDF File 150mg Aliskiren-Containing Agents
AMTURNIDE 150mg, TEKAMLO 150mg, TEKTURNA 150mg, TEKTURNA HCT 150mg 55 KB
PDF File 300mg Aliskiren-Containing Agents
AMTURNIDE 300mg, TEKTURNA 300mg, TEKTURNA HCT 300mg 54 KB
PDF File ACCOLATE
zafirlukast (ACCOLATE) 47 KB
PDF File ACTEMRA
tocilizumab (ACTEMRA) 58 KB
PDF File ACTIQ
oral transmucosal fentanyl (ACTIQ) 63 KB
PDF File ACTOS / DUETACT / OSENI
pioglitazone (ACTOS), pioglitazone/glimepiride (DUETACT), alogliptin/pioglitazone (OSENI) 28 KB
PDF File AGENTS FOR GAUCHER’S DISEASE
CEREZYME, ELELYSO, VPRIV, ZAVESCA 20 KB
PDF File AIMOVIG
erenumab (AIMOVIG) 64 KB
PDF File ALDARA
imiquimod 5% cream (ALDARA) 45 KB
PDF File ALINIA SUSPENSION
nitazoxanide oral suspension (ALINIA) 25 KB
PDF File ALINIA TABLETS
nitazoxanide tablets (ALINIA) 26 KB
PDF File AMITIZA
lubiprostone (AMITIZA) 59 KB
PDF File ANTIEMETICS
ANZEMET, AKYNZEO, aprepitant (EMEND), GRANISETRON, SANCUSO 25 KB
PDF File ANTIPSYCHOTICS
ABILIFY, ABILIFY MAINTENA, AMITRIPTYLINE/PERPHENAZINE, ARIPIPRAZOLE, ARISTADA, CHLORPROMAZINE, CLOZAPINE, CLOZARIL, FANAPT, FAZACLO, FLUPHENAZINE, GEODON, HALOPERIDOL, INVEGA, INVEGA SUSTENNA, INVEGA TRINZA, LATUDA, LOXAPINE, OLANZAPINE, OLANZAPINE/FLUOXETINE, ORAP, PALIPERIDONE, PERPHENAZINE, PIMOZIDE, QUETIAPINE, REXULTI, RISPERDAL, RISPERIDONE, SAPHRIS, SEROQUEL, SEROQUEL XR, SYMBYAX, THIORIDAZINE, THIOTHIXENE, TRIFLUOPERAZINE, VERSACLOZ, VRAYLAR, ZIPRASIDONE, ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ZYDIS 27 KB
PDF File ANXIOLYTICS (alprazolam)
alprazolam (XANAX) 60 KB
PDF File ANXIOLYTICS (chlordiaz., meprobamate, oxazepam)
chlordiazepoxide, meprobamate, oxazepam 67 KB
PDF File ANXIOLYTICS (clonazepam, diazepam)
clonazepam (KLONOPIN), diazepam 70 KB
PDF File ANXIOLYTICS (clorazepate)
clorazepate (TRANXENE) 35 KB
PDF File ANXIOLYTICS (lorazepam)
lorazepam 65 KB
PDF File ARANESP
darbepoetin alfa (ARANESP) 27 KB
PDF File ATTENTION DEFICIT MEDICATIONS (CLONIDINE ER)
clonidine ER 55 KB
PDF File ATTENTION DEFICIT MEDICATIONS (ER FORMULATIONS)
amphetamine/dextroamphetamine (MYDAYIS), amphetamine/dextroamphetamine salts (ADDERALL XR), amphetamine/dextroamphetamine salts (DYANAVEL XR), amphetamine/dextroamphetamine salts (ADZENYS ER), amphetamine/dextroamphetamine salts (ADZENYS XR-ODT), dexmethylphenidate (FOCALIN XR), dextroamphetamine (DEXEDRINE SPANSULE), lisdexamfetamine (VYVANSE) capsule, lisdexamfetamine (VYVANSE) chewable tablet, methylphenidate (APTENSIO XR), methylphenidate (METADATE CD), methylphenidate (RITALIN LA), methylphenidate (QUILLICHEW ER), methylphenidate (QUILLIVANT XR), methylphenidate (METADATE ER), methylphenidate (METHYLIN ER), methylphenidate (RITALIN SR), methylphenidate (CONCERTA), methylphenidate (COTEMPLA), methylphenidate (DAYTRANA TD) 178 KB
PDF File ATTENTION DEFICIT MEDICATIONS (IR FORMULATIONS)
amphetamine/dextroamphetamine salts (ADDERALL), amphetamine sulfate tablet (EVEKEO), dexmethylphenidate (FOCALIN), dextroamphetamine (DEXEDRINE), dextroamphetamine solution (PROCENTRA), dextroamphetamine (ZENZEDI), methamphetamine (DESOXYN), methylphenidate (METHYLIN), methylphenidate (RITALIN) 183 KB
PDF File ATTENTION DEFICIT MEDICATIONS (NON-STIMULANTS)
guanfacine SR (INTUNIV), atomoxetine (STRATTERA) 56 KB
PDF File AUSTEDO & XENAZINE
deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE) 62 KB
PDF File AVANDIA
rosiglitazone (AVANDIA) 25 KB
PDF File Blood Glucose Monitors with Special Features
22 KB
PDF File BUNAVAIL / SUBOXONE / ZUBSOLV
buprenorphine/naloxone (BUNAVAIL, SUBOXONE, ZUBSOLV) 53 KB
PDF File BUPRENORPHINE
buprenorphine 49 KB
PDF File CARISOPRODOL-CONTAINING AGENTS
CARISOPRODOL, CARISOPRODOL COMPOUND TAB, CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE, CARISOPRODOL-ASPIRIN, SOMA 64 KB
PDF File CIMZIA
certolizumab pegol (CIMZIA) 58 KB
PDF File COMPOUND DRUGS
30 KB
PDF File CONTRACEPTIVES - CHIP PLANS ONLY
18 KB
PDF File CONTRACEPTIVES - DELL CHILDREN HEALTH PLAN (SETON)
18 KB
PDF File COSENTYX
secukinumab (COSENTYX) 54 KB
PDF File COUGH & COLD
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, 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 108 KB
PDF File COUGH & COLD
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 119 KB
PDF File COUGH & COLD
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 102 KB
PDF File COUGH & COLD
BENZONATATE 101 KB
PDF File COX-2 INHIBITORS (CELEBREX)
celecoxib (CELEBREX) 57 KB
PDF File COX-2 INHIBITORS (MOBIC)
meloxicam (MOBIC) 30 KB
PDF File CYCLOBENZAPRINE
cyclobenzaprine (FLEXERIL / AMRIX) 26 KB
PDF File DDAVP INJECTABLE
desmopressin injectable (DDAVP) 21 KB
PDF File DDAVP ORAL
desmopressin oral (DDAVP) 87 KB
PDF File DIABETIC SUPPLIES
19 KB
PDF File DICLOFENAC 1.5% & 2% SOLUTION
diclofenac 1.5% topical solution, diclofenac 2% topical solution (PENNSAID 2% PUMP) 49 KB
PDF File DICLOFENAC 3% GEL
diclofenac 3% gel (SOLARAZE 3% GEL) 47 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 56 KB
PDF File DPP-4 INHIBITORS: CRITERIA B
alogliptin 12.5 mg (NESINA 12.5 MG), JANUVIA 50 MG 55 KB
PDF File DPP-4 INHIBITORS: CRITERIA C
alogliptin 25 mg (NESINA 25 MG), JANUVIA 100 MG, ONGLYZA 5 MG 57 KB
PDF File DPP-4 INHIBITORS: CRITERIA D
alogliptin-metformin (KAZANO), alogliptin-pioglitazone (OSENI), GLYXAMBI, JANUMET (XR), JENTADUETO (XR), KOMBIGLYZE XR, QTERN, STEGLUJAN 54 KB
PDF File DRUG REGIMEN OPTIMIZATION - ALTACE / DIOVAN
ramipril (ALTACE), valsartan (DIOVAN) 50 KB
PDF File DUPIXENT - INITIAL REQUESTS
dupilumab (DUPIXENT) 65 KB
PDF File DUPIXENT - RENEWAL REQUESTS
dupilumab (DUPIXENT) 21 KB
PDF File DURAGESIC
transdermal fentanyl (DURAGESIC) 59 KB
PDF File ELIDEL & PROTOPIC 0.03%
pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%) 59 KB
PDF File EMFLAZA - INITIAL REQUESTS
deflazacort (EMFLAZA) 72 KB
PDF File EMFLAZA - RENEWAL REQUESTS
deflazacort (EMFLAZA) 24 KB
PDF File ENBREL
etanercept (ENBREL) 55 KB
PDF File ENZYMES
ALDURAZYME, ADAGEN, CARBAGLU, CEPROTIN, ELAPRASE, FABRAZYME, LUMIZYME, NAGLAZYME, NITYR, ORFADIN, RAVICTI, VIMIZIM 62 KB
PDF File EPOGEN / PROCRIT
epoetin alfa (EPOGEN / PROCRIT) 28 KB
PDF File EUCRISA
crisaborole (EUCRISA) 19 KB
PDF File EXCEPTION TO COVERAGE REQUEST
39 KB
PDF File FENTORA
buccal fentanyl (FENTORA) 61 KB
PDF File GABAPENTIN
gabapentin (NEURONTIN) 60 KB
PDF File GLP-1 RECEPTOR AGONISTS
ADLYXIN, BYDUREON, BYDUREON BCISE, BYETTA, OZEMPIC, SOLIQUA, TANZEUM, TRULICITY, VICTOZA, XULTOPHY 68 KB
PDF File GRALISE
gabapentin extended release (GRALISE) 50 KB
PDF File GROWTH HORMONE - SEROSTIM
somatropin (SEROSTIM) 52 KB
PDF File GROWTH HORMONE - ZORBTIVE
somatropin (ZORBITIVE) 50 KB
PDF File GROWTH HORMONES - GENOTROPIN & NORDITROPIN
GENOTROPIN, NORDITROPIN 109 KB
PDF File GROWTH HORMONES - GENOTROPIN & NORDITROPIN
GENOTROPIN, NORDITROPIN 109 KB
PDF File GROWTH HORMONES - GENOTROPIN & NORDITROPIN
GENOTROPIN, NORDITROPIN 109 KB
PDF File GROWTH HORMONES - OTHER PRODUCTS
HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN 109 KB
PDF File HEPATITIS C - INITIAL REQUEST
sofosbuvir/velpatasvir (EPCLUSA), daclatasvir (DAKLINZA), ledipasvir/sofosbuvir (HARVONI), glecaprevir/pibrentasvir (MAVYRET), simeprevir (OLYSIO), sofosbuvir (SOVALDI), ombitasvir/paritaprevir/ritonavir (TECHNIVIE), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA PAK), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA XR), sofosbuvir/velpatasvir/voxilaprevir (VOSEVI), elbasvir/grazoprevir (ZEPATIER) 102 KB
PDF File HEPATITIS C - REFILL REQUEST
sofosbuvir/velpatasvir (EPCLUSA), daclatasvir (DAKLINZA), ledipasvir/sofosbuvir (HARVONI), glecaprevir/pibrentasvir (MAVYRET), simeprevir (OLYSIO), sofosbuvir (SOVALDI), ombitasvir/paritaprevir/ritonavir (TECHNIVIE), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA PAK), ombitasvir/paritaprevir/ritonavir and dasabuvir (VIEKIRA XR), sofosbuvir/velpatasvir/voxilaprevir (VOSEVI), elbasvir/grazoprevir (ZEPATIER) 77 KB
PDF File HEREDITARY ANGIOEDEMA (HAE) AGENTS
CINRYZE, HAEGARDA 51 KB
PDF File HORIZANT
gabapentin enacarbil (HORIZANT) 52 KB
PDF File HP ACTHAR
corticotropin (HP ACTHAR) 36 KB
PDF File HUMIRA
adalimumab (HUMIRA) 71 KB
PDF File ILARIS
canakinumab (ILARIS) 67 KB
PDF File INCRELEX
mecasermin (INCRELEX) 60 KB
PDF File INGREZZA
valbenazine (INGREZZA) 58 KB
PDF File KALYDECO
ivacaftor (KALYDECO) 84 KB
PDF File KETOROLAC (INJECTION / NASAL)
ketorolac (SPRIX, TORADOL), injection & nasal spray 63 KB
PDF File KETOROLAC (ORAL)
ketorolac (TORADOL), oral 71 KB
PDF File KEVEYIS
dichlorphenamide (KEVEYIS) 50 KB
PDF File KEVZARA
sarilumab (KEVZARA) 56 KB
PDF File KINERET
anakinra (KINERET) 57 KB
PDF File LAZANDA & SUBSYS
fentanyl (LAZANDA / SUBSYS) 55 KB
PDF File LIDODERM
lidocaine patch (LIDODERM) 58 KB
PDF File LINZESS
linaclotide (LINZESS) 86 KB
PDF File LOTRONEX
alosetron (LOTRONEX) 52 KB
PDF File LOVAZA
Omega-3-Acid Ethyl Esters (LOVAZA) 47 KB
PDF File MAKENA
hydroxyprogesterone caproate injection (MAKENA) 43 KB
PDF File MAKENA
hydroxyprogesterone caproate injection (MAKENA) 40 KB
PDF File MAKENA
hydroxyprogesterone caproate injection (MAKENA) 41 KB
PDF File MOVANTIK / SYMPROIC
naloxegol (MOVANTIK), naldemedine (SYMPROIC) 61 KB
PDF File NUPLAZID
pimavanserin (NUPLAZID) 57 KB
PDF File NUVIGIL
armodafinil (NUVIGIL) 59 KB
PDF File OPIOID OVERUTILIZATION
25 KB
PDF File ORALAIR
Grass Pollen Allergen Extract (ORALAIR) 51 KB
PDF File ORENCIA
abatacept (ORENCIA) 57 KB
PDF File ORKAMBI
lumacaftor / ivacaftor (ORKAMBI) 52 KB
PDF File OTEZLA
apremilast (OTEZLA) 59 KB
PDF File OXYCONTIN ER - HIGH DOSE
oxycodone (OXYCONTIN) 60mg & 80mg 59 KB
PDF File OXYCONTIN ER - LOW DOSE
oxycodone (OXYCONTIN) 10mg, 15mg, 20mg, 30mg, 40mg, XTAMPZA 54 KB
PDF File PCSK9 INHIBITORS
alirocumab (PRALUENT), evolocumab (REPATHA) 144 KB
PDF File PHOSPHATE BINDERS
AURYXIA, calcium acetate (PHOSLYRA), lanthanum (FOSRENOL), VELPHORO 46 KB
PDF File PROMETHAZINE & PROMETHAZINE CONTAINING PRODUCTS
PHENADOZ, PHENERGAN, PROMETHAZINE, PROMETHAZINE VC SYRUP, PROMETHAZINE VC-CODEINE SYRUP, PROMETHAZINE-CODEINE SYRUP, PROMETHAZINE-DM SYRUP, PROMETHEGAN 48 KB
PDF File PROPYLTHIOURACIL
propylthiouracil 18 KB
PDF File PROTOPIC 0.1%
tacrolimus (PROTOPIC) 0.1% 55 KB
PDF File PROVIGIL
modafinil (PROVIGIL) 59 KB
PDF File RANEXA
ranolazine (RANEXA) 93 KB
PDF File RELISTOR
methylnaltrexone (RELISTOR) 54 KB
PDF File REVATIO & ADCIRCA
sildenafil (REVATIO), tadalafil (ADCIRCA) 53 KB
PDF File SAVELLA
milnacipran (SAVELLA) 51 KB
PDF File SEDATIVES / HYPNOTICS - ADULTS
AMBIEN, AMBIEN CR, BELSOMRA, EDLUAR, ESTAZOLAM, ESZOPICLONE, INTERMEZZO, LUNESTA, RESTORIL, SONATA, TEMAZEPAM, TRIAZOLAM, ZALEPLON, ZOLPIDEM, ZOLPIDEM ER 30 KB
PDF File SEDATIVES / HYPNOTICS - butabarbital
butabarbital (BUTISOL) 73 KB
PDF File SEDATIVES / HYPNOTICS - flurazepam
flurazepam 73 KB
PDF File SEDATIVES / HYPNOTICS - ramelteon
ramelteon (ROZEREM) 62 KB
PDF File SILIQ
brodalumab (SILIQ) 56 KB
PDF File SIMPONI
golimumab (SIMPONI) 58 KB
PDF File STELARA
ustekinumab (STELARA) 55 KB
PDF File STEP THERAPY Non-Preferred Drug (NPD or NAP)
23 KB
PDF File SYMDEKO
tezacaftor/ivacaftor and ivacaftor (SYMDEKO) 68 KB
PDF File SYMLIN
pramlintide (SYMLIN) 95 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 240 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File SYNAGIS
palivizumab (SYNAGIS) 241 KB
PDF File TALTZ
ixekizumab (TALTZ) 50 KB
PDF File TEXAS STANDARD PRIOR AUTHORIZATION REQUEST FORM
PRESCRIPTION DRUG BENEFITS 233 KB
PDF File TOPICAL ACNE AGENTS
BENZACLIN GEL, BENZACLIN PUMP GEL, ERYTHROMYCIN-BENZOYL GEL, CLINDAMYCIN-BENZOYL PEROXIDE GEL 1.2-5%, CLINDAMYCIN-BENZOYL PEROXIDE GEL, DUAC 1.2-5% GEL 24 KB
PDF File TOPICAL RETINOIDS
ADAPALENE, ADAPALENE-BENZYL PEROXIDE, ATRALIN, AVITA, CLINDAMYCIN-TRETINOIN, DIFFERIN, EPIDUO, EPIDUO FORTE, FABIOR, TAZAROTENE, TAZORAC, TRETINOIN, TRETINOIN GEL MICRO, ZIANA 24 KB
PDF File TREMFYA
guselkumab (TREMFYA) 53 KB
PDF File TRULANCE
plecanatide (TRULANCE) 56 KB
PDF File TYVASO STARTER KIT - CHIP PLANS ONLY
treprostinil (TYVASO STARTER KIT) 16 KB
PDF File VIBERZI
eluxadoline (VIBERZI) 54 KB
PDF File XELJANZ / XELJANZ XR
tofacitinib citrate (XELJANZ / XELJANZ XR) 57 KB
PDF File XENICAL
orlistat (XENICAL) 44 KB
PDF File XIFAXAN 200 MG
rifaximin 200mg (XIFAXAN 200mg) 89 KB
PDF File XIFAXAN 550 MG
rifaximin 550mg (XIFAXAN 550mg) 95 KB
PDF File XYREM
sodium oxybate (XYREM) 46 KB
PDF File ZELBORAF
vemurafenib (ZELBORAF) 22 KB
PDF File ZYCLARA
imiquimod 3.75 % cream (ZYCLARA) 45 KB
PDF File ZYFLO
zileuton (ZYFLO) 48 KB
 

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