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	For Prescription Drug Benefits	319 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	67 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	67 KB
PDF File	ACCOLATE	zafirlukast (ACCOLATE)	59 KB
PDF File	ACNE AGENTS (ORAL) - (PDL) STAR and STAR KID Members Only	ABSORICA cap, isotretinoin cap	126 KB
PDF File	ACNE AGENTS (TOPICAL) - (PDL) 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	ACTEMRA	tocilizumab (ACTEMRA)	66 KB
PDF File	ACTOS / DUETACT	pioglitazone (ACTOS), pioglitazone/metformin (ACTOPLUS MET), pioglitazone/glimepiride (DUETACT)	148 KB
PDF File	ADBRY - INITIAL REQUESTS	tralokinumab-ldrm (ADBRY)	66 KB
PDF File	ADBRY - RENEWAL REQUESTS	tralokinumab-ldrm (ADBRY)	29 KB
PDF File	ADHD - CLONIDINE ER	clonidine ER	27 KB
PDF File	ADHD ER FORMULATIONS	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	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)	196 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 ER (INTUNIV), atomoxetine (STRATTERA)	27 KB
PDF File	AGENTS FOR GAUCHER’S DISEASE	CERDELGA, CEREZYME, ELELYSO, miglustat (ZAVESCA), VPRIV	20 KB
PDF File	ALDARA	imiquimod 5% cream (ALDARA)	52 KB
PDF File	ALINIA	nitazoxanide (ALINIA) tablets	60 KB
PDF File	ALZHEIMER’S AGENTS (PDL) NOTE: Drugs listed are a representative list, only. See plan formulary to verify coverage status. Formulary available at www.txvendordrug.com	ADLARITY, donepezil (ARICEPT), galantamine (RAZADYNE ER), titration pack (NAMENDA), memantine extended-release (NAMENDA XR), NAMZARIC, NAMZARIC PACK, rivastigmine	22 KB
PDF File	AMANTADINE ER AGENTS	Osmolex ER, Gocovri	66 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 (PDL)	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	ANTICOAGULANTS (PDL) STAR and STAR KIDS Members Only	COUMADIN, dabigatran, fondaparinux (ARIXTRA), FRAGMIN, FRAGMIN INJ, LOVENOX, SAVAYSA, XARELTO SUSP	126 KB
PDF File	ANTIDEPRESSANTS (OTHER) (PDL) STAR and STAR KIDS Members Only	APLENZIN, BUPROPION ER, desvenlafaxine ER, EMSAM, FETZIMA, MARPLAN, NARDIL, NEFAZODONE, REMERON, tranylcypromine, TRINTELLIX, venlafaxine (EFFEXOR XR), VIIBRYD, WELLBUTRIN	22 KB
PDF File	ANTIDEPRESSANTS (SSRI) (PDL) STAR and STAR KIDS Members Only	CELEXA, escitalopram solution, fluoxetine tablets, fluoxetine capsules (PROZAC), fluvoxamine, LEXAPRO tablets, paroxetine (PAXIL), ZOLOFT	22 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	meclizine (ANTIVERT), GIMOTI, dronabinol (MARINOL), metoclopramide (REGLAN), prochlorperazine (COMPRO), scopolamine	21 KB
PDF File	ANTIEMETICS	AKYNZEO, ANZEMET, aprepitant (EMEND), EMEND SUSPENSION, GRANISETRON, SANCUSO	28 KB
PDF File	ANTIFUNGALS (ORAL) - (PDL) STAR and STAR KIDS Members Only	BREXAFEMME, CRESEMBA, DIFLUCAN, flucytosine (ANCOBON), griseofulvin, itraconazole (SPORANOX, TOLSURA), ORAVIG, posaconazole (NOXAFIL), VIVJOA, voriconazole tab, voriconazole susp, VFEND TAB	126 KB
PDF File	ANTIFUNGALS (TOPICAL) - (PDL) STAR and STAR KIDS Members Only	athletes foot spray, ciclopirox (LOPROX), clotrimazole/betamethasone, econazole, FUNGOID TINCTURE, ketoconazole (EXTINA), luliconazole, MENTAX, miconazole/petrolatum/zinc oxide, naftifine, nystatin/triamcinolone, oxiconazole (OXISTAT), VUSION	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	ANTIHYPERURICEMICS (PDL) STAR and STAR KIDS Members Only	colchicine cap/tab (COLCRYS), febuxostat (ULORIC), GLOPERBA, MITIGARE, ZYLOPRIM	126 KB
PDF File	ANTIMIGRAINE AGENTS (PDL) STAR and STAR KIDS Members Only	CAMBIA, dihydroergotamine (D.H.E. 45, MIGRANAL), REYVOW, TRUDHESA AER	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**), sumatriptan inj (IMITREX)	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, INBRIJA CAP 42MG, 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 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, amitriptyline/perphenazine, aripiprazole, ARISTADA, ARISTADA INITIO, asenapine, CAPLYTA, chlorpromazine, chlorpromazine inj, clozapine, CLOZARIL, FANAPT, fluphenazine, fluphenazine inj, GEODON, GEODON inj, haloperidol lactate injection, haloperidol tablet, INVEGA, INVEGA HAFYERA, LATUDA, LYBALVI, loxapine, MOLINDONE, 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	31 KB
PDF File	ANTIVIRALS (ANTI-CMV) (PDL) STAR and STAR KIDS Members Only	LIVTENCITY TAB, VALCYTE TAB, valganciclovir soln	126 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)	62 KB
PDF File	ANXIOLYTICS (chlordiaz., meprobamate, oxazepam)	chlordiazepoxide, meprobamate, oxazepam	71 KB
PDF File	ANXIOLYTICS (clonazepam, diazepam)	clonazepam (KLONOPIN), diazepam	74 KB
PDF File	ANXIOLYTICS (clorazepate)	clorazepate (TRANXENE)	67 KB
PDF File	ANXIOLYTICS (lorazepam)	lorazepam	71 KB
PDF File	ARANESP	darbepoetin alfa (ARANESP)	26 KB
PDF File	ARCALYST	rilonacept (ARCALYST)	61 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)	102 KB
PDF File	AUSTEDO & XENAZINE Texas Children’s Health Plan Only	deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE)	118 KB
PDF File	AVANDIA	rosiglitazone (AVANDIA)	137 KB
PDF File	BENIGN PROSTATIC HYPERPLASIA AGENTS (PDL)	doxazosin (CARDURA), dutasteride-tamsulosin (JALYN), dutasteride (AVODART), PROSCAR, silodosin (RAPAFLO), FLOMAX, tadalafil	22 KB
PDF File	BENLYSTA	belimumab (BENLYSTA)	63 KB
PDF File	BETA AGONIST BRONCHODILATORS (PDL) STAR and STAR KIDS Members Only	ALBUTEROL AEROSOL HFA, ALBUTEROL TABLETS, ARCAPTA CAPSULES, arformoterol nebulizer (BROVANA), levalbuterol nebulizer (XOPENEX), metaproterenol syrup, PERFOROMIST, PROAIR RESPICLICK, SEREVENT DISKUS, STRIVERDI RESPIMAT, terbutaline tablets	23 KB
PDF File	BETA BLOCKERS (ORAL) (PDL) 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	BILE SALTS (PDL) STAR and STAR KIDS Members Only	CHENODAL, CHOLBAM, OCALIVA, URSO, URSO FORTE, ursodiol 300mg cap	126 KB
PDF File	BLADDER RELAXANTS (PDL)	darifenacin (ENABLEX), tolterodine (DETROL), tolterodine ER (DETROL LA), oxybutynin (DITROPAN XL), fesoterodine, flavoxate, GELNIQUE, GEMTESA, MYRBETRIQ, OXYTROL, solifenacin, trospium, trospium ER, VESICARE LS	21 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, ibandronate (BONIVA), calcitonin, raloxifene, FOSAMAX, FOSAMAX+D, TERIPARATIDE, TYMLOS	126 KB
PDF File	BONJESTA & DICLEGIS	doxylamine/pyridoxine (BONJESTA, DICLEGIS)	60 KB
PDF File	BUNAVAIL / SUBOXONE / ZUBSOLV	buprenorphine/naloxone (BUNAVAIL, SUBOXONE, ZUBSOLV)	55 KB
PDF File	BUPRENORPHINE	buprenorphine	55 KB
PDF File	BYLVAY	odevixibat (BYLVAY)	64 KB
PDF File	Calcium Channel Blockers (PDL) 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-CONTAINING AGENTS	CARISOPRODOL, CARISOPRODOL-ASPIRIN, CARISOPRODOL COMPOUND TAB, SOMA	68 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	CGRP ANTAGONISTS (PROPHYLAXIS)	erenumab (AIMOVIG), fremanezumab (AJOVY), galcanezumab (EMGALITY), atogepant (QULIPTA)	113 KB
PDF File	CIBINQO	abrocitinib (CIBINQO)	68 KB
PDF File	CIMZIA	certolizumab pegol (CIMZIA)	67 KB
PDF File	COLONY STIMULATING FACTORS (PDL) STAR and STAR KIDS Members Only	FULPHILA, GRANIX, LEUKINE, NEULASTA, NIVESTYM, UDENYCA, 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, DUAKLIR, INCRUSE, LONHALA, roflumilast (DALIRESP), SPIRIVA Respimat (Handihaler is PDL), TUDORZA, UTIBRON, YUPELRI	126 KB
PDF File	COSENTYX	secukinumab (COSENTYX)	67 KB
PDF File	COUGH & COLD (TABLE A) Table A	ALA-HIST PE TABLET, APRODINE TABLET, CHEST CONGESTION RELIEF SOLN, CHEST CONGESTION RELIEF TABLET, CHILD MUCINEX CHEST 100 MG PACKET, CHLO TUSS LIQUID, DECONEX IR TABLET, DEXBROMPHENIR-PHENYLEPH 2-10MG, ED BRON GP LIQUID, HISTEX-PE SYRUP, MUCUS RELIEF 400 MG TABLET, MUCUS RELIEF SINUS TABLET, MUCUS-CHEST CONG 200 MG/10 ML, POLY-HIST PD LIQUID, POLY-VENT IR TABLET, RESCON-GG LIQUID, 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 TABLET, TUSSIN 100 MG/5 ML SYRUP	122 KB
PDF File	COUGH & COLD (TABLE B) Table B	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, V FLU/COLD POW DAYTIME	180 KB
PDF File	COUGH & COLD (TABLE C) Table C	BENZONATATE	102 KB
PDF File	COUGH & COLD (TABLE D) Table D	DEXTROMETHORPHAN 15 MG LIQ GEL, GUAIFENESIN/PSE ER 600-60 MG, GUAIFENESIN-PSE ER 1200-120 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, MUCUS DM MAX ER 1,200-60 MG TAB, MUCUS RELIEF D ER 600-60 MG TB, MUCUS RELIEF ER 1,200 MG TAB, MUCUS RELIEF ER 600 MG TABLET, MUCUS RLF DM ER 600-30 MG TAB, MUCUS RLF DM MAX ER 1200-60 MG, NIGHTTIME COUGH LIQUID, RESCON TABLET, ROBAFEN COUGH 15 MG LIQUIDGEL, SINUS RELIEF 1% NASAL SPRAY, SUDOGEST SINUS & ALLERGY TAB	106 KB
PDF File	COUGH & COLD AGENTS (PDL)	SINUS CONGESTION/PAIN TAB 5-325MG, MAPAP COLD FORMULA TAB, ALL-NITE COLD AND FLU LIQUID, COLD/FLU CAP DAYTIME, COLD AND FLU NIGHTTIME CAP, DURAFLU TAB, MUCINEX FAST-MAX SEVERE COLD LIQUID, MUCINEX FAST-MAX LIQUID, MUCINEX FAST-MAX DAY/NIGHT LIQUID, MUCINEX FAST-MAX DAY/NIGHT TAB, MUCINEX MULTI-SYMPTOM LIQUID, SEVERE COLD/COUGH PAK, FLU HBP TAB 10-325-2, SINUS RELIEF TAB 5-325MG, NIGHTTIME COLD/FLU LIQUID, NIGHTTIME COLD/FLU LIQUID, NIGHTTIME COLD/FLU LIQUID, NIGHTTIME COLD/FLU LIQUID, DAYTIME COLD/FLU LIQUID 10-5-325, DAYTIME COLD/FLU RELIEF LIQUID 10/5/325, SINUS CONGESTION/PAIN SEVERE TAB, ALLERGY MULTI SYMPTOM TAB, SEVERE COLD/FLU TAB, NIGHTTIME COLD/FLU LIQUID, COLD/FLU RELIEF DAYTIME CAP, COLD/FLU REL CAP NITETIME, COLD AND FLU RELIEF NIGHTTIME CAP, SEVERE COLD AND FLU TAB, SINUS+HEADACHE TAB 5-325MG	21 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)	55 KB
PDF File	DICLOFENAC 1.5% & 2% SOLUTION	diclofenac 1.5% topical solution, diclofenac 2% topical solution (PENNSAID 2% PUMP)	59 KB
PDF File	DICLOFENAC 3% GEL	diclofenac 3% gel (SOLARAZE 3% GEL)	53 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)	88 KB
PDF File	DUPIXENT - RENEWAL REQUESTS	dupilumab (DUPIXENT)	34 KB
PDF File	EMFLAZA - INITIAL REQUESTS	deflazacort (EMFLAZA)	76 KB
PDF File	EMFLAZA - RENEWAL REQUESTS	deflazacort (EMFLAZA)	26 KB
PDF File	ENBREL	etanercept (ENBREL)	61 KB
PDF File	ENSPRYNG	satralizumab (ENSPRYNG)	68 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, GALAFOLD, NAGLAZYME, NITYR, ORFADIN, REVCOVI, STRENSIQ, VIMIZIM	70 KB
PDF File	ENZYMES - COOK For Cook Children’s Health Plans Only	ALDURAZYME, CEPROTIN, ELAPRASE, FABRAZYME, GALAFOLD, NAGLAZYME, NITYR, ORFADIN, REVCOVI, STRENSIQ, VIMIZIM	70 KB
PDF File	EPIDIOLEX	cannabidiol (EPIDIOLEX)	56 KB
PDF File	EPINEPHRINE (PDL) STAR and STAR KIDS Members Only	epinephrine inj	126 KB
PDF File	EPOGEN (ESA)	epoetin alfa (EPOGEN)	29 KB
PDF File	EVRYSD I- RENEWAL REQUEST	risdiplam (EVRYSDI)	54 KB
PDF File	EVRYSDI - INITIAL REQUEST	risdiplam (EVRYSDI)	55 KB
PDF File	FASENRA	benralizumab (FASENRA)	57 KB
PDF File	FINTEPLA	fenfluramine (FINTEPLA)	62 KB
PDF File	FIRST GENERATION ANTIHISTAMINES (PDL) STAR and STAR KIDS Members Only	ALLERGY RELI CHW 25MG, clemastine, ed chlorped jr syrup, KARBINAL ER, RYVENT, triprolidine, VISTARIL	126 KB
PDF File	FLUOROQUINOLONES (PDL) STAR and STAR KIDS Members Only	BAXDELA, CIPRO TAB, ciprofloxacin susp, levofloxacin soln, moxifloxacin tab, OFLOXACIN 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 BCISE, BYETTA, MOUNJARO, OZEMPIC, RYBELSUS, SOLIQUA, TRULICITY, VICTOZA, XULTOPHY	81 KB
PDF File	GLUCAGON AGENTS (PDL) STAR and STAR KIDS Members Only	DIAZOXIDE SUS, GVOKE HYPOPEN, GLUCAGON EMR SOL, ZEGALOGUE	21 KB
PDF File	GRALISE	gabapentin extended release (GRALISE)	61 KB
PDF File	GROWTH HORMONE - SEROSTIM	somatropin (SEROSTIM)	67 KB
PDF File	GROWTH HORMONE - ZORBTIVE	somatropin (ZORBITIVE)	137 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN All Plans Except Cook Children’s Health Plan, Driscoll Children’s Health Plan & Texas Children’s Health Plan	GENOTROPIN, NORDITROPIN	132 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN - COOK For Cook Children’s Health Plan Only	GENOTROPIN, NORDITROPIN	132 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN - DCHP Driscoll Children’s Health Plan Only	GENOTROPIN & NORDITROPIN	133 KB
PDF File	GROWTH HORMONES - GENOTROPIN & NORDITROPIN - TCHP For Texas Children’s Health Plan Only	GENOTROPIN, NORDITROPIN	132 KB
PDF File	GROWTH HORMONES - OTHER PRODUCTS	HUMATROPE, NUTROPIN AQ, OMNITROPE, SAIZEN, SKYTROFA	138 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, EPCULSA, HARVONI, SOVALDI, VIEKIRA, VOSEVI, ZEPATIER	22 KB
PDF File	HEREDITARY ANGIOEDEMA (HAE) AGENTS	BERINERT, CINRYZE, icatibant (FIRAZYR), HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO	74 KB
PDF File	HETLIOZ CAPSULES	tasimelteon (HETLIOZ) capsules	65 KB
PDF File	HETLIOZ LQ SUSPENSION	tasimelteon (HETLIOZ LQ) suspension	60 KB
PDF File	HORIZANT	gabapentin enacarbil (HORIZANT)	64 KB
PDF File	HP ACTHAR	corticotropin (HP ACTHAR)	66 KB
PDF File	HUMIRA	adalimumab (HUMIRA)	73 KB
PDF File	HYPOGLYCEMICS, INSULIN (PDL) STAR and STAR KID Members Only	ADMELOG, AFREZZA, APIDRA, BASAGLAR, FIASP, HUMULIN N KWIKPEN, HUMALOG KWIKPEN, INSULIN GLARGINE, INSULIN LISPRO, NOVOLIN, NOVOLIN N, NOVOLIN R, SEMGLEE, TOUJEO, TRESIBA	126 KB
PDF File	HYPOGLYCEMICS, MEGLITINIDES (PDL) STAR and STAR KIDS Members Only	repaglinide/metformin	126 KB
PDF File	HYPOGLYCEMICS, METFORMIN (PDL) 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	IBSRELA	tenapanor (IBSRELA)	64 KB
PDF File	ILARIS	canakinumab (ILARIS)	74 KB
PDF File	ILUMYA	tildrakizumab (ILUMYA)	59 KB
PDF File	IMMUNE GLOBULINS (PDL) STAR and STAR KIDS Members Only	CUTAQUIG, CUVITRU, FLEBOGAMMA, HIZENTRA, 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), mycophenolate, mycophenolic (MYFORTIC, CELLCEPT), NEORAL, PROGRAF, sirolimus tab, sirolimus soln, REZUROCK, TAVNEOS	126 KB
PDF File	INCRELEX	mecasermin (INCRELEX)	67 KB
PDF File	INGREZZA	valbenazine (INGREZZA)	62 KB
PDF File	INHALED ANTIBIOTICS	BETHKIS, CAYSTON, KITABIS, tobramycin (TOBI, TOBI PODHALER)	62 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), FLUTICAS HFA AER, budesonide, 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)	69 KB
PDF File	KALYDECO	ivacaftor (KALYDECO)	58 KB
PDF File	KETOROLAC (INJECTION / NASAL)	ketorolac (TORADOL equiv) injection, ketorolac nasal spray	80 KB
PDF File	KETOROLAC (ORAL)	oral ketorolac (TORADOL equiv)	71 KB
PDF File	KEVEYIS	dichlorphenamide (KEVEYIS)	56 KB
PDF File	KEVZARA	sarilumab (KEVZARA)	62 KB
PDF File	KINERET	anakinra (KINERET)	64 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, LIDOPURE 5% patch, ZILACAINE 5% patch, ZTLIDO 1.8%	60 KB
PDF File	LINCOSAMIDE & RELATED ANTIBIOTICS (PDL) STAR and STAR KIDS Only Members	CLEOCIN, LINCOCIN, linezolid susp, SIVEXTRO	126 KB
PDF File	LINZESS	linaclotide (LINZESS)	125 KB
PDF File	Lipotropics (PDL) STAR and STAR KIDS Members Only	colesevelam, colestipol (COLESTID), ezetimibe, fenofibrate (FENOGLIDE, LIPOFEN, TRICOR, TRILIPIX), fenofibric acid, FENOFIB MICR CAP 90MG, LOPID, niacin extended-release (NIASPAN ER), NEXLETOL, NEXLIZET, QUESTRAN	21 KB
PDF File	Lipotropics (Statins) (PDL) 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	LIVMARLI	maralixibat (LIVMARLI)	63 KB
PDF File	Long-Acting Injectable Antipsychotics	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	31 KB
PDF File	LOTRONEX	alosetron (LOTRONEX)	63 KB
PDF File	LOVAZA & VASCEPA	omega-3-acid ethyl esters (LOVAZA), icosapent ethyl (VASCEPA)	68 KB
PDF File	LUPKYNIS	voclosporin (LUPKYNIS)	63 KB
PDF File	MACROLIDES / KETOLIDES (PDL) STAR and STAR KIDS Members Only	CLARITHROMYCIN, E.E.S. GRANULES, E.E.S. tab, erythromycin, 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)	43 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)	43 KB
PDF File	MAVENCLAD	cladribine (MAVENCLAD)	58 KB
PDF File	MAYZENT	siponimod (MAYZENT)	69 KB
PDF File	MOTEGRITY	prucalopride (MOTEGRITY)	61 KB
PDF File	MOVANTIK	naloxegol (MOVANTIK)	132 KB
PDF File	MUSCLE RELAXERS (PDL) STAR and STAR KIDS Members Only	chlorzoxazone (LORZONE), cyclobenzaprine ER (AMRIX), dantrolene (DANTRIUM), FEXMID, FLEQSUVY, LYVISPAH, metaxalone (SKELAXIN), orphenadrine extended-release, tizanidine	21 KB
PDF File	NEUROPATHIC PAIN (PDL) STAR and STAR KIDS Members Only	duloxetine (CYMBALTA), pregabalin (LYRICA CR)	126 KB
PDF File	NSAIDs (PDL) 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/esomeprazole (VIMOVO), oxaprozin (DAYPRO), piroxicam (FELDENE), tolmetin	21 KB
PDF File	NUCALA	mepolizumab (NUCALA)	74 KB
PDF File	NUPLAZID	pimavanserin (NUPLAZID)	61 KB
PDF File	NURTEC - Acute	rimegepant (NURTEC): Acute or As Needed Use Only	59 KB
PDF File	NURTEC - Prophylaxis	rimegepant (NURTEC): Prophylaxis or Long Term Preventive Use Only	77 KB
PDF File	NUVIGIL	armodafinil (NUVIGIL)	65 KB
PDF File	OLUMIANT	baricitinib (OLUMIANT)	68 KB
PDF File	OPHTHALMIC IMMUNOMODULATORS	EYSUVIS, RESTASIS, TYRVAYA, XIIDRA	81 KB
PDF File	OPHTHALMICS - GLAUCOMA AGENTS (PDL) 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, timolol maleate (ISTALOL), TIMOPTIC, TIMOPTIC XE, TRAVOPROST, TRUSOPT, VUITY, VYZULTA, XALATAN, ZIOPTAN	126 KB
PDF File	OPHTHALMICS, ALLERGIC CONJUNCTIVITIS (PDL) 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	OPHTHALMICS, ANTI-INFLAMMATORIES (PDL) 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	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	OPIOID - CARISOPRODOL CODEINE	CARISOPRODOL ASPIRIN AND CODEINE PHOSPHATE	91 KB
PDF File	OPIOID - COUGH & COLD	codeine-guaifenesin, guaiatussin, hydrocodone-homatropin, hydrocodone-chlorpheniramine polistirex	77 KB
PDF File	OPIOID - FENTANYL AGENTS - ACTIQ	oral transmucosal fentanyl (ACTIQ)	95 KB
PDF File	OPIOID - FENTANYL AGENTS - FENTORA	buccal fentanyl citrate (FENTORA)	95 KB
PDF File	OPIOID - FENTANYL AGENTS: DURAGESIC	transdermal fentanyl (DURAGESIC)	90 KB
PDF File	OPIOID - OXYCONTIN ER - HIGH DOSE	oxycodone (OXYCONTIN) 60mg & 80mg	91 KB
PDF File	OPIOID - OXYCONTIN ER - LOW DOSE	oxycodone (OXYCONTIN) 10mg, 15mg, 20mg, 30mg, 40mg / XTAMPZA	86 KB
PDF File	OPIOID POLICY	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	ORAL GLUCOCORTICOIDS (PDL) 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	ORALAIR	Grass Pollen Allergen Extract (ORALAIR)	60 KB
PDF File	ORENCIA	abatacept (ORENCIA)	66 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)	63 KB
PDF File	OXERVATE	cenegermin-bkbj (OXERVATE)	54 KB
PDF File	PALFORZIA	peanut allergen powder (PALFORZIA)	63 KB
PDF File	PANCREATIC ENZYMES (PDL) STAR and STAR KIDS Members Only	PERTZYE, VIOKACE	126 KB
PDF File	PDE5-INHIBITORS	sildenafil (REVATIO), tadalafil (ADCIRCA), tadalafil (ALYQ)	69 KB
PDF File	PDL - ROSACEA AGENTS (TOPICAL) STAR and STAR KID Members Only	ivermectin cream, METROGEL, METROCREAM, MIRVASO GEL	21 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), sevelamer (RENAGEL), sevelamer carbonate (RENVELA), VELPHORO	128 KB
PDF File	PLATELET AGGREGATION INHIBITORS (PDL) STAR and STAR KIDS Members Only	dipyridamole (PERSANTINE), prasugrel (EFFIENT), clopidogrel (PLAVIX)	126 KB
PDF File	PONVORY	ponesimod (PONVORY)	69 KB
PDF File	POTASSIUM BINDERS (PDL)	VELTASSA	21 KB
PDF File	PRALUENT	alirocumab (PRALUENT)	68 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)	36 KB
PDF File	PROGESTINS FOR CACHEXIA (PDL) STAR and STAR KIDS Members Only	megestrol ES 625mg/5ml susp	126 KB
PDF File	PROMETHAZINE Agents	PHENERGAN, PROMETHAZINE	57 KB
PDF File	PROPYLTHIOURACIL	propylthiouracil	18 KB
PDF File	Proton Pump Inhibitors (PPIs) (PDL) 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	PROVIGIL	modafinil (PROVIGIL)	64 KB
PDF File	PULMONARY ARTERIAL HYPERTENSION (ORAL/INHALED)	ADEMPAS, ambrisentan (LETAIRIS), OPSUMIT, ORENITRAM, bosentan (TRACLEER), TYVASO inhalation solution, UPTRAVI, VENTAVIS inhalation solution	30 KB
PDF File	PULMOZYME	dornase alfa (PULMOZYME)	53 KB
PDF File	QELBREE	viloxazine (QELBREE)	72 KB
PDF File	RANEXA	ranolazine (RANEXA)	60 KB
PDF File	RECORLEV	levoketoconazole (RECORLEV)	58 KB
PDF File	RELISTOR	methylnaltrexone (RELISTOR)	59 KB
PDF File	REPATHA	evolocumab (REPATHA)	78 KB
PDF File	RETACRIT	epoetin alfa (RETACRIT)	28 KB
PDF File	RINVOQ	upadacitinib (RINVOQ)	80 KB
PDF File	ROZEREM	ramelteon (ROZEREM)	63 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, LUNESTA, RESTORIL, temazepam, TRIAZOLAM, QUVIVIQ, ZALEPLON, zolpidem, zolpidem ER, zolpidem SL	62 KB
PDF File	SEDATIVES / HYPNOTICS - FLURAZEPAM	flurazepam	63 KB
PDF File	SGLT2 INHIBITOR COMBINATION AGENTS	INVOKAMET XR, SEGLUROMET, SYNJARDY XR	139 KB
PDF File	SGLT2 INHIBITOR SINGLE AGENTS	FARXIGA, INVOKANA, JARDIANCE, STEGLATRO	65 KB
PDF File	SILIQ	brodalumab (SILIQ)	64 KB
PDF File	SIMPONI	golimumab (SIMPONI)	69 KB
PDF File	SKYRIZI	risankizumab (SKYRIZI)	62 KB
PDF File	SMOKING CESSATION (PDL) STAR and STAR KIDS Members Only	NICOTROL INHALER, NICOTROL NS, varenicline	126 KB
PDF File	STELARA	ustekinumab (STELARA)	63 KB
PDF File	STEROIDS, TOPICAL (PDL) 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, prednicarbate, triamcinolone acetate (TRIANEX), triamcinolone dental paste	126 KB
PDF File	SUNOSI	solriamfetol (SUNOSI)	66 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 2022-2023	palivizumab (SYNAGIS)	274 KB
PDF File	SYNAGIS - COMMUNITY HEALTH CHOICE For Community Health Choice Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - COOK CHILDREN'S HEALTH PLANS For Cook Children's Health Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - DELL CHILDREN'S (SETON) HEALTH PLANS For Dell Children's Health (Seton) Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - DRISCOLL CHILDREN'S HEALTH PLANS For Driscoll Children's Health Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - EL PASO FIRST HEALTH PLANS For El Paso First Health Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - FIRSTCARE HEALTH PLANS For FirstCare Health Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - PARKLAND COMMUNITY HEALTH PLANS For Parkland Community Health Plans Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - SCOTT & WHITE HEALTH PLANS For Scott & White Health Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	SYNAGIS - TEXAS CHILDREN'S HEALTH PLANS For Texas Children's Health Plan Only - RSV Season Dates 2022-2023	palivizumab (SYNAGIS)	262 KB
PDF File	TALTZ	ixekizumab (TALTZ)	63 KB
PDF File	TEGSEDI	inotersen (TEGSEDI)	59 KB
PDF File	TETRACYCLINES (PDL) 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	THROMBOPOIESIS STIMULATING PROTEINS (PDL) STAR and STAR KIDS Members Only	DOPTELET, MULPLETA, PROMACTA POW, TAVALISSE	126 KB
PDF File	TOPICAL ACNE AGENTS (ACNE)	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	TOPICAL ACNE AGENTS (ANTIFUNGAL)	salicylic acid 3% (BENSAL HP) ointment	26 KB
PDF File	TOPICAL ACNE AGENTS (ROSACEA)	azelaic acid gel 15% (FINACEA 15% GEL), metronidazole lotion 0.75%	26 KB
PDF File	TOPICAL ANDROGENIC AGENTS (PDL) STAR and STAR KIDS Members Only	testosterone ( 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 FOR ONYCHOMYCOSIS	CICLOPIROX 8% SOLUTION, JUBLIA 10% TOPICAL SOLUTION, and KERYDIN (TAVABOROLE) 5% TOPICAL SOLUTION	66 KB
PDF File	TOPICAL ANTIVIRALS (PDL) STAR and STAR KIDS Members Only	acyclovir cream, acyclovir ointment, docosanol cream, XERESE	126 KB
PDF File	TOPICAL IMMUNOMODULATORS - OPZELURA	ruxolitinib phosphate cream (OPZELURA)	74 KB
PDF File	TOPICAL IMMUNOMODULATORS - ELIDEL & PROTOPIC 0.03%	pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%)	78 KB
PDF File	TOPICAL IMMUNOMODULATORS - EUCRISA	crisaborole (EUCRISA)	21 KB
PDF File	TOPICAL IMMUNOMODULATORS - PROTOPIC 0.1%	tacrolimus (PROTOPIC) 0.1%	72 KB
PDF File	TOPICAL RETINOIDS	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	TREMFYA	guselkumab (TREMFYA)	58 KB
PDF File	TRIKAFTA	elexcaftor/tezacaftor/ivacaftor (TRIKAFTA)	56 KB
PDF File	TRULANCE	plecanatide (TRULANCE)	61 KB
PDF File	UBRELVY	ubrogepant (UBRELVY)	64 KB
PDF File	ULCERATIVE COLITIS AGENTS (PDL) 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
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)	64 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	VIVJOA	Recurrent Vulvovaginal Candidiasis (RVVC) Agents	58 KB
PDF File	VOXZOGO	vosoritide (VOXZOGO)	59 KB
PDF File	VYNDAMAX & VYNDAQEL	tafamidis (VYNDAMAX) and tafamidis meglumine (VYNDAQEL)	58 KB
PDF File	WAKIX	pitolisant (WAKIX)	67 KB
PDF File	XELJANZ / XELJANZ XR	tofacitinib citrate (XELJANZ / XELJANZ XR)	67 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	XOLAIR - INITIAL REQUESTS	omalizumab (XOLAIR)	84 KB
PDF File	XOLAIR - RENEWAL REQUESTS	omalizumab (XOLAIR)	33 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)	52 KB
PDF File	ZYFLO	zileuton (ZYFLO)	60 KB

Type

Date

Name

File Size

.txt

3/1/2023

Texas-STAR-Kids-Dual-Formulary-3-1-2023

865 kB

.txt

3/1/2023

Texas-STAR-Formulary-3-1-2023

3.3 MB

.txt

3/1/2023

Texas-CHIP-Formulary-3-1-2023

2.4 MB