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	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	tralokinumab-ldrm (ADBRY)	214 KB
PDF File	ADHD (ATOMOXETINE)	atomoxetine (STRATTERA)	212 KB
PDF File	ADHD (GUANFACINE ER)	guanfacine extended-release (INTUNIV ER)	205 KB
PDF File	ADHD (QELBREE)	viloxazine (QELBREE)	214 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	AGENTS FOR GAUCHER’S DISEASE	CERDELGA, CEREZYME, ELELYSO, miglustat (ZAVESCA), VPRIV	20 KB
PDF File	ALDARA	imiquimod 5% cream (ALDARA)	52 KB
PDF File	ALDURAZYME	laronidase (ALDURAZYME)	166 KB
PDF File	ALINIA	nitazoxanide (ALINIA) tablets	60 KB
PDF File	ALLERGEN EXTRACTS (ORALAIR)	grass pollen allergen extract (ORALAIR)	216 KB
PDF File	ALLERGEN EXTRACTS (PALFORZIA)	peanut allergen powder (PALFORZIA)	198 KB
PDF File	ALZHEIMER’S AGENTS (PDL) STAR and STAR KID Members Only	ADLARITY, donepezil (ARICEPT), galantamine (RAZADYNE ER), memantine (NAMENDA), memantine extended-release (NAMENDA XR), NAMZARIC, NAMZARIC PACK, rivastigmine	22 KB
PDF File	AMANTADINE ER AGENTS	Osmolex ER, Gocovri	66 KB
PDF File	AMITIZA	lubiprostone (AMITIZA)	203 KB
PDF File	ANDROGENIC AGENTS	testosterone (ANDRODERM, ANDROGEL, FORTESTA, TESTIM, VOGELXO), testosterone solution	198 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) STAR and STAR KID Members Only	ACCUPRIL, ALTACE, AVALIDE, AVAPRO, benazepril/hydrochlorothiazide, candesartan (ATACAND), candesartan/hydrochlorothiazide (ATACAND HCT), captopril, COZAAR, EDARBI, EDARBYCLOR, enalapril (VASOTEC), fosinopril/hydrochlorothiazide, HYZAAR, moexipril, olmesartan (BENICAR), olmesartan/hydrochlorothiazide (BENICAR HCT), perindopril, QBRELIS, quinapril/hydrochlorothiazide (ACCURETIC), telmisartan (MICARDIS), telmisartan/hydrochlorothiazide (MICARDIS HCT), trandolapril, valsartan, valsartan/hydrochlorothiazide (DIOVAN HCT), VASERETIC, ZESTORETIC	55 KB
PDF File	ANTICOAGULANTS (PDL) STAR and STAR KIDS Members Only	COUMADIN, dabigatran etexilate mesylate (PRADAXA), fondaparinux (ARIXTRA), FRAGMIN, FRAGMIN INJ, LOVENOX, SAVAYSA	126 KB
PDF File	ANTIDEPRESSANTS (OTHER) (PDL) STAR and STAR KIDS Members Only	APLENZIN, AUVELITY, BUPROPION ER, desvenlafaxine ER, EMSAM, FETZIMA, MARPLAN, NARDIL, NEFAZODONE, REMERON, tranylcypromine, TRINTELLIX, venlafaxine (EFFEXOR XR), VIIBRYD, VILAZODONE, WELLBUTRIN	22 KB
PDF File	ANTIDEPRESSANTS (SSRI) (PDL) STAR and STAR KIDS Members Only	CELEXA, escitalopram solution, fluoxetine tablets, fluoxetine capsules (PROZAC), fluvoxamine, LEXAPRO tablets, paroxetine (PAXIL), paroxetine ER, ZOLOFT	22 KB
PDF File	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 (VFEND), voriconazole susp	126 KB
PDF File	ANTIFUNGALS (TOPICAL) - (PDL) STAR and STAR KIDS Members Only	athletes foot spray, ciclopirox (LOPROX), clotrimazole/betamethasone, CLOTRIMAZOLE SOL, econazole, FUNGOID TINCTURE, ketoconazole (EXTINA), luliconazole, miconazole/petrolatum/zinc oxide, naftifine, nystatin/triamcinolone, oxiconazole (OXISTAT), TM-TOLNAFTATE LIQ, VUSION	126 KB
PDF File	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, loratadine ODT, SEMPREX-D	126 KB
PDF File	ANTIHYPERURICEMICS (PDL) STAR and STAR KIDS Members Only	colchicine cap/tab, febuxostat (ULORIC), MITIGARE	126 KB
PDF File	ANTIMIGRAINE AGENTS (PDL) STAR and STAR KIDS Members Only	diclofenac pow (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, diclofenac powder, eletriptan (RELPAX), frovatriptan (FROVA), MAXALT, naratriptan, sumatriptan (ZEMBRACE), sumatriptan/naproxen, 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, NEUPRO, ONGENTYS CAP, OSMOLEX ER, pramipexole ER (MIRAPEX ER), rasagiline (AZILECT), ropinirole ER (REQUIP XL 6mg and 12mg), RYTARY, selegiline, STALEVO, tolcapone (TASMAR), ZELAPAR	212 KB
PDF File	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, aripiprazole, asenapine, CAPLYTA, chlorpromazine, chlorpromazine inj, clozapine, FANAPT, fluphenazine, fluphenazine inj, GEODON, GEODON inj, haloperidol lactate injection, haloperidol tablet, INVEGA, loxapine, lurasidone (LATUDA), LYBALVI, MOLINDONE, olanzapine, olanzapine inj, olanzapine/fluoxetine, paliperidone, perphenazine, pimozide, quetiapine (SEROQUEL & SEROQUEL XR), REXULTI, RISPERDAL, risperidone, SAPHRIS, SECUADO, SYMBYAX, thioridazine, thiothixene, trifluoperazine VRAYLAR, ziprasidone, ZYPREXA, ZYPREXA ZYDIS	198 KB
PDF File	ANTISEIZURE AGENTS (DIACOMIT)	stiripentol (DIACOMIT)	177 KB
PDF File	ANTISEIZURE AGENTS (EPIDOLEX)	cannabidiol (EPIDIOLEX)	179 KB
PDF File	ANTISEIZURE AGENTS (FINTEPLA)	fenfluramine (FINTEPLA)	185 KB
PDF File	ANTIVIRALS (ANTI-CMV) (PDL) STAR and STAR KIDS Members Only	LIVTENCITY TAB, valganciclovir soln, valganciclovir tab	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)	199 KB
PDF File	ANXIOLYTICS (CLONAZEPAM & DIAZEPAM)	clonazepam (KLONOPIN), diazepam	231 KB
PDF File	ANXIOLYTICS (CLORAZEPATE)	clorazepate	205 KB
PDF File	ANXIOLYTICS (LORAZEPAM)	lorazepam	216 KB
PDF File	ANXIOLYTICS(CHLORDIAZEPOXIDE, MEPOBAMATE, OXAZEPAM	chlordiazepoxide, meprobamate, oxazepam	217 KB
PDF File	ARCALYST	rilonacept (ARCALYST)	201 KB
PDF File	ARIKAYCE	amikacin (ARIKAYCE)	70 KB
PDF File	AVANDIA	rosiglitazone (AVANDIA)	137 KB
PDF File	BENIGN PROSTATIC HYPERPLASIA AGENTS (PDL) STAR and STAR KID Members Only	doxazosin (CARDURA), dutasteride-tamsulosin (JALYN), dutasteride (AVODART), ENTADFI, 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), formoterol nebulizer (PERFOROMIST), levalbuterol nebulizer, metaproterenol syrup, PROAIR DIGIHALER, PROAIR RESPICLICK, 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) STAR and STAR KID Members Only	darifenacin (ENABLEX), tolterodine (DETROL), tolterodine ER (DETROL LA), oxybutynin (DITROPAN XL), fesoterodine, flavoxate, GELNIQUE, GEMTESA, OXYTROL, solifenacin, trospium, trospium ER, VESICARE LS	21 KB
PDF File	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)	179 KB
PDF File	BUPRENORPHINE	buprenorphine	176 KB
PDF File	BYLVAY	odevixibat (BYLVAY)	206 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	CEPROTIN	protein C concentrate human (CEPROTIN)	166 KB
PDF File	CGRP ANTAGONISTS (ACUTE-UBRELVY)	ubrogepant (UBRELVY)	201 KB
PDF File	CGRP ANTAGONISTS (NURTEC)	rimegepant (NURTEC)	222 KB
PDF File	CGRP ANTAGONISTS (PROPHYLAXIS)	erenumab (AIMOVIG), fremanezumab (AJOVY), galcanezumab (EMGALITY), atogepant (QULIPTA)	262 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	COPD AGENTS (PDL) STAR and STAR KIDS Members Only	BEVESPI, DALIRESP, DUAKLIR, INCRUSE, LONHALA, roflumilast, TUDORZA, UTIBRON, YUPELRI	126 KB
PDF File	COUGH & COLD (TABLE A) Table A	ALAHIST PE TAB 2-7.5MG, APRODINE TAB, CHEST CONGESTION SYRUP 100/5ML, CHEST CONGESTION TAB 400MG, CHEST CONGESTION TAB 400MG, CHEST CONGESTION TAB RELIEF PE, CHEST CONGESTION TAB RELIEF PE, CHLO TUSS LIQUID, COLD AND ALLERGY CHILDRENS LIQUID, DECONEX IR TAB 10-385MG, DEXBROMPHENIRAMINE/PHENYLEPHRINE TAB 2-10MG, ED BRON GP LIQUID, HISTEX-PE LIQUID, MUCUS AND CHEST LIQUID 100MG/5ML, MUCUS RELIEF TAB 10-400MG, MUCUS/CHEST LIQUID 100/5ML, MUCUS/CHEST LIQUID 100/5ML, POLY-VENT IR TAB 60-380MG, RESCON-GG LIQUID, RESCON-GG LIQUID, ROBAFEN LIQUID 200MG/10ML, RU-HIST D TAB, RYNEX PE ELIXIR, RYNEX PSE ELIXIR	179 KB
PDF File	COUGH & COLD (TABLE B) Table B	12 HOUR NASAL SPRAY, ALAHIST, ALA-HIST IR TAB, BPM-PSE-DM LIQ, BROM/PSE/DM SYRUP, BROTAPP DM LIQ, CHEST CONGESTION RELIEF DM SYRUP, CHLOR/DEXCH/PSE LIQ, COLD RELIEF CHILDRENS LIQ, COUGH DM SUSP, COUGH/CHEST DM SYRUP, DECONEX DMX TAB, DEXTROMETHORPHAN LIQ, DM/GG/PHENYL, DOXYLAMINE/PHENYLEPHRINE TAB, ED A-HIST, ENDACOF-DM LIQ, FLU/COLD DAYTIME POWDER, GNP TUSSIN DM LIQ, HISTEX-DM SYRUP, LOHIST-D LIQ, LOHIST-DM SYRUP, M-END DMX LIQ, MUCUS RELIEF LIQ, MUCUS/COUGH RELIEF, NASAL DECONGESTANT SPRAY, NASAL NO DRIP SPRAY, NASAL RELIEF SPRAY, NASOPEN PE LIQ, NINJACOF LIQ, NOHIST-DM LIQ, NOHIST-LQ LIQ, OXYMETAZOLINE NASAL SOLN, PEDIATRIC COUGH/COLD LIQ, PHENYLEPHRINE/BROMPHENIRAMINE/DM LIQ, POLY HIST FORTE TAB, POLY-HIST DM LIQ, POLYTUSSIN DM, POLY-VENT DM TAB, PROMETHAZINE DM SOLN, PROMETHAZINE DM SYRUP, PSEUDOEPHEDRINE-GUAIFENESIN TAB, RESCON DM SYRUP, ROBAFEN, RYMED TAB, RYNEX DM LIQ, SILTUSSIN DM DAS LIQ, SM TUSSIN, TUSSIN, VANACOF, VANATAB DM TAB, WESTUSSIN DM SYRUP	180 KB
PDF File	COUGH & COLD (TABLE C) Table C	BENZONATATE	163 KB
PDF File	COUGH & COLD (TABLE D) Table D	CHEST CONGESTION RELIEF D TAB 20-400MG, COUGH AND COLD TAB 4-30MG, DEXTROMETHORPHAN CAP 15MG, GUAIFENESIN/PSE ER TAB 120/1200, GUAIFENESIN/PSEUDOEPHEDRINE ER TAB 600-60MG, MUCUS RELIEF D TAB 60-600MG, MUCUS RELIEF DM COUGH TAB, MUCUS RELIEF DM ER TAB 30-600MG, MUCUS RELIEF ER TAB 30-600, MUCUS RELIEF ER TAB 600MG, MUCUS RELIEF TAB 1200MG, MUCUS RELIEF TAB 60-1200, NIGHTTIME LIQUID COUGH, PSEUDOEPHEDRINE/GUAIFENESIN ER TAB 60-600MG, PSEUDOEPHEDRINE/GUAIFENESIN TAB 60-600MG, RESCON TAB	179 KB
PDF File	COUGH & COLD AGENTS (PDL) STAR and STAR KID Members Only	ALLERGY MULTI SYMPTOM TAB, ALL-NITE COLD AND FLU LIQUID, COLD AND FLU DAYTIME LIQUID, COLD AND FLU NIGHTTIME CAP, COLD AND FLU RELIEF NIGHTTIME CAP, COLD AND SINUS CAP 30-200MG, COLD AND SINUS TAB 30-200MG, COLD/FLU CAP DAYTIME, COLD/FLU REL CAP NITETIME, COLD/FLU RELIEF DAYTIME CAP, DAYTIME COLD/FLU LIQUID 10-5-325, DAYTIME COLD/FLU RELIEF LIQUID 10/5/325, FLU HBP TAB 10-325-2, HEAD CONGESTION/MUCUS TAB, MAPAP COLD FORMULA TAB, NIGHTTIME COLD/FLU LIQUID, SEVERE COLD AND FLU TAB, SEVERE COLD/COUGH PAK, SEVERE COLD/FLU TAB, SINUS CONGESTION/PAIN TAB 5-325MG, SINUS RELIEF SEVERE TAB, SINUS RELIEF SOLN 1%, SINUS RELIEF TAB 5-325MG, SINUS/COLD-D TAB 120-220MG, SINUS+HEADACHE TAB 5-325MG, TUSSIN CF COUGH/FLU LIQUID	21 KB
PDF File	CYSTIC FIBROSIS AGENTS (KALYDECO)	ivacaftor (KALYDECO)	213 KB
PDF File	CYSTIC FIBROSIS AGENTS (ORKAMBI)	lumacaftor / ivacaftor (ORKAMBI)	199 KB
PDF File	CYSTIC FIBROSIS AGENTS (SYMDEKO)	tezacaftor/ivacaftor and ivacaftor (SYMDEKO)	205 KB
PDF File	CYSTIC FIBROSIS AGENTS (TRIKAFTA)	elexcaftor/tezacaftor/ivacaftor (TRIKAFTA)	207 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (ADALIMUMAB)	adalimumab-atto (AMJEVITA), adalimumab (HUMIRA)	258 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (CIBINQO)	abrocitinib (CIBINQO)	226 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (CIMZIA)	certolizumab pegol (CIMZIA)	213 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (COSENTYX)	secukinumab (COSENTYX)	211 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (ENBREL)	etanercept (ENBREL)	200 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (ENSPRYNG)	satralizumab-mwge (ENSPRYNG)	204 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (ILARIS)	canakinumab (ILARIS)	203 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (ILUMYA)	tildrakizumab (ILUMYA)	192 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (KEVZARA)	sarilumab (KEVZARA)	206 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (KINERET)	anakinra (KINERET)	205 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (ORENCIA)	abatacept (ORENCIA)	207 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (OTEZLA)	apremilast (OTEZLA)	189 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (RINVOQ)	upadacitinib (RINVOQ)	241 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (SILIQ)	brodalumab (SILIQ)	205 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (SIMPONI)	golimumab (SIMPONI)	218 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (SKYRIZI)	risankizumab (SKYRIZI)	193 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (STELARA)	ustekinumab (STELARA)	205 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (TALTZ)	ixekizumab (TALTZ)	207 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (TREMFYA)	guselkumab (TREMFYA)	211 KB
PDF File	CYTOKINE & CAM ANTAGONISTS (XELJANZ)	tofacitinib citrate (XELJANZ / XELJANZ XR)	232 KB
PDF File	DDAVP INJECTABLE	desmopressin injectable (DDAVP)	175 KB
PDF File	DDAVP ORAL	desmopressin oral (DDAVP)	172 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)	59 KB
PDF File	DICLOFENAC 3% GEL	diclofenac 3% gel (SOLARAZE 3% GEL)	53 KB
PDF File	DOPAMINE AGONISTS	apomorphine (APOKYN) inj & apomorphine (KYNMOBI) film	197 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	dupilumab (DUPIXENT)	250 KB
PDF File	ELAPRASE For Cook Children’s Health Plans Only	idursulfase (ELAPRASE)	196 KB
PDF File	ELAPRASE	idursulfase (ELAPRASE)	165 KB
PDF File	EMFLAZA - INITIAL REQUESTS	deflazacort (EMFLAZA)	76 KB
PDF File	EMFLAZA - RENEWAL REQUESTS	deflazacort (EMFLAZA)	26 KB
PDF File	EPINEPHRINE (PDL) STAR and STAR KIDS Members Only	AUVI-Q ,epinephrine inj	126 KB
PDF File	ESA (ARANESP)	darbepoetin alfa (ARANESP)	26 KB
PDF File	ESA (EPOGEN)	epoetin alfa (EPOGEN)	29 KB
PDF File	ESA (PROCRIT)	epoetin alfa (PROCRIT)	36 KB
PDF File	ESA (RETACRIT)	epoetin alfa (RETACRIT)	28 KB
PDF File	EVRYSD I- RENEWAL REQUEST	risdiplam (EVRYSDI)	54 KB
PDF File	EVRYSDI - INITIAL REQUEST	risdiplam (EVRYSDI)	55 KB
PDF File	FABRAZYME	agalsidase beta (FABRAZYME)	170 KB
PDF File	FASENRA	benralizumab (FASENRA)	193 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	GALAFOLD	migalastat (GALAFOLD)	167 KB
PDF File	GATTEX	teduglutide (GATTEX)	195 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	218 KB
PDF File	GLUCAGON AGENTS (PDL) STAR and STAR KIDS Members Only	DIAZOXIDE SUS, GLUCAGON EMERGENCY SOLN, GVOKE KIT SOLN, GVOKE PFS , ZEGALOGUE	21 KB
PDF File	GNRH RECEPTOR ANTAGONISTS	relugolix-estradiol-norethindrone (MYFEMBREE), elagolix-estradiol-norethindrone acetate (ORIHANN)	217 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	HAE AGENTS	BERINERT, CINRYZE, icatibant (FIRAZYR), HAEGARDA, KALBITOR, RUCONEST, TAKHZYRO	241 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	HORIZANT	gabapentin enacarbil (HORIZANT)	64 KB
PDF File	HP ACTHAR	corticotropin (HP ACTHAR)	66 KB
PDF File	HYPERLIPIDEMIA AGENTS (PRALUENT)	alirocumab (PRALUENT)	221 KB
PDF File	HYPOGLYCEMICS, INSULIN (PDL) STAR and STAR KID Members Only	ADMELOG, AFREZZA, APIDRA, BASAGLAR, BASAGLAR TEMPO, FIASP, HUMULIN N KWIKPEN, HUMALOG KWIKPEN, HUMALOG TEMPO, LYUMJEV, INSULIN GLARGINE, INSULIN LISPRO, INSULIN DEGLUDEC, NOVOLIN, NOVOLIN N, NOVOLIN R, SEMGLEE, TOUJEO, TRESIBA	126 KB
PDF File	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)	199 KB
PDF File	IMMUNE GLOBULINS (PDL) STAR and STAR KIDS Members Only	CUTAQUIG, 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), mycophenolate, mycophenolic (MYFORTIC, CELLCEPT), NEORAL, PROGRAF, sirolimus tab, sirolimus soln, REZUROCK, TAVNEOS	126 KB
PDF File	INCRELEX	mecasermin (INCRELEX)	67 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, FLUTICASONE HFA AER, FLUTICASONE FUROATE/VILAN, budesonide, PULMICORT SUSP, 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, RYALTRIS, 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	KETOROLAC (INJECTION / NASAL)	injectable/nasal ketorolac (TORADOL equiv)	201 KB
PDF File	KETOROLAC (ORAL)	oral ketorolac (TORADOL)	178 KB
PDF File	KEVEYIS	dichlorphenamide (KEVEYIS)	56 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)	183 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, icosapent (VASCEPA), 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)	205 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	196 KB
PDF File	LOTRONEX	alosetron (LOTRONEX)	196 KB
PDF File	LUPKYNIS	voclosporin (LUPKYNIS)	63 KB
PDF File	LYRICA	pregabalin (LYRICA)	189 KB
PDF File	MACROLIDES / KETOLIDES (PDL) STAR and STAR KIDS Members Only	CLARITHROMYCIN, E.E.S. GRANULES, E.E.S. tab, erythromycin suspension, ZITHROMAX	23 KB
PDF File	MOTEGRITY	prucalopride (MOTEGRITY)	194 KB
PDF File	MOVANTIK	naloxegol (MOVANTIK) & naldemedine (SYMPROIC)	207 KB
PDF File	MS AGENTS (AMPYRA)	dalfampridine (AMPYRA)	177 KB
PDF File	MS AGENTS (AUBAGIO)	teriflunomide (AUBAGIO)	189 KB
PDF File	MS AGENTS (MAVENCLAD)	cladribine (MAVENCLAD)	187 KB
PDF File	MS AGENTS (MAYZENT)	siponimod (MAYZENT)	191 KB
PDF File	MS AGENTS (PONVORY)	ponesimod (PONVORY)	192 KB
PDF File	MS AGENTS (TASCENSO ODT)	fingolimod (TASCENSO) ODT	193 KB
PDF File	MS AGENTS (ZEPOSIA)	ozanimod (ZEPOSIA)	197 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, orphenadine/aspirin/caffeine tablet (ORPHENGESIC FORTE), tizanidine	21 KB
PDF File	NAGLAZYME	galsulfase (NAGLAZYME)	170 KB
PDF File	NEUROPATHIC PAIN (PDL) STAR and STAR KIDS Members Only	duloxetine (CYMBALTA)	126 KB
PDF File	NITYR & ORFADIN	nitisinone (NITYR & ORFADIN)	166 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 suspension, naproxen/esomeprazole (VIMOVO), oxaprozin (DAYPRO), piroxicam (FELDENE), tolmetin	21 KB
PDF File	NUCALA	mepolizumab (NUCALA)	249 KB
PDF File	NUPLAZID	pimavanserin (NUPLAZID)	61 KB
PDF File	NUVIGIL	armodafinil (NUVIGIL)	195 KB
PDF File	OLUMIANT	baricitinib (OLUMIANT)	204 KB
PDF File	OMEGA-3 FATTY ACIDS	omega-3-acid ethyl esters (LOVAZA), icosapent ethyl (VASCEPA)	221 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, tafluprost (ZIOPTAN), timolol maleate (ISTALOL), TIMOPTIC, TIMOPTIC XE, TRAVOPROST, TRUSOPT, VUITY, VYZULTA, XALATAN	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 (TABLE E) Table E	codeine-guaifenesin, guaiatussin, hydrocodone-homatropin, hydrocodone-chlorpheniramine polistirex	223 KB
PDF File	OPIOID - FENTANYL AGENTS - ACTIQ	oral transmucosal fentanyl (ACTIQ)	234 KB
PDF File	OPIOID - FENTANYL AGENTS - FENTORA	buccal fentanyl citrate (FENTORA)	243 KB
PDF File	OPIOID - FENTANYL AGENTS: DURAGESIC	transdermal fentanyl (DURAGESIC)	228 KB
PDF File	OPIOID - OXYCONTIN ER - HIGH DOSE	oxycodone extended-release (OXYCONTIN) 60mg & 80mg	228 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	OPIOID POLICY (OXYCODONE ER AGENTS-LOW DOSE)	oxycodone extended-release (OXYCONTIN) 10mg, 15mg, 20mg, 30mg, 40mg; oxycodone extended-release (XTAMPZA ER)	217 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	ORILISSA	elagolix (ORILISSA)	64 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	PANCREATIC ENZYMES (PDL) STAR and STAR KIDS Members Only	PERTZYE, VIOKACE	126 KB
PDF File	PDE5 INHIBITORS	sildenafil (REVATIO), tadalafil (ADCIRCA), tadalafil (ALYQ), TADLIQ suspension	208 KB
PDF File	PDL - ROSACEA AGENTS (TOPICAL) STAR and STAR KID Members Only	ivermectin cream, METROGEL, METROCREAM, MIRVASO GEL	21 KB
PDF File	PDL ANTI-ALLERGENS (ORAL) STAR and STAR KID Members Only	GRASTEK SUBLINGUAL, RAGWITEK SUBLINGUAL	170 KB
PDF File	PEDIATRIC VITAMIN PREPARATIONS STAR and STAR KIDS Members Only	ANIMAL SHAPE CHW + IRON, FLORIVA, POLY-VI-FLOR, QUFLORA, TRI-VI-FLOR suspension, TRI-VIT/FLUO drops, vitamin A/C/D fluoride drops	134 KB
PDF File	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	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, ELITE-OB, NESTABS DHA, NESTABS, OB COMPLETE, PNV-DHA, PNV-OMEGA, PNV-SELECT, PRENAISSANCE, PRENATE AM, PRENATE, PRENATE DHA, PRENATE ELITE, PRENATE ESSENTIAL, PRENATE MINI, PRENATE PIXIE, PRENATE RESTORE, PRENATE STAR, SELECT-OB, SE-NATAL 19, TARON-C DHA, TRISTART DHA, WESTGEL DHA C, ZATEAN-PN	126 KB
PDF File	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)	195 KB
PDF File	PULMONARY ARTERIAL HYPERTENSION (ORAL/INHALED)	ADEMPAS, ambrisentan (LETAIRIS), bosentan (TRACLEER), OPSUMIT, ORENITRAM, TYVASO inhalation solution, UPTRAVI, VENTAVIS inhalation solution	192 KB
PDF File	PULMOZYME	dornase alfa (PULMOZYME)	53 KB
PDF File	RANEXA	ranolazine (RANEXA)	60 KB
PDF File	RECORLEV	levoketoconazole (RECORLEV)	58 KB
PDF File	RELISTOR	methylnaltrexone (RELISTOR)	194 KB
PDF File	REPATHA	evolocumab (REPATHA)	221 KB
PDF File	REVCOVI	elapegademase (REVCOVI)	169 KB
PDF File	RVVC AGENTS (VIVJOA)	oteseconazole (VIVJOA)	200 KB
PDF File	SAVELLA	milnacipran (SAVELLA)	141 KB
PDF File	SEDATIVES / HYPNOTICS (PDL) STAR and STAR KIDS Members Only	doxepin (SILENOR), DORAL, QUAZEPAM	126 KB
PDF File	SEDATIVES-HYPNOTICS (HETLIOZ CAPSULES)	tasimelteon (HETLIOZ) capsules	206 KB
PDF File	SEDATIVES-HYPNOTICS (HETLIOZ LQ SUSPENSION)	tasimelteon (HETLIOZ LQ) suspension	198 KB
PDF File	SEDATIVES-HYPNOTICS (RAMELTON)	ramelteon (ROZEREM)	226 KB
PDF File	SEDATIVES-HYPONOTICS (ADULTS)	BELSOMRA, DAYVIGO, EDLUAR, estazolam, eszopiclone (LUNESTA), QUVIVIQ, temazepam (RESTORIL), triazolam, zaleplon, zolpidem (AMBIEN, AMBIEN CR, EDLUAR)	193 KB
PDF File	SGLT2 INHIBITOR (COMBINATION AGENTS)	canagliflozin/metformin (INVOKAMET, INVOKAMET XR), ertugliflozin/metformin (SEGLUROMET), empagliflozin/metformin (SYNJARDY, SYNJARDY XR), dapagliflozin/metformin (XIGDUO XR)	202 KB
PDF File	SGLT2 INHIBITOR (SINGLE AGENTS)	FARXIGA, INVOKANA, JARDIANCE, STEGLATRO	215 KB
PDF File	SMOKING CESSATION (PDL) STAR and STAR KIDS Members Only	NICOTROL INHALER, NICOTROL NS	126 KB
PDF File	SOTYKTU	deucravacitinib (SOTYKTU)	208 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, PANDEL CREAM, prednicarbate, triamcinolone acetate (TRIANEX), triamcinolone dental paste	126 KB
PDF File	STRENSIQ	asfotase alfa (STRENSIQ)	167 KB
PDF File	SUNOSI	solriamfetol (SUNOSI)	202 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 2023-2024	palivizumab (SYNAGIS)	306 KB
PDF File	SYNAGIS - COMMUNITY HEALTH CHOICE For Community Health Choice Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	283 KB
PDF File	SYNAGIS - COOK CHILDREN'S HEALTH PLANS For Cook Children's Health Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	283 KB
PDF File	SYNAGIS - DELL CHILDREN'S (SETON) HEALTH PLANS For Dell Children's Health (Seton) Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	283 KB
PDF File	SYNAGIS - DRISCOLL CHILDREN'S HEALTH PLANS For Driscoll Children's Health Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	284 KB
PDF File	SYNAGIS - EL PASO FIRST HEALTH PLANS For El Paso First Health Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	283 KB
PDF File	SYNAGIS - FIRSTCARE HEALTH PLANS For FirstCare Health Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	296 KB
PDF File	SYNAGIS - PARKLAND COMMUNITY HEALTH PLANS For Parkland Community Health Plans Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	289 KB
PDF File	SYNAGIS - SCOTT & WHITE HEALTH PLANS For Scott & White Health Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	296 KB
PDF File	SYNAGIS - TEXAS CHILDREN'S HEALTH PLANS For Texas Children's Health Plan Only - RSV Season Dates 2023-2024	palivizumab (SYNAGIS)	283 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	NATESTO GEL	126 KB
PDF File	TOPICAL ANTIBIOTICS (PDL) STAR and STAR KIDS Members Only	bacitracin zinc, CENTANY, gentamicin, mupirocin cream	126 KB
PDF File	TOPICAL ANTIFUNGALS FOR ONYCHOMYCOSIS	CICLOPIROX 8% SOLUTION, JUBLIA 10% TOPICAL SOLUTION, KERYDIN (TAVABOROLE) 5% TOPICAL SOLUTION, OXISTAT LOTION 1%, TM-TOLNAFTAT LIQUID 1%	66 KB
PDF File	TOPICAL ANTIVIRALS (PDL) STAR and STAR KIDS Members Only	acyclovir cream, acyclovir ointment, docosanol cream, penciclovir cream, XERESE	126 KB
PDF File	TOPICAL IMMUNOMODULATORS (ELIDEL & PROTOPIC 0.03)	pimecrolimus (ELIDEL), tacrolimus (PROTOPIC 0.03%)	227 KB
PDF File	TOPICAL IMMUNOMODULATORS (EUCRISA)	crisaborole (EUCRISA)	176 KB
PDF File	TOPICAL IMMUNOMODULATORS (OPZELURA)	ruxolitinib phosphate cream (OPZELURA)	213 KB
PDF File	TOPICAL IMMUNOMODULATORS (PROTOPIC 0.1)	tacrolimus (PROTOPIC) 0.1%	227 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	TRULANCE	plecanatide (TRULANCE)	195 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)	189 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)	203 KB
PDF File	VIMIZIM For Cook Children’s Health Plans Only	elosulfase alfa (VIMIZIM)	200 KB
PDF File	VIMIZIM	elosulfase alfa (VIMIZIM)	168 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	VMAT2 INHIBITORS (AUSTEDO & XENAZINE) All Plans Except Texas Children’s Health Plan	deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE)	223 KB
PDF File	VMAT2 INHIBITORS (AUSTEDO & XENAZINE) Texas Children’s Health Plan Only	deutetrabenazine (AUSTEDO), tetrabenazine (XENAZINE)	227 KB
PDF File	VMAT2 INHIBITORS (INGREZZA)	valbenazine (INGREZZA)	208 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)	201 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	omalizumab (XOLAIR)	285 KB
PDF File	XYREM / XYWAV	sodium oxybate (XYREM) / XYWAV	56 KB
PDF File	ZTALMY	ganaxolone (ZTALMY)	173 KB
PDF File	ZYCLARA	imiquimod 3.75 % cream (ZYCLARA)	52 KB
PDF File	ZYFLO	zileuton (ZYFLO)	60 KB

Type

Date

Name

File Size

.txt

9/1/2023

Texas-STAR-Kids-Dual-Formulary-9-1-2023

877 kB

.txt

9/1/2023

Texas-STAR-Formulary-9-1-2023

3.3 MB

.txt

9/1/2023

Texas-CHIP-Formulary-9-1-2023

2.4 MB

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