Psychiatric Drug Formulary

State Hospitals & State Supported Living Centers & Community Mental Health Centers

20218T 1

Approved October 2020

Updated July 2021

Table of Contents

Table of Contents ...... 2

Introduction ...... 4

Members of the HHSC Psychiatric Executive Formulary Committee ...... 7

HHS Psychiatric Drug Formulary editor ...... 7

Procedure for Addition of Drugs to the Formulary ...... 8

Psychotropic Dosage Guidelines ...... 9 Children and Adolescent Treatment of Behavioral Emergencies ...... 10 Adult Treatment of Behavioral Emergencies ...... 11 Antipsychotics ...... 13 Antidepressants ...... 15 Mood Stabilizers ...... 17 Stimulants ...... 19 Miscellaneous Drugs Used for Psychotropic Purposes ...... 20 Anxiolytics ...... 21 Hypnotics ...... 22

Reserve Drugs ...... 23

Therapeutic Reference Ranges ...... 30

Alphabetical Listing ...... 32

Therapeutic Classification/Cost Index ...... 80 Antidiabetic Agents ...... 80 Antidotes ...... 80 Antineoplastic Agents ...... 81 Blood Modifying Agents ...... 81 Cardiovascular Agents ...... 82 Central Nervous System Agents ...... 84 Endocrine Agents ...... 92 Gastrointestinal Agents ...... 94 Genitourinary Agents ...... 97 Immunological Agents ...... 98 Infectious Disease Agents ...... 99 Parenteral Solutions and Additives ...... 102 Nutritional Agents ...... 103 Respiratory Agents ...... 104 Topical Agents ...... 106 Nutritional Supplements ...... 115

Index ...... 116

Texas HHS Psychiatric Drug Formulary 2021

Introduction 2 Appendix A. New Drug Application Form ...... A1

Appendix B. PEFC Conflict of Interest Policy ...... B1

Appendix C. PEFC Disclosure Form ...... C1

Appendix D. Non-Formulary Drug Justification Form ...... D1

Texas HHS Psychiatric Drug Formulary 2021

Introduction 3 Introduction

The Texas Health and Human Services Psychiatric Drug Formulary is the publication that outlines the medications that have been approved for use in Community Mental Health Centers, Mental Health State Hospitals and the State Supported Living Centers. The formulary is published annually around the beginning of the calendar year. This document is divided into three sections (Alphabetical Listing, Therapeutic Classification/Cost Index, and Alphabetical Index) to facilitate usage.

Alphabetical Listing:

This section lists all the medications alphabetically by generic (nonproprietary) name. Trade (proprietary) names and abbreviations are listed in parenthesis after the generic name. In this section, all approved dosage forms are listed. All available strengths of approved dosage forms are considered formulary unless specifically noted otherwise.

Therapeutic Classification/Cost Index:

This section groups the medications by therapeutic usage and lists them alphabetically by generic (nonproprietary) name. Medications may be listed in multiple categories. For trade names, consult the alphabetical index. Also in this section is a relative cost index so that medications used in similar situations can be evaluated keeping cost of care in mind. Relative cost is noted as either low, moderate, or high and is based on cost per day of the average dose. The relative cost of bulk items is indexed per unit (gram, ml).

Alphabetical Index:

This section lists all the medications alphabetically by trade name, generic name, and abbreviations. Page numbers for each of the listings is provided.

The purpose of the HHSC Psychiatric Executive Formulary Committee is to maintain and update the Formulary and to recommend standards for drug use within the Community Mental Health

Texas HHS Psychiatric Drug Formulary 2021

Introduction 4 Centers, State Hospitals and the State Supported Living Centers. The Committee is concerned with maintaining the highest standards for drug use. To assist the clinician in prescribing the most cost effective agents a Therapeutic Classification with relative cost data is provided. Because of their frequency of use, the highest level of concern and vigilance centers on the psychotropic medications. For the clinician's reference, the Formulary provides tables summarizing the recommended dosage ranges for the psychotropic drugs; however, these guidelines are not intended to replace other references or the clinician's clinical judgment. The clinician is urged to check with other references, including the Texas Administrative Code, Title 25, Part 1, Chapter 415, Subchapter A, Prescribing of Psychoactive Medication, The American Hospital Formulary Service Drug Information, Facts & Comparisons, and The AMA Drug Evaluations among other reliable sources.

This Formulary, is not intended to be a reference for drug use. Rather it is to serve the clinician as a listing of drugs, which are approved for use. Approval of a drug entity for inclusion in the Formulary does not imply approval of all formulations containing that entity. The HHSC Psychiatric Executive Formulary Committee will decide which formulations are approved for use. Not all drugs listed in the Formulary will be stocked at each facility's pharmacy. If a physician, dentist, nurse or pharmacist desires to have a drug added to the Formulary, he or she should complete and submit the appropriate form (New Drug Application, see Appendix 1) to the facility’s Pharmacy and Therapeutics Committee. If it is approved at the facility level, the facility’s Director of Pharmacy must then forward the request to the HHSC Psychiatric Executive Formulary Committee in care of the State Hospitals. Requests received at least 30 days prior to the quarterly meeting will be considered at that meeting. Requests received less than 30 days before the meeting will not be considered until the following meeting. Clinicians and facilities are encouraged to submit supporting documents with their formulary request. The HHSC Psychiatric Executive Formulary Committee will evaluate the submission's appropriateness based upon the efficacy and safety of the proposed drug compared with existing formulary items and cost effectiveness of the new agent. When appropriate, the HHSC Psychiatric Executive Formulary Committee will add the new drug or replace old agents in the same pharmacological/therapeutic category with the new agent.

The Formulary consists of routine and reserve drugs. Drugs in the reserve class have specific guidelines for use printed in the Formulary. These guidelines will be used to audit the appropriate use of reserve drugs. Based on the audit results, continuing education will be developed and targeted as needed. The purpose of reserve status is to stimulate thought and promote care in prescribing. Discussions about the use of reserve status drugs with peers are encouraged. Use of reserve status drugs requires documentation of justification in the patient’s progress notes.

As a means of preventing medication errors, the Formulary has incorporated TALL MAN characters to assist in distinguishing look-alike drug names. TALL MAN characters are being implemented in various parts of the pharmaceutical industry in order to prevent medication

Texas HHS Psychiatric Drug Formulary 2021

Introduction 5 errors. Even though the Formulary may not play a major role in preventing medication errors, hopefully this change will stimulate the awareness of TALL MAN characters and assist in implementing this print style in other areas of our medication use process.

The HHSC System utilizes a closed formulary system. Only drugs listed in the Formulary are to be stocked, prescribed and dispensed in State Hospitals and State Supported Living Centers including pharmaceutical products recommended by consultants for specialized treatments. When a patient's condition requires a drug not listed in the Formulary, limited quantities can be obtained for use in that particular patient. However, documentation (Non-Formulary Drug Justification Form, see Appendix 3) or other appropriate pharmacy software generated report should be submitted to the facility Medical Director and the State Hospital Chief Medical Director’s office where it will be reviewed by the HHSC Psychiatric Executive Formulary Committee to assure reasonable compliance with the Formulary.

When requested by the Commissioner, the HHSC Psychiatric Executive Formulary Committee will make other recommendations regarding drug use. If facility clinicians have topics for committee consideration, these requests should be sent to the Chairperson, HHSC Psychiatric Executive Formulary Committee in care of the State Hospitals (mail code 2023). The Committee also appreciates your comments concerning the printing of the Formulary and Committee deliberations and decisions. Please feel free to provide input.

David Moron, M.D. David Moron, M.D. Chairperson HHSC Psychiatric Executive Formulary Committee October 2020

Texas HHS Psychiatric Drug Formulary 2021

Introduction 6 Members of the HHSC Psychiatric Executive Formulary Committee Yekini Adeyemi, RN Jeffery Matthews, MD Austin State Supported Living Center State Hospitals Angela Babin, RPh David Moron, MD Harris Center for Mental Health & IDD Rio Grand State Center Jean Baemayr, PharmD Leah Nunez, PharmD State Hospitals Rio Grande State Center John Bennett, MD Brittany Parmentier, PharmD Dallas Metrocare Services Fisch College of Pharmacy, UT Tyler Giovanna Betancourt, PharmD Kenda Pittman, PharmD El Paso Supported Living Center State Supported Living Centers Rakesh Chadalavada, MD Rishi Sawhney, MD Terrell State Hospital BHS Community Behavioral Health German Corso, MD Glenn Shipley, DO Tropical Texas Behavioral Health State Supported Living Centers Brad Fitzwater, MD Lesia Trickett, MD HHSC Substance Use State Supported Living Centers Catherine S. Hall, PharmD Ashton Wickramasinghe, MD San Antonio State Hospital Austin State Supported Living Center Dana Hopkins, RN Patrick Young, MD Austin State Hospital Betty Hardwick Center Vicky Litton, MD Kerrville State Hospital

HHS Psychiatric Drug Formulary editor Jean Baemayr, PharmD

Texas HHS Psychiatric Drug Formulary 2021

Introduction 7 Procedure for Addition of Drugs to the Formulary

A physician, dentist, nurse or pharmacist desiring that a new drug be added to the Formulary should submit a new drug application (New Drug Application, see Appendix 1) to the facility's formulary committee. If approved, the new drug application should be forwarded to the HHSC Psychiatric Executive Formulary Committee. The following information should accompany the application:

1. published articles in the biomedical literature that substantiate the efficacy and safety of the proposed new drug; 2. advantages of the proposed new drug compared with similar therapeutic agents presently in the Formulary; 3. drugs in the Formulary which the proposed agent will replace or supplement; 4. cost effectiveness data.

New drug applications should be received by the secretary of the committee thirty days prior to the committee's scheduled meeting date. Applications received after this time will be considered at the next meeting.

The chairperson will assign a committee member to present an objective treatise and recommendations concerning the proposed to new drug to the HHSC Psychiatric Executive Formulary Committee. The committee may decide to approve or deny the drug's inclusion, approve the drug on a trial basis, or postpone a decision until the following meeting of the committee. The committee, at its discretion, may approve a drug's inclusion in the Formulary subject to specific limitations (e.g., recommendation by qualified specialists or consultants) or as a reserve drug.

The specific limitations or guidelines for use of a reserve drug are stated in the formulary. A credentialed clinician may prescribe reserve drugs outside Formulary guidelines; however, such exceptions must be justified in the patient record and must be reviewed in routine facility audits of reserve drug utilization.

HHSC Psychiatric Executive Formulary Committee Texas Health and Human Services, Health and Specialty Care System P.O. Box 149347 Mail Code 2023 Austin, TX 78714-9347

Texas HHS Psychiatric Drug Formulary 2021

Procedure for Addition of Drugs to the Formulary 8 Psychotropic Dosage Guidelines

The following is a list of psychotropic drug dosages. These guidelines are not intended to establish rigid standards of treatment but to assist in monitoring the pharmacotherapy of the patient. Furthermore, guidelines for special patient populations are not intended to be absolute. For those medications that have a well-established therapeutic serum range, the dosage should be based upon the desired serum range and response rather than a specific maximum administered daily dosage. These guidelines should be used in conjunction with sound clinical judgment and the prescriber’s experience.

In children and adolescents, metabolic and physiologic differences from adults should be considered when prescribing. Dosing based on body weight may be more accurate when treating these patients.

Different dosage requirements are usually necessary in the geriatric population. Since there is no standard definition for “geriatric”, the arbitrary age of 65 has been chosen to identify geriatric patients. In general, geriatric patient dosing guidelines should reflect a “go low, go slow” approach. Standard reference books should be consulted if needed for appropriate dosages when treating this population.

In general, when treating patients with intellectual disabilities, a “go low, go slow” approach is recommended when increasing or decreasing psychotropic medication. The use of psychotropic medication can be therapeutic and empowering for a person with both intellectual disabilities and mental illness. The primary goal is to obtain an accurate diagnosis of behavioral and psychiatric symptoms so that the patients’ treatment is appropriate. A functional analysis by a psychologist is vital prior to starting any psychotropic medication except in an emergency.

Prescribing psychotropic medication should be based on the following resources:

Texas Administrative Code, Title 25, Part 1, Chapter 415, Subchapter A, Prescribing of Psychoactive Medications

Other useful resources that reflect current Standards of Care for the mentally ill include but are not limited to the following:

American Psychiatric Association Practice Guidelines

Texas Health and Human Services: Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 9 Children and Adolescent Treatment of Behavioral Emergencies

Intramuscular Short-Acting Agents

Unless noted by reference, the dose was obtained from a survey of use that was completed by practitioners that treat this population within our agency.

Children (< 12 y/o) Drug Maximum Single Minimum Interval Maximum Total dose (mg) (hrs) Dose per day (mg)

chlorproMAZINE1,2,4,7,8,9,10 0.55 mg/kg 25 – 50 6 to 8 < 5 y/o: 40 ≥ 5 y/o: 75

*diphenhydrAMINE1,2,4,7 1 mg/kg 50 4 to 6 100

Haloperidol1,2,3,4,5,6 0.05-0.15 mg/kg 5 4 to 6 10

hydrOXYzine 25 – 50 4 to 6 150

LORazepam1,2,3,4,5 0.05-0.1 mg/kg 2 4 to 8 4

OLANZapine1,3,5,6 5 4 to 6 10-20

^Ziprasidone3,5,6 5 4 to 6 20

Adolescent (12 y/o to < 18 y/o) Drug Maximum Single Minimum Interval Maximum Total dose (mg) (hrs) Dose per day (mg)

chlorproMAZINE1,2,4,7,8,9,10 0.55 mg/kg 25 – 50 6 to 8 75

*diphenhydrAMINE1,2,4,7 1 mg/kg 50 4 to 6 200

Haloperidol1,2,3,4,5,6 0.05-0.15 mg/kg 5 4 to 6 15

hydrOXYzine 50 – 100 4 to 6 200

LORazepam1,2,3,4,5 0.05-0.1 mg/kg 2 4 to 8 8

OLANZapine1,3,5,6 10 4 to 6 20

^Ziprasidone3,5,6 10 4 to 6 20

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 10 *diphenhydrAMINE use in behavioral emergencies is not supported in the literature and there are a high rate of paradoxical reactions in this population

^ Gerson and colleagues did not recommend ziprasidone due to activating potential and QT prolongation

1. Gerson R, Malas N, Feuer V, et. Al. Best Practices for Evaluation and Treatment of agitated children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association of Emergency Psychiatry. West J of Emerg Med. 2019;20(2):409- 418. 2. Fox, S (2016, August 5; Updated 2017, August 29). Agitation. Pediatric EM Morsels. Retrieved from https://pedemmorsels.com/agitation/ 3. Chun TH, Mace SE, Katz ER. Evaluation and Management of Children and Adolescents with Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients with Mental Health and/or Behavioral Emergencies. Pediatrics. 2016;138(3):e1- e22. 4. Carubia B, Becker A, Levine BH. Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges Curr Psychiatry Rep. 2016;18(41):1-8. 5. Marzullo LR. Pharmacologic Management of the Agitated Child. Pediatric Emergency Care. 2014;30(4):269-275. 6. Sonnier L, Barzman D. Pharmacologic Management of Acutely Agitated Pediatric Patients. Pediatr Drugs. 2011;13(1):1-10. 7. Savarese, DMF, & Zand, JM. (2020). In JM Zand (Ed.), UpToDate. Cited September 8, 2020, from https://www.uptodate.com/contents/search. 8. Drug Facts and Comparisons. eFacts [online]. 2020. Available from Wolters Kluwer Health, Inc. Accessed September 8, 2020. 9. Product Information: Chlorpromazine hydrochloride injection (prescribing information). Eatontown, NJ; West-Ward Pharmaceuticals; November 2016. 10.Micromedex® [electronic version]. Truven Health Analytics, Greenwood Village, CO, USA (cited 09-10-20).

Tables added February 2009; Reviewed October 2020 Adult Treatment of Behavioral Emergencies

Intramuscular Short-Acting Agents

Drug Maximum Single Minimum Interval Maximum Total dose (mg) (hrs) Dose per day (mg)

IM chlorproMAZINE1 100* 2 400

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 11 Drug Maximum Single Minimum Interval Maximum Total dose (mg) (hrs) Dose per day (mg)

IM 100 1 400 diphenhydrAMINE2,3,8

IM fluPHENAZine3,4 10 1 10^

IM Haloperidol1 10 1 40

IM hydrOXYzine2,3 100 1 400

IM LORazepam1,5 4 0.5 12

IM OLANZapine1,6 10 2 30

IM Ziprasidone7 10 2 40

IM Ziprasidone7 20 4 40

*Initial dose is not recommended to be greater than 50 mg if tolerability is unknown

^Use doses exceeding 10 mg daily with caution

1. Allen MG, Currier GW, Carpenter D, et al. Treatment of Behavioral Emergencies Expert Consensus Guidelines Series. Journal of Psychiatric Practice 2005; 11 [Suppl 1]:1-108. 2. Savarese, DMF, & Zand, JM. (2020). In JM Zand (Ed.), UpToDate. Cited September 8, 2020, from https://www.uptodate.com/contents/search. 3. Micromedex® [electronic version]. Truven Health Analytics, Greenwood Village, CO, USA (cited 07-24-20). 4. Product Information: Fluphenazine hydrochloride injection. Fesenius Kabi, Lake Zurich, IL, 2016. 5. Lukens TW, Wolf SJ, Edlow JA, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med 2006; 47:79-99. 6. Product Information: Zyprexa®, olanzapine intramuscular injection. Eli Lilly and Company, Indianapolis, IN, USA, 3-2018. 7. Product Information: GEODON® ziprasidone mesylate IM injection. Pfizer, Inc, New York, NY, 11-2018. 8. Drug Facts and Comparisons. eFacts [online]. 2020. Available from Wolters Kluwer Health, Inc. Accessed September 8, 2020.

Reviewed October 2020

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 12 Antipsychotics

Suggested maximum doses (mg/day)

Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

ARIPiprazole (Abilify) 30 4 to 11 y/o: 15 (Lit) 30 Tourette’s (FDA) Tourette’s (FDA) 6 - < 12 y/o 104 (<50 kg) 104 (<50 kg) 204 (≥50 kg) 204 (≥50 kg) Autistic Disorder Autistic Disorder 15 6-11 y/o: 15

ARIPiprazole Extended 400 per 4 weeks NL NL Release (Abilify Maintena)

ARIPiprazole Initio 675 once, along NR NR (Aristada) with 30 mg oral once

ARIPiprazole lauroxil 882 per 4 weeks NL NL (Aristada) 1064 per 8 weeks

Asenapine (Saphris) 20 10 to < 12 y/o: 20 20

Brexpiprazole (Rexulti) 4 R-NR R-NR

Cariprazine (Vraylar) 6 R-NR R-NR

chlorproMAZINE 2,000 5 – 12 y/o: 75 (Lit) 800 (Lit) (Thorazine)

cloZAPine (Clozaril, 900 8 – 11 y/o: 300 (Lit) 600 (Lit) Fazaclo, Versacloz) RESERVE USE

fluPHENAZine (oral) 40 NL NL (Prolixin)

fluPHENAZine Decanoate 400 per 4 weeks NL NL (Prolixin Decanoate)

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 13 Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

Haloperidol (oral) 40 3 – 12 y/o: > 12 y/o: (Haldol) Lesser of 0.15 mg/kg Acute agitation 10 or 6 (Lit) Psychosis 15 Tourette’s 15 (Lit)4

Haloperidol Decanoate 450 per month NL NL (Haldol Decanoate)

Iloperidone (Fanapt) 24 R-NR R-NR RESERVE USE

Loxapine (Loxitane) 250 NL NL

Lumateperone (Caplyta) 42 NL NL

Lurasidone (Latuda) 160 10 – 11 y/o: 805 (Lit) 13 – 17 y/o: 80

OLANZapine (ZyPREXA, 30 4 – 5 y/o: 12.5 (Lit) 12 y/o:20 (Lit) ZyPREXA Zydis) 6 – <12 y/o: 20 (Lit) 13 – 17 y/o: 20 (FDA)

OLANZapine pamoate 300 per 2 weeks NL NL (ZyPREXA Relprevv) 405 per 4 weeks RESERVE USE

Paliperidone (Invega) 12 R-NR 6 (< 51 kg) 12 (≥ 51 kg)

Paliperidone palmitate 234 per 4 weeks NL NL (Invega Sustenna)

Paliperidone palmitate 819 per 3 months NL NL (Invega Trinza) NON-Formulary

Perphenazine (Trilafon) 64 R-NR > 12 y/o: 64 (Lit)

QUEtiapine (SEROquel) 800 5 – 9 y/o: 400 (Lit) 13 – 17 y/o: 800 10–12 y/o: 800 (Lit)

risperiDONE (RisperDAL, 81 *5 to < 12 y/o: 3 6 RisperDAL M-Tab)

RisperDAL Consta 50 per 2 weeks NL NL

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 14 Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

Thioridazine (Mellaril)2 (ABSOLUTE) 800 NL NL RESERVE USE

Thiothixene (Navane) 60 NL NL

Trifluoperazine 40 NL NL (Stelazine)

Ziprasidone (Geodon) 240 10 – 11 y/o: 1603 (> 45 kg) (Lit) 803 (≤ 45 kg) 1603 (> 45 kg) (Lit)

1. Risperidone doses > 6 mg/day have increased risk of EPS 2. A boxed warning has been added to advise clinicians of prolongation of the QTc interval 3. Bipolar Disorder 4. Tourette’s Disorder 5. Bipolar I Depression

* Any approved indication Lit= Literature support NL= Not Listed. Not listed in Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version), thus not recommended. NR= Not Recommended R-NR= Reviewed, not recommended. Reviewed for Psychotropic Medication Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version) but not recommended. Reviewed October 2020 Antidepressants

Suggested maximum doses (mg/day)

Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

Amitriptyline (Elavil) 300 NL NL

buPROPion (Wellbutrin) 450 (with no 6 to < 12 y/o: Lesser of Lesser of 6 mg/kg single dose > 150) 6 mg/kg or 300 (Lit)1 or 300 (Lit)1 (with no single dose > (with no single 150) dose > 150)

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 15 Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

buPROPion SR 400 (with no ID 400 (Lit)1 (Wellbutrin SR) single dose > 200)

buPROPion XL 450 ID 450 (Lit)1 (Wellbutrin XL)

Citalopram** (CeleXA) 40 6 to < 12 y/o: 40 (Lit) 40 (Lit) 120 (OCD)

clomiPRAMINE 250 10 – 11 y/o: Lesser of 3 Lesser of 3 mg/kg (Anafranil) mg/kg or 200 mg (OCD) or 200 mg (OCD)

Desipramine 300* NL NL (Norpramin)

Doxepin (SINEquan) 300 NL NL

DULoxetine (Cymbalta) 120 7 – <12 y/o: 1203 1203

Escitalopram** 20 6 – 11 y/o: 20 (Lit) ≥ 12 y/o: 30 (Lit) (Lexapro) 60 (OCD)

FLUoxetine** (PROzac) 80 6 to < 12 y/o: 60 (Lit) 60 120 (OCD – Lit)

fluvoxaMINE (Luvox) 300 8 – 11 y/o: 200 (OCD) 12 – 17 y/o: 300 450 (OCD) (OCD)

Imipramine (Tofranil) 300* R-NR R-NR

Mirtazapine (Remeron) 45 3 to < 12 y/o: 45 (Lit) 45 (Lit)

Nortriptyline (Pamelor) 150* NL NL

PARoxetine (Paxil) 60 R-NR R-NR 100 (OCD)

Phenelzine (Nardil) 90 NL NL

Protriptyline (Vivactil) 60 NL NL NON-Formulary

Sertraline** (Zoloft) 200 ≥ 6 y/o 200 200 400 (OCD – Lit)

Tranylcypromine 60 NL NL (Parnate)

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 16 Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

traZODone (Desyrel) 600 R-NR 100 (Lit)2

Venlafaxine (Effexor) 375 R-NR R-NR

Venlafaxine XR (Effexor 225 R-NR R-NR XR)

*Plasma concentration monitoring is recommended if these doses are exceeded **Dose varies with diagnosis 1For ADHD 2For sedative hypnotic 3FDA approved GAD 120 OCD- Obessive Compulsive Disorder ID- insufficient data to suggest support regarding its efficacy or to provide maximum dosing guidelines in this patient group Lit- Literature support NL= Not Listed. Not listed in Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version), thus not recommended. NR= Not Recommended R-NR= Reviewed, not recommended. Reviewed for Psychotropic Medication Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version) but not recommended. Reviewed October 2020 Mood Stabilizers

Suggested maximum doses (mg/day)

Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

carBAMazepine 1,600 < 6 y/o: 35 mg/kg # (TEGretol, TEGretol XR, 6 to < 12 y/o: 1,000 mg (6 12 – 15 y/o: 1,000 Carbatrol) – 12 mcg/ml) > 15 y/o: 1,200

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 17 Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

lamoTRIgine (LaMICtal) With VPA: 100 6 to < 12 y/o: With VPA: 200 Monotherapy: With VPA: 1 - 3 mg/kg With VPA & EIAED: 200 With VPA & EIAED: 1 - 5 400 With EIAED: mg/kg Monotherapy: 375 400 Monotherapy: 4.5 - 7.5 With EIAED: 500 mg/kg With EIAED: 5 - 15 mg/kg

Lithium (Lithobid, < 65 y/o: # # Eskalith) 3,600 7 to < 12 y/o > 30 kg ≥ 65 y/o: 20 – 30 kg: 1,800 or 1.2 mEq/L 1,800 Acute: 1,500 (Lit) Maintenance: 1,200

OXcarbazepine 2,400 R-NR R-NR (Trileptal)

Valproic Acid/Valproate, 60 mg/kg 6 to < 10 y/o: 60 mg/kg 60 mg/kg # Divalproex (Depakene, (Lit) Depakote, Depakote ≥ 10 y/o to <12 y/o: 60 ER) mg/kg #

Plasma concentration monitoring recommended if these doses are exceeded #- Maximum daily dose typically determined by drug serum concentration and individual patient tolerability Lit- Literature support EIAED- Enzyme inducing anti-epileptic drugs (e.g., carbamazepine, phenobarbital, phenytoin, primidone) VPA- valproic acid-valproate R-NR= Reviewed, not recommended. Reviewed for Psychotropic Medication Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version) but not recommended. Reviewed October 2020

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 18 Stimulants

Suggested maximum doses (mg/day)

Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

Amphetamine Mixture 60 > 3 y/o: 40 (FDA) ≤ 50 kg: 40 (Adderall) 3-5 y/o: 30 (Lit) > 50 kg: 60 (Lit) ≥ 6 y/o: ≤ 50 kg: 40 > 50 kg: 60 (Lit)

Amphetamine Mixture 60 ≥ 6 y/o: ≤ 50 kg: 30 (Adderall XR) ≤ 50 kg: 30 > 50 kg: 60 (Lit) > 50 kg: 60 (Lit)

Dexmethylphenidate, 40 ≥ 6 y/o: 50 (Lit) 50 (Lit) extended release (Focalin XR)

Dextroamphetamine 60 3-5 y/o: 30 (FDA) ≤ 50 kg: 40 immediate release 3 – 5 y/o: 30 (Lit) > 50 kg: 60 (Lit) (Dexedrine) ≥ 6 y/o: ≤ 50 kg: 40 (Lit) > 50 kg: 60 (Lit)

Dextroamphetamine 60 ≥ 6 y/o: ≤ 50 kg: 40 extended release, ≤ 50 kg: 40 (Lit) > 50 kg: 60 (Lit) Dexedrine Spansules > 50 kg: 60 (Lit)

Lisdexamfetamine 70 6 – <12 y/o: 70 70 (Vyvanse)

Methylphenidate, 60 3 – 5 y/o: 22.5 (Lit) ≤ 50 kg: 60 immediate release ≥ 6 y/o: > 50 kg: 100 (Lit)* (Ritalin, Methylin, ≤ 50 kg: 60 Metadate), sustained > 50 kg: 100 (Lit)* release (Ritalin XR)

Methylphenidate, 72 3-5 y/o: 36 (Lit) 12 y/o: 72 (Lit) sustained release, ≥ 6 y/o: 72 (Lit) ≥ 13 y/o: 72 osmotic release (Concerta)

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 19 * Any dose exceeding 60 mg/day should be used with caution and with attentive monitoring Reviewed October 2020 Miscellaneous Drugs Used for Psychotropic Purposes

Suggested maximum doses (mg/day)

Drug Adult Child (< 12 y/o) Adolescent (12 y/o to < 18 y/o)

atoMOXetine (Strattera) 100 ≥ 6 y/o: whichever is Whichever is less 1.8 less 1.8 mg/kg or 100 mg/kg or 100 (Lit) (Lit)

cloNIDine (Catapres) 0.4 ≥ 6 y/o: (> 45 kg) 0.4 (27 – 40.5 kg) 0.2 # (Lit) (40.5 – 45 kg) 0.3 # (Lit)

cloNIDine Extended 0.4 ≥ 6 y/o: 0.4* 0.4 Release (Kapvay) NON- Formulary

guanFACINE (Tenex) 4 ≥ 6 y/o: (> 45 kg) 4 (27 – 40.5 kg) 2 # (Lit) (40.5 – 45 kg) 3 # (Lit)

guanFACINE Extended ID 6 - 12 y/o: 4* 12 y/o: 4 Release (Intuniv) ≥ 13 y/o: 7

Naltrexone (ReVia) 200 NL LO

Naltrexone microspheres 380 per 4 weeks NL LO (Vivitrol) RESERVE USE

Propranolol (Inderal) 160 NL NL (anxiety)***

*Not studied in children < 6 years old ***Maximum dose has not been determined for aggression or self-injurious behavior (SIB) #For ADHD Lit- Literature support ID= Insufficient data to suggest support regarding its efficacy or to provide maximum dose guidelines for this patient population. LO= Limited options for treating opioid use disorder in Adolescents. Federal laws apply.

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 20 NL= Not Listed. Not listed in Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version), thus not recommended. Reviewed October 2020 Anxiolytics

Suggested maximum doses (mg/day)

Drug Under 65 years 65 years and over (mg/day) (mg/day)

ALPRAZolam (Xanax) 4 2 (exception: for panic (10) N/A disorder)

busPIRone (BuSpar) 60 60

chlordiazePOXIDE (Librium) 100* 40*

clonazePAM (KlonoPIN) 4^ 4^

Clorazepate (Tranxene) 60 30

diazePAM (Valium) 60 20

LORazepam (Ativan) 10* 3*

Oxazepam (Serax) 90 60

*Larger doses may be necessary in some cases of alcohol-substance withdrawal. 1Long acting benzodiazepines are not recommended in the geriatric population. ^doses up to 20 mg have been used to treat seizure disorders Reviewed October 2020

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 21 Hypnotics

Suggested maximum doses (mg/day)

Drug Under 65 65 years and Child Adolescent years older (< 12 y/o) (12 y/o to < (mg/day) (mg/day) 18 y/o)

∆*diphenhydrAMINE 300 300 25 – 37 lb: 50 – 99 lb: 25 (Benadryl) 12.5 ≥ 100 lb: 50 38-49 lb: 19 (Lit) 50 – 99 lb: 25 >12 y/o: 50 ≥ 100 lb: 50 (FDA) (Lit)

∆Eszopiclone 3 2 R-NR R-NR (Lunesta)

∆hydrOXYzine 400 300 <6 y/o: 50 > 12 y/o: 100 (Atarax, Vistaril) >6 y/o: 100 (Lit) (Lit)

∆Temazepam 30 15 R-NR R-NR (Restoril)

traZODone 200 150 R-NR 100 (Lit) (Desyrel)

∆Triazolam 0.25 0.125 NL NL (Halcion) (0.5) (0.25) (Conscious sedation dosing)

∆Zolpidem Males: 10 5 R-NR R-NR (Ambien) Females: 5

*Evidence suggests that tolerance develops to the hypnotic effects within 5 – 7 nights of continuous use ∆Medication found on the 2019 American Geriatrics Society (AGS) Beers Criteria Medication List NL= Not Listed. Not listed in Psychotropic Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version), thus not recommended. R-NR= Reviewed, not recommended. Reviewed for Psychotropic Medication Medication Utilization Parameters for Children and Youth in Texas Public Behavioral Health (6th Version) but not recommended.

Reviewed October 2020

Texas HHS Psychiatric Drug Formulary 2021

Psychotropic Dosage Guidelines 22 Reserve Drugs

The purpose of the reserve drug class is to stimulate thought and promote care in prescribing. Discussions and interaction with other prescribers is strongly encouraged. When reserve status drugs are utilized, documentation of justification in the patient’s progress notes is mandated. To assist the prescriber, specific guidelines have been developed by the HHSC Psychiatric Executive Formulary Committee for use of each drug so classified. The guidelines will be used to audit the appropriate use of reserve drugs. Based on the audit results, continuing education will be developed and targeted as needed.

Drug Guidelines for Use

ARIPiprazole To be used if the patient has demonstrated tolerability to ARIPiprazole Initio (Aristada) through either a two-week trial of oral ARIPiprazole or a history of ARIPiprazole LAI use

Adenosine To be used in an ECT suite or under the direction of an anesthesiologist (Adenocard)

Betamethasone To be used under the direction of a dermatologist dipropionate, augmented (Diprolene A/F)

Buprenorphine 1. Admitted on the drug and the medication is continued. Use must be (Subutex) verified with the treating physician/clinic. 2. If initiated, the prescribing physician must meet the Drug Addiction Treatment Act (DATA) criteria and thus have been assigned a Unique Identification Number (or “X” number).

Buprenorphine- 1. Admitted on the drug and the medication is continued. Use must be naloxone verified with the treating physician/clinic. (Suboxone) 2. If initiated, the prescribing physician must meet the Drug Addiction Treatment Act (DATA) criteria and thus have been assigned a Unique Identification Number (or “X” number).

Cannabidiol 1. To be used in patients with a diagnosis of Lennox-Gastaut syndrome or (Epidiolex) Dravet syndrome; and 2. Having treatment-resistant seizures after failed trials of adequate dose and duration of two other antepileptic agents; and 3. When recommended by a neurologist.

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 23 Drug Guidelines for Use

Celecoxib 1. Patients with a history of serious gastrointestinal complications with (CeleBREX) nonselective-NSAID use; or 2. Those patients with ongoing gastrointestinal complications in whom NSAID therapy is necessary.

CloBAZam (Onfi) To be used for the treatment of seizures

Clobetasol To be used under the direction of a dermatologist (Temovate)

cloZAPine 1. For use in patients with refractory schizophrenia or schizoaffective (Clozaril, Fazaclo, disorder [defined as failure on two antipsychotics from two different Versacloz) chemical families given for sufficient time (6-12 weeks) at a sufficient dose (1,000 mg/day of chlorpromazine equivalents); or 2. For use in schizophrenic or schizoaffective patients who cannot tolerate other antipsychotics; or 3. Psychosis associated with other organic conditions who have failed two antipsychotics or who cannot tolerate other antipsychotics; or 4. Manic disorders with psychosis in patients who have failed two antipsychotics 5. Reduction in the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective

Diclofenac Gel Oral therapy is deemed too risky due to cardiac and gastrointestinal (Voltaren Gel) complications, or; Other topical therapies have proven to be ineffective

DOPamine To be used in an ECT Suite or under the direction of an anesthesiologist (Inotropin)

Epoetin alfa When recommended by a consultant physician (Epogen, Procrit)

Esketamine 1. All REMS requirements must be followed. (Spravato) 2. The patient must have a history of three failed antidepressant trials of adequate dose and duration involving more than one class of antidepressant. 3. The patient’s blood pressure must be monitored for two hours post administration. 4. The patient should have a depressive episode rating of severe as measured using the Montgomery-Asberg Depression Rating Scale (MADRS). 5. The severity of the depression should be measured using the MADRS at baseline and then weekly for the duration of treatment with esketamine nasal spray.

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 24 Drug Guidelines for Use

Felbamate Weekly progress note by physician monitoring for response and adverse (Felbatol) effects for at least two weeks following initiation of therapy

Iloperidone For use in patients that have failed on two antipsychotics given for a (Fanapt) sufficient time; or for patients who cannot tolerate other antipsychotics due to akathisia

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 25 Ketamine 1. A comprehensive diagnostic assessment should be completed to (Ketalar) establish current diagnosis and evaluate history of substance use and psychotic disorders. 2. Assessment of baseline symptom severity should be completed to allow later assessments of clinical change with treatmenta. 3. A thorough history of antidepressant treatment should be collected and documented to confirm previous adequate trials of antidepressant treatments. 4. A thorough review of systems should be performed to evaluate potential risk factors associated with ketamine treatmentb. 5. Decisions on the specific physical examination and laboratory screening assessments should be made according to established guidelines and advisories issued by the American College of Cardiology Foundation/American Heart Association and the American Society of Anesthesiologists and should be based on a patient’s individual clinical characteristicsc. 6. A careful review of past medical and psychiatric records and/or corroboration of the past history by family members are strongly encouraged; all current medications and allergies should be reviewed, including histories of opiate and benzodiazepine use; the use of a baseline urine toxicology screen is strongly encouraged to ensure the accuracy of the reported substance use and medication record. 7. An informed consent process, including discussion of the risks associated with the treatmentPdP, the limits of the available information pertaining to the potential benefits of the treatment, the fact that this is an off-label use of ketamine, and a discussion of alternative treatment options should be completed; this discussion should be complemented with written materials, and the patient should provide written informed consent before initiating treatment. a Self-report versions of the Inventory of Depressive Symptomatology and Quick Inventory of Depressive Symptomatology (http://counsellingresource.com/quizzes/depression-testing/qids-depression/) are examples of scales that are available at no cost to clinicians and researchers. b This review should also include questions pertaining to functional exercise capacity, which has been demonstrated to provide a good screening tool for patients that are at increased risk for adverse events associated with anesthesia exposure and surgical procedures. c American College of Cardiology Foundation and the American Heart Association guidelines for perioperative cardiovascular evaluation and

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 26 Drug Guidelines for Use

management of patients undergoing noncardiac surgery and practice advisory from the American Society of Anesthesiologists. d The Ketalar package insert provides essential information related to risk of ketamine administration.

Linaclotide Patients who are receiving enteral nutrition or who require a modified diet (Linzess) texture

Linezolid (Zyvox) When recommended by a consultant physician

Lisdexamfetamine Continued therapy on admission; or (Vyvanse) Failed other stimulants

Mirabegron Unable to tolerate anticholinergic medications (Myrbetriq)

Moxifloxacin For bacterial conjunctivitis where MRSA or gram negative microorganisms (Moxeza, is identified or suspected. Vigamox)

Nabumetone For the treatment of chronic osteoarthritis or chronic rheumatoid arthritis (Relafen)

Naloxone To be dispensed only as a discharge medication for patients that have (Narcan) Nasal been determined to be at risk of an opiate overdose. spray

Naltrexone (ReVia Not to be used for the treatment of opioid use disorders.

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 27 Drug Guidelines for Use

Naltrexone 1. For those that are not candidates for or who have not responded to or microspheres tolerated other available formulary therapies for alcohol use disorders (Vivitrol)- and do not have a contraindication to the use of extended release naltrexone. Or For those with opioid use disorder for whom opioid agonist treatment (buprenorphine/naloxone, methadone) is contraindicated, unacceptable, unavailable, or discontinued and who have established abstinence for a sufficient period of time. 2. Failure of at least a 30-day trial of oral naltrexone may be considered before use of extended release naltrexone. 3. Use should be part of a comprehensive management program that includes psychosocial support for the specific substance use. 4. FDA REMS process must be followed which includes review of the potential risks associated with extended release naltrexone use. 5. Medication Guide must be provided to patients before each administration. 6. Monitor closely for treatment emergent depression and/or suicidal ideation. 7. Those with serious mental illness should be monitored closely for exacerbation of psychiatric symptoms including psychosis, mania or depression during treatment with extended release naltrexone. 8. Initiate only after a 7-14-day opioid-free interval, negative urine drug screen for opiates, and negative naloxone challenge test. 9. Other required monitoring includes liver function tests, baseline and periodic serum creatinine and assessment of CrCl, pregnancy test in females of child bearing potential, signs and symptoms of opioid withdrawal, injection site reactions. 10.The patient must be given a safety bracelet and wallet card that indicates treatment with extended release naltrexone in case of emergency. 11.Hospital use requires MHA approval prior to initiation.

Norepinephrine or To be used in an ECT Suite or under the direction of an anesthesiologist. Levarterenol (Levophed)

OLANZapine 1. Written approval by the Hospital Clinical Director and the local mental pamoate health authority clinical director prior to initiation of therapy with (ZyPREXA olanzapine pamoate Relprevv) 2. Compliance with the Risk Evaluation and Mitigation Strategy (REMS)

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 28 Drug Guidelines for Use

Olmesartan In cases of drug shortages of formulary ARBs. (Benicar)

Ophthalmic Consultation with an Ophthalmologist or Therapeutic Optometrist prior to agents containing initiation. a steroid

Pentamidine 1. Prophylaxis post-treatment of documented Pneumocystis carinii (Pentam) pneumonia; or 2. Prophylaxis of Pneumocystis carinii in patients with CD4 counts less than 200

Thioridazine 1. Indicated only for patients with refractory schizophrenia (failed other (Mellaril) classes of antipsychotics) 2. EKG prior to initiating therapy: 7 – 14 days after dose change; 7 – 14 days after other medication changes that could significantly alter the cardiac effects of Thioridazine; every six months; and as clinically indicated 3. Potassium level prior to initiating therapy; every six months; and as clinically indicated 4. Magnesium level prior to initiating therapy; and as clinically indicated (especially if potassium level is low)

tiZANidine 1. Documented failure or intolerance to baclofen (Zanaflex) 2. Liver enzymes obtained at baseline, 1, 3, and 6 months and at least annually 3. Documentation of efficacy after one month of therapy 4. The dose should be decreased in severe renal dysfunction (CrCl <25 mL/min)

Texas HHS Psychiatric Drug Formulary 2021

Reserve Drugs 29 Therapeutic Reference Ranges

Drug Therapeutic Reference Range

Amitriptyline 80 - 200 ng/mL1,2 Depression: 125 - 210 ng/mL3

carBAMazepine 4 – 12 mcg/mL1,3 Mood: 4 – 10 mcg/mL Anticonvulsants: 4 - 12 mcg/mL 2

cloZAPine 350 – 600 ng/mL1,2 350 - 450 ng/mL3

Desipramine 100 – 300 ng/mL1,2,3

Doxepin 50 - 150 ng/mL1,2 greater than 100 ng/mL3

Ethosuximide 40 – 100 mcg/mL1,2

fluPHENAZine 1 – 10 ng/mL1,2 0.2 - 2.8 ng/mL3

Haloperidol 1 – 10 ng/mL1,2 5 - 15 ng/mL3

Imipramine 175 - 300ng/mL1,2 Endogenous depression: greater than 200 ng/mL prepubertal depressive symptoms: 200 - 225 ng/mL3

lamoTRIgine Bipolar Disorder: 1 – 6 mcg/mL1,2 Epilepsy: 3 – 15 mcg/mL1,2 Seizure Disorder: 3 - 35 mcg/mL3

Lithium 0.5 - 1.2 mmol/L2 Acute Mania: 0.8 - 1.2 mEq/L1 Acute Mania: 1 - 1.5 mEq/L3 Maintenance: 0.6 - 1.0 mEq/L1 Maintenance: 0.6 - 1.2 mEq/L3 Depression: 0.6 - 1.0 mEq/L1 Depression: 0.3 - 0.6 mEq/L3

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Reference Ranges 30 Drug Therapeutic Reference Range

Nortriptyline 70 - 170 ng/mL1,2 50 - 150 ng/mL3

OLANZapine 20 – 80 ng/mL1,2

Perphenazine 0.6 - 2.4 ng/mL2 2 - 6 nmol/L3

PHENobarbital 10 – 40 mcg/mL1,2

Thioridazine 100 – 200 ng/mL2

Phenytoin 10 – 20 mcg/mL1,2

Valproic Acid/Valproate, Divalproex 50 - 100mcg/mL2,3 Epilepsy: 50 – 100 mcg/mL1,3 Bipolar Disorder: 50 – 125 mcg/mL1,3 Mood: 50 - 100 mcg/mL3

Specific Labs may have different reporting ranges based on lab variability and source data. Serum concentrations are useful in the evaluation of therapy. However, they should only be considered as a guide to treatment, not the sole criterion for determination of dosage regimens.

The following anticonvulsants do not have an established therapeutic serum concentration range. Routine monitoring of these anticonvulsants is not warranted as serum concentrations cannot be correlated with clinical efficacy.

Benzodiazepines cloBAZam RESERVE USE Gabapentin Lacosamide levETIRAcetam OXcarbazepine Pregabalin Rufinamide tiaGABine Topiramate Zonisamide

Sources: 1Lexicomp accessed 11/2020 2Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017 (Pharmacopsychiatry 2018; 51:9-62) 3Micromedex accessed 11/2020

Reviewed January 2021

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Reference Ranges 31 Alphabetical Listing

Acamprosate (Campral) Tablet, delayed release

Acetaminophen (Tylenol) Capsule, oral Liquid, oral Suppository, rectal Tablet, oral Tablet, chewable, oral

Acetaminophen-Codeine C-III Liquid, oral: Acetaminophen 120 mg-Codeine 12 mg per 5 ml (C-V) Tablet: #2: Acetaminophen 300 mg-Codeine 15 mg #3: Acetaminophen 300 mg-Codeine 30 mg #4: Acetaminophen 300 mg-Codeine 60 mg

Acetaminophen-HYDROcodone (Lortab, Vicodin, Vicodin ES) C-II Elixir: Acetaminophen 300 mg- HYDROcodone 10 mg per 15 mL Acetaminophen 325 mg- HYDROcodone 7.5 mg per 15 mL Acetaminophen 325 mg- HYDROcodone 10 mg per 15 mL Tablet: Acetaminophen 300 mg- HYDROcodone 5 mg Acetaminophen 300 mg- HYDROcodone 7.5 mg Acetaminophen 300 mg- HYDROcodone 10mg Acetaminophen 325 mg- HYDROcodone 2.5 mg Acetaminophen 325 mg- HYDROcodone 5 mg Acetaminophen 325 mg- HYDROcodone 7.5 mg Acetaminophen 325 mg- HYDROcodone 10 mg

AcetaZOLAMIDE (Diamox) Capsule, sustained release, oral Tablet, oral

Acetic Acid Solution, otic

Acetic Acid-Hydrocortisone (VoSol HC) Solution, otic

Acetylcysteine Solution, inhalation

Acyclovir (Zovirax) Capsule, oral Cream, topical

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 32 Powder for injection Ointment, topical Suspension, oral Tablet, oral

Adapalene (Differin) Cream, topical Gel, topical

Adenosine (Adenocard)- RESERVE USE Injection

Albuterol (ProAir Respiclick, Proventil, Ventolin) Aerosol, oral inhalation, HFA Powder, oral inhalation (ProAir Respiclick) Nebulization solution, oral inhalation Tablet, oral

Albuterol-Ipratropium (Combivent) Nebulization solution, oral inhalation Solution, oral inhalalation (Combivent Respimat)

Alendronate (Fosamax, Binosto) Solution, oral Tablet, oral Tablet, effervescent, oral

Allopurinol (Zyloprim) Tablet, oral

ALPRAZolam (Xanax, Xanax XR) C-IV Tablet, oral Tablet, sustained release, oral

Aluminum Chloride Hexahydrate (Drysol) Liquid, topical

Aluminum Hydroxide Suspension/gel, oral

Aluminum Hydroxide-Magnesium Trisilicate (Gaviscon) Tablet, chewable, oral Suspension, oral

Aluminum Hydroxide-Magnesium Hydroxide (Maalox) Suspension, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 33 Aluminum Hydroxide-Magnesium Hydroxide-Simethicone (Mylanta) Suspension, oral Tablet, oral

Amantadine Capsule, oral Syrup, oral

Amikacin Injection

Amino Acid Injection (Aminosyn) Infusion

Amino Acid Injection-Dextrose-Electrolytes (Clinimix E) Infusion

Amiodarone (Pacerone, Cordarone) Tablet, oral

Amitriptyline (Elavil) Tablet, oral amLODIPine (Norvasc) Tablet, extended release, oral

Amoxicillin (Amoxil, Polymox) Capsule, oral Powder for suspension, oral Tablet, oral Tablet, chewable, oral

Amoxicillin-Clavulanate (Augmentin) Suspension, oral Tablet, oral Tablet, chewable, oral Tablet, extended release, oral

Amphetamine Mixture (Adderall, Adderall XR) CII Capsule, extended release, oral Tablet, oral

Ampicillin (Polycillin, Omnipen) Capsule, oral Powder for suspension, oral Powder for injection

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 34 Antineoplastic Agents In consultation with the oncologist or field specialist

Antiviral Agents All commercially available antiviral agents used in the treatment of AIDS/HIV are considered to be formulary agents

Apixaban (Eliquis) Tablet, oral

ARIPiprazole (Abilify, Abilify discmelt, Abilify Maintena, Aristada, Aristada Initio) Injection, extended release (Maintena): 300 mg, 400 mg Injection, extended release (Aristada): 441 mg, 662 mg, 882 mg, 1,064 mg Injection, extended release (Aristada Initio): 675 mg RESERVE USE Solution, oral Tablet, oral Tablet, rapid dissolving, oral

Ascorbic Acid (Vitamin C) Solution, oral Tablet, oral Tablet, chewable, oral

Asenapine (Saphris) Tablet, sublingual

Aspirin Caplet, oral Suppository, rectal Tablet, oral Tablet, buffered, oral Tablet, chewable, oral Tablet, enteric coated, oral

Aspirin-Acetaminophen-Caffeine (Excedrin Migraine) Tablet, oral

Atenolol (Tenormin) Tablet, oral atoMOXetine (Strattera) Capsule, oral atorvaSTATin (Lipitor) Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 35 Atropine Sulfate (Isopto Atropine) Ointment, ophthalmic Solution, ophthalmic

Azelastine Spray, nasal inhalation

Azithromycin (Zithromax) Powder for solution, oral Tablet, oral

Bacitracin Injection Ointment, ophthalmic Ointment, topical

Bacitracin-Polymyxin B (Polysporin) Ointment, ophthalmic Ointment, topical

Baclofen Tablet, oral

Balanced Salt Solution Ophthalmic Irrigating Solution (BSS, Eye Stream) Solution, ophthalmic

Beclomethasone, (QVAR Redihaler, Beconase) Aerosol, oral inhalation Suspension, nasal inhalation

Benazepril (Lotensin) Tablet, oral

Benzocaine (Lanacaine, Cepacol, Orajel) Topical, dermatologic Cream, topical Ointment Spray Topical, Mouth-Throat preparations: Gel Liquid Lozenge

Benzoin, Compound Tincture Tincture, topical (may also contain aloe, storax, tolu balsam, 74% to 80% alcohol)

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 36 Benzonatate Capsule, oral

Benzoyl Peroxide Gel, topical Liquid, topical Wash, topical

Benzoyl Peroxide-Clindamycin (BenzaClin) Gel, topical: Benzoyl Peroxide 5%-Clindamycin 1%

Benztropine (Cogentin) Injection Tablet, oral

Betamethasone dipropionate (Diprolene) Cream, topical Lotion, topical Ointment, topical

Betamethasone dipropionate, augmented (Diprolene A/F)- RESERVE USE Cream, topical Gel, topical Lotion, topical Ointment, topical

Betamethasone Valerate (Valisone) Cream, topical Lotion, topical Ointment, topical

Betaxolol (Betoptic S) Solution, ophthalmic Suspension, ophthalmic

Bethanechol (Urecholine) Tablet, oral

Bimatoprost (Lumigan) Solution, ophthalmic

Bisacodyl (Dulcolax) Suppository, rectal Tablet, enteric coated, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 37 Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Liquid, oral Tablet, chewable, oral

Brexpiprazole (Rexulti) Tablet, oral

Brimonidine (Alphagan P) Solution, ophthalmic

Bromocriptine Capsule, oral Tablet, oral

Brompheniramine-Phenylephrine (Dimetapp Children’s Cold and Allergy) Liquid, oral

Brompheniramine-Pseudoephedrine, Rynex PSE) Liquid, oral

Budesonide (Pulmicort) Nebulization suspension, oral inhalation Powder, oral inhalation

Budesonide-Formoterol (Symbicort) Aerosol, oral inhalation

Buprenorphine (Subutex)- RESERVE USE Tablet, sublingual

Buprenorphine-naloxone (Suboxone)- RESERVE USE Film, sublingual Tablet, sublingual buPROPion (Budeprion, Wellbutrin, Zyban) Tablet, oral Tablet, sustained release, oral Tablet, extended release, oral busPIRone (BuSpar) Tablet, oral

Calamine-Zinc Oxide-Glycerin (Calamine Lotion) Lotion, topical

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 38 Calamine-Pramoxine (Caladryl) Lotion, topical

Calcipotriene (Dovonex) Cream, topical Ointment, topical Solution, topical

Calcitonin-Salmon (Miacalcin) Spray, Nasal inhalation

Calcium Carbonate (Os-Cal, Tums) [40% elemental calcium] Suspension, oral Tablet, oral Tablet, oral, chewable

Calcium Carbonate-Vitamin D3 (Os-Cal + D, Os-Cal chewable) Tablet, oral Tablet, chewable, oral

Calcium Citrate (Citracal) [20% elemental calcium] Tablet, oral

Calcium Citrate-Vitamin D3 (Citracal-D) Tablet, oral

Camphor-Phenol (Campho-Phenique) Liquid, topical: Camphor 10.8%-Phenol 4.7% [with eucalyptus oil and mineral oil]

Canagliflozin (Invokana) Tablet, oral

Cannabidiol (Epidiolex) C-V RESERVE USE Solution, oral

Captopril (Capoten) Table, oral carBAMazepine (TEGretol, TEGretol XR, Carbatrol) Capsule, extended release 12 h, oral Suspension, oral Tablet, oral Tablet, chewable, oral Tablet, extended release 12 hr, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 39 Carbamide Peroxide (Debrox, Gly-Oxide) Solution, mouth/throat mucous membrane Solution, otic

Carbidopa-Levodopa (Sinemet) Tablet, oral: Tablet, Sustained release, oral

Carboxymethylcellulose Liquigel, ophthalmic

Cariprazine (Vraylar) Capsule, oral

Carvedilol (Coreg, Coreg CR) Tablet, oral Capsule, extended release 24 hr, oral ceFAZolin (Kefzol) Injection

Cefdinir (Omnicef) Capsule, oral Powder for suspension, oral

Cefepime (Maxipime) Injection cefTRIAXone (Rocephin) Solution premixed in dextrose for injection Powder for injection

Cefuroxime Axetil (Ceftin) - Oral form only - Tablet, oral

Celecoxib (CeleBREX)- RESERVE USE Capsule, oral

Cellulose (Unifiber) Powder, oral

Cephalexin (Keflex) Capsule, oral Powder for suspension, oral Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 40 Cetirizine (ZyrTEC) Syrup, oral Tablet, oralt

Cetirizine-Pseudoephedrine (ZyrTEC D) Tablet, 12hr, oral chlordiazePOXIDE (Librium) - oral form only - C-IV Capsule, oral

Chlorhexidine (Peridex) Liquid, topical, with 4% isopropyl alcohol Rinse, oral, with 12% alcohol

Chlorpheniramine Syrup, oral Tablet, oral Tablet, timed release, oral chlorproMAZINE (Thorazine) Injection Tablet, oral

Chlorthalidone Tablet, oral

Cholecalciferol (Calcitrol, Rocaltrol) See Vitamin D3

Cholestyramine **Product may contain phenylalanine** Powder, oral Powder for oral suspension light (aspartame)

Ciclopirox (Loprox, Penlac) Cream, topical Shampoo, topical Solution, topical

Ciprofloxacin (Cipro, Ciloxan) Injection Ointment, ophthalmic Solution, ophthalmic Suspension, oral Table, oral

Ciprofloxacin-Dexamethasone (Ciprodex)

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 41 Suspension, otic

Ciprofloxacin-Hydrocortisone (Cipro Otic) Solution, otic

Citalopram (CeleXA) Solution, oral Tablet, oral

Clarithromycin (Biaxin) Granules for suspension, oral Tablet, film coated, oral

Clindamycin (Cleocin, Cleocin T) Capsule, oral Gel, topical Granules for solution, oral Injection Lotion, topical Solution, topical cloBAZam (Onfi) C-IV RESERVE USE Suspension, oral Tablet, oral

Clobetasol (Temovate, Cormax, Clobex)- RESERVE USE Cream, topical Cream, topical, in emollient base Gel, topical Lotion, topical Ointment, topical Solution, topical scalp application clomiPRAMINE (Anafranil) Capsule, oral clonazePAM (KlonoPIN) C-IV Tablet, oral Tablet, oral disintegrating, oral cloNIDine (Catapres) Patch, weekly transdermal Tablet, oral

Clopidogrel (Plavix) Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 42 Clorazepate (Tranxene) C-IV Tablet, oral

Clotrimazole (Lotrimin, Gyne-Lotrimin Cream, topical Cream, vaginal Solution, topical Troche, oral

Clotrimazole-Betamethasone dipropionate (Lotrisone) Cream, topical cloZAPine (Clozaril, Fazaclo, Versacloz)- RESERVE USE Suspension, oral Tablet, oral Tablet, oral disintegrating, oral

Coal Tar Shampoo, topical Solution, topical

Cod Liver Oil-Zinc Oxide-Talc (Desitin) Ointment, topical: Zinc Oxide 40% [with Cod Liver Oil, Talc, Petrolatum, Lanolin, and Methylparaben]

Colchicine Tablet, oral

Collagenase (Santyl) Ointment, topical

Oral Contraceptives All commercially available oral contraceptive agents are considered to be formulary agents

Cromolyn Solution, ophthalmic

Cyanocobalamin (Vitamin B12) Injection Tablet, oral Tablet, sublingual

Cyclobenzaprine Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 43 Cyproheptadine (Periactin) Syrup, oral Tablet, oral

Dantrolene (Dantrium) Capsule, oral Powder for injection

Dapsone Tablet, oral

Darifenacin (Enablex) Tablet, extended release 24 hour, oral

Denosumab (Prolia) Injection

Desipramine (Norpramin) Tablet, oral

Desmopressin (DDAVP, Stimate) Injection Solution, nasal inhalation Tablet, oral

Desonide (Desowen, Tridesilon) Cream, topical Lotion, topical Ointment, topical

Dexamethasone Injection, as sodium phosphate Solution, oral Suspension, ophthalmic RESERVE USE Tablet, oral

Dexmethylphenidate, extended release (Focalin XR) CII Capsule, oral, extended release

Dextroamphetamine (Dexedrine, Dexedrine spansules) C-II Capsule, extended release 24 hr, oral Tablet, oral

Dextromethorphan Any combination of drugs with dextromethorphan are on Formulary as long as the individual ingredients are on the Formulary and the dosage form is listed as being on formulary.

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 44 Capsule, oral Liquid, oral Liquid, sustained release, oral Lozenge, oral

Dextrose 5%-Sodium Chloride Intravenous Solution Infusion

Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution Infusion

Dextrose 5% in Water Infusion

Dextrose 5% in Ringer's Lactate Infusion

Dextrose 50% in Water Infusion Syringe Vials

Diaper Rash Ointment

Diaper Rash Powder (Mexsana) Powder, topical: contains kaolin, eucalyptus oil, camphor, corn starch, lemon oil, zinc oxide diazePAM (Valium, Diastat) C-IV Gel, rectal Injection Solution, oral Tablet, oral

Diclofenac Gel (Voltaren Gel)- RESERVE USE Gel, topical

Dicyclomine (Bentyl) Capsule, oral Injection Syrup, oral Tablet, oral

Digoxin (Lanoxin) Elixir, oral Injection Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 45 dilTIAZem (Cardizem) Capsule, extended release 12 hr: Generic: 60 mg, 90 mg, 120 mg Capsule, extended release 24 hr: Generic: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Cardizem CD: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg Tiazac: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Diltiazem CD: 120 mg, 180 mg, 240 mg Tablet: Generic: 30 mg, 60 mg, 90 mg, 120 mg Cardizem: 30 mg, 60 mg, 120 mg Tablet, sustained release 24 hr: Generic: 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Cardizem LA 24 hr: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diphenhydrAMINE (Benadryl) Capsule, oral Cream, topical Injection Liquid, oral Tablet, oral

Diphtheria-Tetanus Toxoids Adsorbed (DT) Injection, single dose

Diphtheria-Tetanus Toxoids Adsorbed for Adult Use (Td) Injection, single dose

Diphtheria-Tetanus-Acellular Pertussis (Tdap, Boostrix, Adacel) Injection, single dose

Disulfiram (Antabuse) Tablet, oral

Divalproex (Depakote, Depakote ER) Capsule, delayed release sprinkles, oral Tablet, delayed release, oral Tablet, extended release 24 hr, oral

Docusate Calcium (Surfak) Capsule, oral

Docusate Sodium (Colace) Capsule, oral Liquid, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 46 amitizDocusate Sodium-Sennosides (Peri-Colace) Tablet, oral

Donepezil (Aricept) Tablet, oral Tablet, oral disintegrating

DOPamine (Intropin)- RESERVE USE Infusion in D5W Injection

Doxepin (SINEquan, Zonalon) Capsule, oral Concentrate, oral

Doxycycline (Vibramycin) Capsule, oral Powder for suspension, oral Tablet, oral

DULoxetine (Cymbalta) Capsule, delayed release, oral

Emollient Gel Gel, topical

Emollient Lotion-Cream (Lubriderm, Keri Lotion, Cetaphil, Eucerin, Nutraderm) Cream, topical Lotion, topical

Emollient Ointment (Lanolin, Aquaphor) Ointment, topical

Empagliflozin (Jardiance) Tablet, oral

Enalapril (Vasotec) Tablet, oral

Enoxaparin (Lovenox) Injection

Entacapone (Comtan) Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 47 EPINEPHrine (Adrenalin, EpiPen) Auto-injector Injection

Epoetin alfa (Epogen, Procrit)- RESERVE USE Injection

Ergocalciferol (Calciferol, Drisdol)

See Vitamin D2

Erythromycin Erythromycin base (Eryc, Erythrocin): Capsule, delayed release, oral Tablet, film coated, oral Erythromycin Ethylsuccinate (EryPed, E.E.S.): Granules/Powder for oral suspension Suspension, oral Tablet, oral Ointment, ophthalmic

Erythromycin-Benzoyl Peroxide (Benzamycin) Gel, topical: Erythromycin 3%-Benzoyl Peroxide 5% (with 20% alcohol)

Escitalopram (Lexapro) Solution, oral Tablet, oral

Esketamine (Spravato) C-III RESERVE USE Spray, nasal

Esomeprazole (NexIUM) Capsule, oral Suspension packet, oral

Estradiol (Estrace, Vivelle, Alora, Climara, Estraderm, Vagifem) Cream, vaginal Systems, transdermal Tablet, oral Tablet, vaginal

Estrogen-medroxyPROGESTERone (PremPro, Premphase) Tablet, oral

Estrogens, Conjugated (Premarin) Cream, vaginal Injection

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 48 Tablet, oral

Ethambutol (Myambutol) Tablet, oral

Ethionamide (Trecator) Tablet, sugar coated, oral

Ethosuximide (Zarontin) Capsule, oral Syrup, oral

Ethyl Chloride Spray, topical

Famotidine (Pepcid) Injection Powder for oral suspension Tablet, oral

Felbamate (Felbatol)- RESERVE USE Suspension, oral Tablet, oral

Fenofibrate (Antara, Lofibra, Tricor, Triglide) Capsule, oral Capsule, micronized, oral Tablet, oral Tablet, nanocrystallized, oral fentaNYL (Duragesic) C-II Patch, transdermal

Ferrous Fumarate-Docusate Sodium (Ferro-Sequels)[contains 33% elemental iron] Tablet, timed released, oral

Ferrous Sulfate (Feosol, Fer-In-Sol) [contains 20% elemental iron] Elixir with 5% alcohol, oral Tablet, oral Tablet, extended release, oral

Fexofenadine (Allegra) Tablet, oral

Fexofenadine - Pseudoephedrine (Allegra-D) Tablet, extended release 12 hour, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 49 Tablet, extended release 24 hour, oral

Finasteride (Proscar) Tablet, oral

Fish Oil (Nature Made Fish Oil NUTRITIONAL SUPPLEMENT) Capsule, oral

Fluconazole (Diflucan) Suspension, oral Tablet, oral

Fludrocortisone Tablet, oral

Fluocinolone (Capex, Derma-Smooth/FS, Synalar) Cream, topical Oil, topical Ointment, topical Shampoo Solution, topical

Fluocinonide Cream, topical Gel, topical Ointment, topical Solution, topical

Fluorescein Sodium(Bio Glo, FUL-GLO) Strip, ophthalmic

Fluorescein-benoxinate (Altafluor Benox) Solution, ophthalmic: fluorescein sodium 0.25% and benoxinate hydrochloride 0.4%

Fluoride(PerioMed) Solution, oral Tablet, chewable, oral

FLUoxetine (PROzac) Capsule, oral Liquid, oral Tablet, oral fluPHENAZine (Prolixin) Concentrate, oral, 14% alcohol Elixir, oral, with 14% alcohol Injection, as decanoate

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 50 Injection, as hydrochloride Tablet, oral

Fluticasone (Flonase, Flovent) Aerosol, oral inhalation Solution, nasal inhalation Powder, oral inhalation diskus

Fluticasone-Salmeterol (Advair) Aerosol, oral inhalation (HFA) Powder, oral inhalation fluvoxaMINE (Luvox) Tablet, oral

Folic Acid (Folvite) Tablet, oral

Fondaparinux (Arixtra) Injection

Fosfomycin (Monurol) Sachet, oral

Fosphenytoin (Cerebyx) Injection

Furosemide (Lasix) Injection Solution, oral Tablet, oral

Gabapentin (Neurontin) Capsule, oral Solution, oral Tablet, oral

Galantamine (Razadyne) Capsule, 24hr, oral Solution, oral Tablet, film coated, oral

Gentamicin Cream, topical Infusion, premixed in NS Injection Injection, intrathecal, preservative free

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 51 Ointment, ophthalmic Ointment, topical Solution, ophthalmic glipiZIDE (Glucotrol) Tablet, oral Tablet, extended release, oral

Glucosamine NUTRITIONAL SUPPLEMENT Capsule, oral Tablet, oral

Glucagon Powder for injection

Glucose Gel, oral Tablet, oral

Glycerin (Sani-Supp) Suppository, rectal

Glycopyrrolate (Robinul) Tablet, oral

Griseofulvin (Fulvicin, Grifulvin V, Gris-Peg) Suspension, Microsize, oral Tablet, Microsize, oral Tablet, Ultramicrosize, oral guaiFENesin (Robitussin, Mucinex) Any combination of drugs with guiaFENesin are on Formulary as long as the individual ingredients are on the Formulary and the dosage form is listed as being on formulary Liquid, oral Tablet, oral Tablet, sustained release, oral guaiFENesin-Codeine C-V Syrup, oral guaiFENesin-Dextromethorphan Liquid, oral Tablet, sustained release guaiFENesin-Pseudoephedrine (Mucinex D) Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 52 guanFACINE (Tenex, Intuniv) Tablet, oral Tablet, extended release 24 hr, oral

Haloperidol (Haldol) Concentrate, oral Injection, as decanoate Injection, as lactate Tablet, oral

Heparin Injection

Hepatitis A Vaccine (Vaqta, Havrix) Injection, single dose

Hepatitis A-Hepatitis B Vaccine (Twinrix) Injection, single dose

Hepatitis B Immune Globulin (HBIG) Injection, single dose

Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B, Heplisav-B ) Injection

Hexachlorophene Liquid, topical

Homatropine Solution, ophthalmic hydrALAZINE Tablet, oral hydroCHLOROthiazide Capsule, oral Tablet, oral

Hydrocortisone (Cortef, Lanacort, Corticaine, Anusol-HC, Proctofoam-HC) Injection, as sodium succinate Cream, topical Lotion, topical Ointment, topical Cream, rectal Foam, rectal Suppositories, rectal

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 53 Tablet, oral

Hydrogen Peroxide Solution, topical hydrOXYzine (Atarax, Vistaril) Capsule, oral Injection, as hydrochloride Syrup, as hydrochloride, oral Tablet, oral

Ibandronate (Boniva) Tablet, oral Injection

Ibuprofen (Motrin) Capsule, oral Suspension, oral Tablet, oral Tablet, chewable, oral

Iloperidone (Fanapt)- RESERVE USE Tablet, oral

Imipramine (Tofranil) Tablet, oral

Influenza Virus Vaccine Injection, single dose

Insulin, Aspart (NovoLOG) Injection: 100 units/mL

Insulin, Combination (70/30) Injection: 100 units/mL

Insulin, Detemir (Levemir) Injection: 100 units/mL

Insulin, Glargine (Lantus) Injection: 100 units/mL

Insulin, Lispro (HumaLOG) Injection: 100 units/mL

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 54 Insulin, Lispro protamine suspension-insulin lispro, (HumaLOG Mix 75/25), HumaLOG Mix 50/50 Injection: 100 units/mL

Insulin, NPH Injection: 100 units/mL

Insulin, Regular (HumuLIN, NovoLIN) Injection: 100 units/mL

Ipratropium (Atrovent) Aerosol, oral inhalation Nebulization solution, oral inhalation Solution, nasal inhalation

Iron salts with or without vitamins and/or minerals (Hemocyte Plus, Niferex-150, Niferex-150 Forte) Capsule, oral Solution, oral Tablet, oral

Isoniazid (INH) Injection Syrup, oral Tablet, oral

Isosorbide Dinitrate (Isordil) Capsule, sustained release, oral Tablet, oral Tablet, sustained release, oral

Isosorbide Mononitrate Tablet, oral Tablet, extended release, oral

Ivermectin (Stromectol) Tablet, oral

Ketamine (Ketalar) C-III RESERVE USE Intravenous

Ketoconazole (Nizoral) Cream, topical Shampoo, topical Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 55 Ketorolac (Toradol) Injection Tablet, oral

Ketotifen (Zaditor) Solution, ophthalmic

Labetalol (Normodyne) Tablet, oral

Lacosamide (Vimpat) C-V Solution, oral Solution, intravenous Tablet, oral

Lactobacillus Acidophilus (Lactinex, Bacid, Florajen) Capsule, oral Granules, oral Tablet, chewable, oral

Lactulose (Enulose) Syrup, oral lamoTRIgine (LaMICtal) Tablet, oral Tablet, chewable, oral Tablet, dispersible, oral

Lansoprazole (Prevacid) Capsule, enteric coated granules, oral

Latanoprost (Xalatan) Solution, ophthalmic

Levalbuterol (Xopenex) Aerosol, oral inhalation, HFA Nebulization Solution, oral inhalation

Levarterenol (Levophed)or Norepinephrine -RESERVE USE Injection levETIRAcetam (Keppra) Solution, oral Tablet, oral

Levocarnitine (Carnitor)

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 56 Tablet, oral Solution, oral levoFLOXacin (Levaquin) Injection Solution, oral Tablet, oral

Levothyroxine (Synthroid, Levoxyl) Powder for injection Tablet, oral

Lidocaine (Lidoderm, Xylocaine) Injection Gel, topical Liquid, viscous, oral Ointment, topical Patch, topical Solution, topical

Lidocaine-Prilocaine (EMLA) Cream, topical

Linezolid (Zyvox)- RESERVE USE Suspension, oral Tablet, oral

Linaclotide (Linzess)- RESERVE USE Capsule, oral

Liraglutide (Victoza) Injection

Lisdexamfetamine (Vyvanse) C-II- RESERVE USE Capsule, oral

Lisinopril (Prinivil, Zestril) Tablet, oral

Lithium Carbonate (Eskalith, Lithonate, Lithobid) Capsule, oral Tablet, oral Tablet, controlled release, oral Tablet, slow release, oral

Lithium Citrate Syrup, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 57 Loperamide (Imodium) Capsule, oral Liquid, oral Tablet, oral

Loratadine (Claritin) Liquid, oral Tablet, oral

Loratadine-Pseudoephedrine (Claritin D) Tablet, 12 hour sustained release, oral Tablet, 24 hour sustained release, oral

LORazepam (Ativan) C-IV Injection Solution, oral Tablet, oral

Losartan (Cozaar) Tablet, oral

Lumateperone (Caplyta) Capsule, oral

Loxapine (Loxitane) Capsule, oral

Eszopiclone (Lunesta) Tablet, oral

Lurasidone (Latuda) Tablet, oral

Lubiprostone (Amitiza) Capsule, oral

Magnesium Citrate Solution, oral

Magnesium Hydroxide (Milk of Magnesia) Suspension, oral Tablet, chewable

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 58 Magnesium L-lactate dihydrate (Mag-Tab SR) NUTRITIONAL SUPPLEMENT Tablet, oral

Magnesium Sulfate (Epsom Salt) Granules, topical Injection Infusion, premixed

Measles-Mumps-Rubella Virus Vaccine, Live (MMR II) Injection, single dose

Meclizine (Antivert, Bonine) Tablet, oral medroxyPROGESTERone (Provera) Injection Tablet, oral

Megestrol (Megace, Megace ES) Suspension, oral Tablet, oral

Melatonin NUTRITIONAL SUPPLEMENT Capsule, oral Tablet, oral Tablet, sublingual Tablet, sustained release, oral

Meloxicam (Mobic) Tablet, oral

Memantine (Namenda) Tablet, oral

Menthol

Menthol-Methyl Salicylate (Ben-Gay) Cream, topical Ointment, topical

Menthol-Zinc Oxide (Calmoseptine, Risamine) Ointment, topical

Mesalamine (Asacol HD, Pentasa, Rowasa, Canasa) Capsule, controlled release, oral Suppository, rectal

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 59 Suspension, rectal enema Tablet, delayed release, oral metFORMIN (Glucophage, Glucophage XR) Tablet, oral Tablet, extended release, oral Solution, oral

Methadone (Dolophine) C-II Solution, oral Tablet, oral Tablet for oral suspension methIMAzole (Tapazole) Tablet, oral

Methocarbamol (Robaxin) Tablet, oral

Methylcellulose (Citrucel) Powder, oral

Methyldopa Injection Tablet, oral

Methylphenidate, immediate release (Ritalin, Methylin, Metadate) C-II Tablet, oral

Methylphenidate, sustained release (Ritalin SR, Concerta, Metadate CD) C-II Capsule, extended release, oral (Metadate CD) Tablet, extended release, oral (Concerta) Tablet, sustained release, oral (Ritalin SR) methylPREDNISolone (Medrol, DEPO-Medrol, SOLU-Medrol) Injection, as acetate Injection, as sodium succinate Tablet, oral

Metoclopramide (Reglan) Injection Liquid, oral Tablet, oral

Metoprolol (Lopressor, Toprol XL) Tablet, oral Tablet, extended release, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 60 metroNIDAZOLE (Flagyl, Noritate, MetroGel) Capsule, oral Cream, topical Gel, topical Gel, vaginal Injection Powder for injection Tablet, oral

Miconazole Cream, topical Cream, vaginal Injection Powder, topical Spray, topical Suppository, vaginal

Midazolam (Versed, Nayzilam ) C-IV Injection Spray, nasal Syrup, oral

Mineral Oil - for topical use only

Mineral Oil-Petrolatum (Akwa Tears, Refresh Lacrilube) Ointment, ophthalmic

Minocycline Capsule, oral Capsule, pellet filled, oral

Mirabegron (Myrbetriq)- RESERVE USE Tablet, extended release 24 hr, oral

Mirtazapine (Remeron, Remeron SolTab) Tablet, oral Tablet, rapid dissolving, oral miSOPROStol (Cytotec) Tablet, oral

Mometasone (Nasonex) Inhalation, nasal

Montelukast (Singulair) Tablet, chewable, oral Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 61 Morphine C-II Injection Solution, oral Suppository, rectal Tablet, controlled release, oral Tablet, sublingual

Moxifloxacin (Avelox, Moxeza, Vigamox) Infusion Solution, Ophthalmic: RESERVE USE Tablet, oral

Multivitamin (Unicap, Hexavitamins) Liquid, oral Tablet, oral Tablet, chewable, oral

Multivitamin-Minerals Liquid, oral Tablet, oral Tablet, chewable, oral

Multivitamins, Pediatric (Poly-Vi-Sol) Liquid, oral

Multivitamin, Prenatal (Filibon) Tablet, oral

Mupirocin (Bactroban) Cream, topical Ointment, intranasal Ointment, topical

Nabumetone (Relafen)- RESERVE USE Tablet, oral

Nafcillin Powder for injection

Naloxone (Narcan) Injection Solution, nasal RESERVE USE

Naltrexone (ReVia), Naltrexone microspheres (Vivitrol) Tablet, oral- RESERVE USE Injection, long-acting - RESERVE USE

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 62 Naphazoline Solution, ophthalmic

Naproxen (Naprosyn) Tablet, oral Tablet, delayed release, oral

Neomycin Tablet, oral

Neomycin-Polymyxin B-Bacitracin (Triple Antibiotic Ointment) Ointment, topical

Neomycin-Polymyxin B-Hydrocortisone (Cortisporin) Cream, topical Solution, otic Suspension, otic

Niacin-Nicotinamide (Nicobid) Capsule, extended release, oral Tablet, oral Tablet, extended release, oral

Nicotine (Nicoderm, Nicotrol, Nicorette) Patch, transdermal: Gum, chewing, as polacrilex

NIFEdipine (Procardia, Procardia XL, Adalat CC) Capsule, liquid-filled, oral Tablet, sustained release, oral

Nitrofurantoin (Macrodantin) Capsule, macrocrystal, oral Capsule, macrocrystal/monohydrate, oral Suspension, oral

Nitroglycerin Capsule, sustained release, oral Ointment, topical Patch 24 hour, transdermal Spray, translingual Tablet, sublingual

Non-Soap Cleanser (Cetaphil) Bar

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 63 Lotion

Norepinephrine or Levarterenol (Levophed)- RESERVE USE Injection

Nortriptyline (Pamelor) Capsule, oral Solution, oral

Nystatin (Mycostatin) Cream, topical Ointment, topical Powder, topical Suspension, oral Tablet, oral

OLANZapine (ZyPREXA, ZyPREXA Zydis, ZyPREXA Relprevv) Injection Injection as pamoate- RESERVE USE Tablet, oral Tablet, rapid dissolving, oral

Olmesartan (Benicar)- RESERVE USE Tablet, oral

Olopatadine (Patanol) Solution, ophthalmic

Omega-3-acid ethyl esters (Lovaza) Capsule, oral

Omeprazole (PriLOSEC) Capsule, delayed release, oral Suspension, oral

Ondansetron (Zofran, Zofran ODT) Injection Tablet, oral Tablet, oral disintegrating

Oseltamivir (Tamiflu) Capsule, oral Suspension, oral

Oxazepam (Serax) C-IV Capsule, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 64 OXcarbazepine (Trileptal) Suspension, oral Tablet, oral

Oxybenzone-PDO-Pet Hy-Phl (Vaseline Lip Therapy) Ointment, topical

Oxybutynin (Ditropan XL) Syrup, oral Tablet, oral Tablet, extended release, oral oxyCODONE (OxyCONTIN) C-II Tablet, oral Tablet, controlled release, oral

Oxymetazoline (Afrin) Solution, drops, nasal inhalation Solution, spray, nasal inhalation

Paliperidone (Invega, Invega Sustenna) Injection, long acting Tablet, extended release, oral

Pancrelipase (Pancreaze, Creon) Capsule, oral: contains lipase, protease and amylase

Pantoprazole (Protonix) Injection Suspension Packets, oral Tablet, oral

PARoxetine (Paxil) Suspension, oral Tablet, oral Tablet, extended release 24 hr, oral penicillin G Benzathine (Bicillin LA) Injection penicillin V Potassium (Pen-Vee K, V-Cillin K) Powder for solution, oral Tablet, oral

Pentamidine (Pentam)- RESERVE USE Inhalation

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 65 Powder for injection

Permethrin (Elimite, NIX) Cream, topical Lotion, topical Cream rinse, topical

Perphenazine (Trilafon) Tablet, oral

Petrolatum, White (Vaseline) Ointment, topical

Phenazopyridine (Pyridium) Tablet, oral

Phenelzine (Nardil) Tablet, oral

PHENobarbital (Luminal) C-IV Injection Solution, oral Tablet, oral

Phenol (Chloraseptic) Mouthwash/Gargle Throat Spray

Phenylephrine (Neo-Synephrine, Preparation H) Ointment, rectal Cream, rectal Suppository, rectal Solution, drops, nasal inhalation Solution, spray, nasal inhalation Solution, ophthalmic

Phenytoin (Dilantin) Capsule, extended release, oral Injection Suspension, oral Tablet, chewable, oral

Phytonadione (Vitamin K1, Mephyton) Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 66 Pilocarpine (Isopto Carpine) Solution, ophthalmic, as hydrochloride

Pimecrolimus (Elidel) Cream, topical

Pioglitazone (Actos) Tablet, oral

Piperacillin-Tazobactam (Zosyn) Injection

Pneumococcal Vaccine, Conjugate (Prevnar 13) Injection, single dose

Pneumococcal Vaccine, Polyvalent (Pneumovax 23) Injection, single dose

Podophyllum Resin (Podocon-25) Liquid, topical

Polycarbophil (Fibercon, Fiber-Lax) Tablet, oral

Polyethylene Glycol (MiraLax) Powder for oral solution

Polyethylene Glycol Electrolyte Solution (PEG, Co-Lyte, GoLYTELY) Powder for oral solution

Polymyxin B-Bacitracin (Polysporin) Ointment, ophthalmic Ointment, topical Powder, topical

Polymyxin B-Trimethoprim (Polytrim) Solution, ophthalmic

Polyvinyl Alcohol (Artifical Tears, Akwa Tears) Solution, ophthalmic

Potassium Chloride Capsule, oral Capsule, sustained release, oral Liquid, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 67 Powder for suspension, oral Injection, concentrate Tablet, controlled release (microencapsulated) Tablet, controlled release (wax matrix)

Potassium Citrate (Urocit K) Tablet, oral Tablet, extended release, oral

Potassium Citrate Combinations (Polycitra-LC, Polycitra K Solution, oral: containing Sodium Citrate-Potassium Citrate-Citric Acid Solution, oral: containing Sodium Citrate-Potassium Citrate

Potassium Iodide (SSKI) Solution, oral

Potassium Phosphate (Neutra-Phos-K) Powder for oral solution

Povidone-Iodine (Betadine) Ointment, topical Surgical scrub, topical Solution, topical

Pramipexole (Mirapex) Tablet, oral

Pramoxine Cream, topical Foam, topical Gel, topical Lotion, topical Spray, topical

Pramoxine–Hydrocortisone (Analpram HC) Cream, Rectal

Pramoxine-Zinc (Caladryl Clear) Lotion, topical

Pravastatin (Pravachol) Tablet, oral

Prazosin (Minipress) Capsule, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 68 prednisoLONE (Pred Mild, Pred Forte) Solution, oral Syrup, oral Tablet, oral Solution, ophthalmic RESERVE USE predniSONE (Deltasone) Solution, oral Tablet, oral

Pregabalin (Lyrica) C-V Capsule, oral

Primidone (Mysoline) Tablet, oral

Prochlorperazine (Compazine) Injection Suppository, rectal Tablet, oral

Promethazine (Phenergan) Suppository, rectal Syrup, oral Tablet, oral

Proparacaine (Alcaine) Solution, ophthalmic

Propranolol (Inderal) Capsule, sustained release, oral Injection Solution, oral Tablet, oral

Propylthiouracil Tablet, oral

Pseudoephedrine (Sudafed) Liquid, oral Tablet, immediate release, oral Tablet, extended release, oral

Psyllium (Konsyl, Metamucil) All products of psyllium, psyllium husk, and psyllium seed, alone or in combination with dextrose, aspartame, sugar or sucrose are considered to be formulary.

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 69 Pyrazinamide Tablet, oral

Pyrethins 0.33%-Piperonyl Butoxide 4% (Pronto, RID) Liquid, topical Shampoo, topical

Pyridoxine (Vitamin B6) Injection Tablet, oral

QUEtiapine (SEROquel) Tablet, oral

Raloxifene (Evista) Tablet, oral raNITIdine Injection Syrup, oral Tablet, oral

Rasagiline (Azilect) Tablet, oral

Repaglinide (Prandin) Tablet, oral

Rifabutin (Mycobutin) Capsule, oral rifAMPin (Rifadin) Capsule, oral Injection rifAMPin-Isoniazid (Rifamate) Capsule, oral

Risedronate (Actonel) Tablet, oral risperiDONE (RisperDAL, RisperDAL M-Tab, RisperDAL Consta) Injection, long acting Solution, oral Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 70 Tablet, orally disintegrating

Rivaroxaban (Xarelto) Tablet, oral

Rivastigmine (Exelon, Exelon Patches) Capsule, oral Patch, transdermal

Rosuvastatin (Crestor) Tablet, oral

Rufinamide (Banzel) Tablet, oral

Saccharomyces boulardii (Florastor) Capsule, oral

Salicylic Acid All available salicylic acid products as a single agent are considered to be on formulary

Salicylic Acid-Sulfur All commercially available forms are on formulary

Saliva Substitute (Biotene) Gel Mouthwash Spray

Salmeterol (Serevent) Powder, oral inhalation

Selegiline (Eldepryl) Capsule, oral Tablet, oral

Selenium Sulfide Shampoo, topical

Senna (Senokot) Tablet, oral

Sertraline (Zoloft) Concentrate, oral Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 71 Sevelamer (Renagel) Tablet, oral

Silver Nitrate Applicator sticks, topical

Silver SulfADIAZINE (Silvadene) Cream, topical

Simethicone (Gas-X, Phazyme ) Drops, oral Tablet, chewable, oral

Simvastatin (Zocor) Tablet, oral

Sitagliptin (Januvia) Tablet, oral

Sodium Bicarbonate Tablet, oral

Sodium Chloride Drops, nasal Infusion Injection, bacteriostatic Injection, for admixtures Injection, for reconstitution Nebulization solution, oral inhalation Ointment, ophthalmic Solution, irrigation, topical Solution, nasal inhalation Solution, ophthalmic Tablet, oral Tablet, enteric coated, oral Tablet, slow release, oral

Sodium Chloride Intravenous Solution Infusion

Sodium Citrate-Citric Acid (Oracit) Solution, oral

Sodium Polystyrene Sulfonate Powder for suspension, oral Suspension, oral (with sorbitol and alcohol)

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 72 Solifenacin (Vesicare) Tablet, oral

Sorbitol Solution, oral

Spironolactone (Aldactone) Tablet, oral

Spironolactone-hydroCHLOROthiazide (Aldactazide) Tablet, oral

Sucralfate (Carafate) Suspension, oral Tablet, oral

Sulfacetamide Sodium (Bleph-10) Lotion, topical Ointment, ophthalmic Solution, ophthalmic

Sulfamethoxazole-Trimethoprim (Bactrim) The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage forms Injection Suspension, oral Tablet, oral sulfaSALAzine (Azulfidine) Tablet, oral Tablet, delayed release, oral

Sulindac (Clinoril) Tablet, oral

SUMAtriptan (Imitrex) Injection Spray, nasal Tablet, oral

Sunscreen-Block Cream-Lotion, topical: contains a minimum SPF of 15

Tacrolimus (Protopic) Ointment, topical

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 73 Tamoxifen Tablet, oral

Tamsulosin (Flomax) Capsule, oral

Tazarotene (Tazorac, Avage) Cream, topical Gel, topical

Temazepam (Restoril) C-IV Capsule, oral

Terbinafine (LamISIL) Cream, topical Tablet, oral

Testosterone (Androlan) C-IV Injection, in oil, as cypionate

Tetracycline Capsule, oral

Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing) Solution, ophthalmic

Tetrahydrozoline-Zinc Sulfate (Visine A.C. ) Solution, ophthalmic

Thiamine (Vitamin B1) Injection Tablet, oral

Thioridazine (Mellaril)- RESERVE USE Tablet, oral

Thiothixene (Navane) Capsule, oral tiaGABine (Gabatril) Tablet, oral

Timolol (Timoptic, Timoptic XE) Gel, ophthalmic Solution, as maleate, ophthalmic

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 74 Solution, as maleate, ophthalmic, preservative free, single use

Timolol-Dorzolamide (Cosopt) Solution, ophthalmic

Tioconazole Ointment, vaginal

Tiotropium (Spiriva) Capsule, oral inhalation (with device) Aerosol solution, oral inhalation (Spiriva Respimat) tiZANidine (Zanaflex)- RESERVE USE Capsule, oral Tablet, oral

Tobramycin (Tobrex) Injection Ointment, ophthalmic Solution, ophthalmic

Tobramycin-Dexamethasone (TobraDex) [contains Benzalkonium]- RESERVE USE Ointment, ophthalmic Suspension, ophthalmic

Tolnaftate (Tinactin) Aerosol, topical, liquid Aerosol, topical, powder Cream, topical Powder, topical Solution, topical

Tolterodine (Detrol, Detrol LA) Capsule, extended release, oral Tablet, oral

Topiramate (Topamax) Capsule, sprinkle, oral Tablet, oral traMADol (Ultram) C-IV Tablet, oral

Tranylcypromine (Parnate) Tablet, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 75 Travoprost (Travatan Z) Solution, ophthalmic traZODone (Desyrel) Tablet, oral

Tretinoin (Retin-A) Cream, topical Gel, topical

Triamcinolone (Nasacort) Aerosol, topical Cream, topical Lotion, topical Ointment, topical Paste, dental Spray, nasal inhalation

Triamterene-hydroCHLOROthiazide (Dyazide, Maxzide) Capsule, oral Tablet, oral

Triazolam (Halcion) C-IV Tablet, oral

Trifluoperazine (Stelazine) Tablet, oral

Trihexyphenidyl (Artane) Elixir, oral Tablet, oral

Trimethobenzamide (Tigan) Capsule, oral Injection, oral

Triprolidine-Pseudoephedrine (Aprodine) Tablet, oral

Tropicamide (Mydriacyl) Solution, ophthalmic

Trospium Tablet, oral Capsule, extended release 24 hour, oral

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 76 Trypsin-Balsam Peru-Castor Oil (Granulex, Revina, TBC) Aeroso, topical Ointment, topical

Tuberculin, Purified Protein Derivative (P.P.D.) Intermediate test strength: 5 TU/0.1 mL

Urea Cream, topical Lotion, topical valACYclovir (Valtrex) Caplet, oral Tablet, oral

Valproic Acid/Valproate (Depakene) Capsule, sprinkle, oral Tablet, oral

Valsartan (Diovan) Tablet, oral

Vancomycin (Vancocin) Capsule, oral Powder for injection

Varicella Virus Vaccine, Live (Varivax) Injection, single dose

Venlafaxine (Effexor) Capsule, extended release 24 hr, oral Tablet, oral Tablet, extended release 24 hr, oral

Verapamil (Calan, Isoptin, Calan SR, Isoptin SR, Verelan Verelan PM) Capsule, sustained release, oral Injection Tablet, immediate release, oral Tablet, sustained release, oral

Vitamin A (Aquasol A) Capsule, oral

Vitamin A&D Topical Ointment, topical

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 77 Vitamin B Complex Tablet, oral

Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C, Nephrocaps, Nephro-vite) Capsule, oral Tablet, oral

Vitamin B Complex-Vitamin C-Zinc Tablet, oral

Vitamin D2 (Ergocalciferol, Calciferol, Drisdol) Capsule, oral Drops, oral Tablet, oral

Vitamin D3 (Calcitrol, Rocaltrol, Cholecalciferol) Capsule, oral Drops, oral Tablets, oral

Vitamin E (Aquasol E) Capsule, oral

Warfarin (Coumadin) Tablet, oral

Water for Injection Injection, for constitution

Water for Irrigation Solution, irrigation, topical

Wound Cleanser (Carrington Clara-Klenz) Spray, topical

Zanamivir (Relenza) Powder for Inhalation

Zinc Oxide Ointment, topical Paste, topical

Zinc Oxide-Petrolatum-Imidazolidinyl Urea (Diaperene) Ointment, topical

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 78 Zinc Sulfate Capsule, oral Tablet, oral

Ziprasidone (Geodon) Capsule, oral Injection

Zoledronic Acid (Reclast) Injection

Zolpidem (Ambien) C-IV Tablet, oral

Zonisamide (Zonegran) Capsule, oral

Zoster Vaccine- Recombinant, Adjuvanted (Shingrix) Intramuscular Suspension

Texas HHS Psychiatric Drug Formulary 2021

Alphabetical Listing 79 Therapeutic Classification/Cost Index

Antidiabetic Agents

Insulins, Human Cost Index

Insulin, Aspart (NovoLOG) Moderate

Insulin, Combination (70/30) Moderate

Insulin, Detemir (Levemir) High

Insulin, Glargine (Lantus) Moderate

Insulin, Lispro (HumaLOG) Moderate

Insulin, Combination, lispro protamine suspension-insulin lispro, Moderate (HumaLOG Mix 75/25, HumaLOG Mix 50/50)

Insulin, NPH Low

Insulin, Regular (HumuLIN, NovoLIN) Low

Sulfonylureas Cost Index

glipiZIDE (Glucotrol) Low

Miscellaneous Antidiabetic Agents Cost Index

Canagliflozin (Invokana) High

Empagliflozin (Jardiance) High

Liraglutide (Victoza) High

metFORMIN (Glucophage, Glucophage XR) Low

Pioglitazone (Actos) Low

Repaglinide (Prandin) Low

Sitagliptin (Januvia) High

Antidotes

Antidotes Cost Index

EPINEPHrine EpiPen) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 80 Antidotes Cost Index

Glucagon High

Glucose, oral Moderate

Naloxone (Narcan) High

Phytonadione (Vitamin K1, Mephyton) High

Sodium Polystyrene Sulfonate High

Antineoplastic Agents

Antineoplastic Agents Cost Index

Tamoxifen Low

All commercially available oncologic agents used in the treatment of cancer are considered to be formulary agents, if prescribed by an oncologist for the active treatment of cancer. All commercially available oncologic agents prescribed by field specialists are considered to be on formulary. Blood Modifying Agents

Antiplatelet Agents Cost Index

Aspirin Low

Clopidogrel (Plavix) Low

Anticoagulants Cost Index

Apixaban (Eliquis) High

Enoxaparin (Lovenox) High

Fondaparinux (Arixtra) High

Heparin Moderate

Rivaroxaban (Xarelto) High

Warfarin (Coumadin) Low

Anticoagulation Antagonists Cost Index

Phytonadione (Vitamin K1, Mephyton) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 81

Miscellaneous Blood Modifying Agents Cost Index

Epoetin alfa (Epogen, Procrit) RESERVE USE High

Ferrous Fumarate-Docusate Sodium (Ferro-Sequels) [33% elemental iron] Low

Ferrous Sulfate (Feosol, Fer-In-Sol) [20% elemental iron] Low

Cardiovascular Agents

Diuretics-Thiazides & Related Diuretics Cost Index

Chlorthalidone Low

hydroCHLOROthiazide Low

Diuretics-Loop Diuretics Cost Index

Furosemide (Lasix) Low

Diuretics-Potassium-Sparing Diuretics Cost Index

Spironolactone (Aldactone) Low

Diuretics-Carbonic Anhydrase Inhibitors Cost Index

acetaZOLAMIDE (Diamox) Moderate

Diuretics-Combination Diuretics Cost Index

Spironolactone-hydroCHLOROthiazide (Aldactazide) Low

Triamterene-hydroCHLOROthiazide (Dyazide, Maxzide) Low

Cardiac Glycosides Cost Index

Digoxin (Lanoxin) Low

Antianginals Cost Index

Isosorbide Dinitrate (Isordil) Low

Isosorbide Mononitrate Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 82 Antianginals Cost Index

Nitroglycerin Low

Antiarrhythmics Cost Index

Adenosine (Adenocard) Reserve Use Moderate-High

Amiodarone (Pacerone, Cordarone) Low

Calcium Channel Blockers Cost Index

amLODIPine (Norvasc) Low

dilTIAZem (Cardizem) Low

NIFEdipine (Procardia, Procardia XL, Adalat CC) Low

Verapamil (Calan, Isoptin, Calan SR, Isoptin SR, Verelan Verelan PM) Low

Beta-Adrenergic Blockers Cost Index

Atenolol (Tenormin) Low

Carvedilol (Coreg, Coreg CR) Low

Labetalol (Normodyne) Low

Metoprolol (Lopressor, Toprol XL) Low

Propranolol (Inderal) Low

Antihyperlipidemics Cost Index

atorvaSTATin (Lipitor) Low

Cholestyramine Moderate

Fenofibrate (Antara, Lofibra, Tricor, Triglide) Low

Niacin-Nicotinamide (Nicobid) Low

Pravastatin (Pravachol) Low

Rosuvastatin (Crestor) Low

Simvastatin (Zocor) Low

Omega-3-acid ethyl esters (Lovaza) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 83

Angiotensin Converting Enzyme Inhibitors Cost Index

Benazepril (Lotensin) Low

Captopril (Capoten) Moderate

Enalapril (Vasotec) Low

Lisinopril (Prinivil, Zestril) Low

Angiotensin Receptor Blockers Cost Index

Losartan (Cozaar) Low

Olmesartan (Benicar) RESERVE USE Low

Valsartan (Diovan) Low

Vasopressors Cost Index

DOPamine (Intropin) RESERVE USE High

EPINEPHrine (Adrenalin) High

Norepinephrine or Levarterenol (Levophed) RESERVE USE High

Miscellaneous Antihypertensives Cost Index

cloNIDine (Catapres) Low-Moderate

hydrALAZINE Low

Methyldopa Low

Central Nervous System Agents

Agents for Migraine Cost Index

Amitriptyline (Elavil) Low

Aspirin-Acetaminophen-Caffeine (Excedrine Migraine) Low

Atenolol (Tenormin) Low

Divalproex (Depakote, Depakote ER) Low

Metoprolol (Lopressor, Toprol XL) Low

Naproxen (Naprosyn) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 84 Agents for Migraine Cost Index

Propranolol (Inderal) Low

SUMAtriptan (Imitrex) Low-High

Topiramate (Topamax) Low

Valproic Acid/Valproate (Depakene) Low

Venlafaxine (Effexor) Low

Verapamil (Calan, Isoptin, Verelan Verelan PM) Low

Analgesics-Nonsteroidal Anti-Inflammatory Agents Cost Index

Aspirin Low

Celecoxib (CeleBREX)- RESERVE USE Low

Ibuprofen (Motrin) Low

Ketorolac (Toradol) Moderate

Meloxicam (Mobic) Low

Nabumetone (Relafen) - RESERVE USE Low

Naproxen (Naprosyn) Low

Sulindac (Clinoril) Low

Analgesics-Opiate Agonists Cost Index

Acetaminophen-Codeine C-III Low

Acetaminophen-HYDROcodone (Lortab, Vicodin, Vicodin ES) C-II Low-Moderate

Methadone (Dolophine) C-II Low

Morphine C-II Low-Moderate

oxyCODONE (OxyCONTIN) C-II Moderate-High

Opiate agonists include a range of dosage forms and strengths. Dosing of each is dependent on the individual patient and condition treated.

Miscellaneous Analgesic, Antipyretic, & Anti-Inflammatory Agents Cost Index

Acetaminophen (Tylenol) Low

Colchicine High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 85 Miscellaneous Analgesic, Antipyretic, & Anti-Inflammatory Agents Cost Index

traMADol (Ultram) C-IV Low

Anticonvulsants-Barbiturates Cost Index

PHENobarbital (Luminal) C-IV Low

Primidone (Mysoline) Low

Anticonvulsants-Benzodiazepines Cost Index

cloBAZam (Onfi) C-IV RESERVE USE Low

clonazePAM (KlonoPIN) C-IV Low

Clorazepate (Tranxene) C-IV Moderate-High

diazePAM (Valium, Diastat) C-IV Low-High

LORazepam (Ativan) C-IV Low

Midazolam (Nayzilam) C-IV High

Anticonvulsants-Hydantoins Cost Index

Fosphenytoin (Cerebyx) High

Phenytoin (Dilantin) Low-High

Anticonvulsants-Succinimides Cost Index

Ethosuximide (Zarontin) Moderate-High

Miscellaneous Anticonvulsants Cost Index

Cannabidiol (Epidiolex) C-V RESERVE USE High

carBAMazepine (TEGretol) Low-High

Divalproex (Depakote) Low-Moderate

Felbamate (Felbatol) - RESERVE USE High

Gabapentin (Neurontin) Low

Lacosamide (Vimpat) C-V High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 86 Miscellaneous Anticonvulsants Cost Index

lamoTRIgine (LaMICtal) Low

levETIRAcetam (Keppra) Low

OXcarbazepine (Trileptal) Low

Pregabalin (Lyrica) C-V Low

Rufinamide (Banzel) High

tiaGABine (Gabatril) High

Topiramate (Topamax) Low

Valproic Acid/Valproate Low (Depakene)

Zonisamide (Zonegran) Low

Antiemetics-Antivertigo Cost Index

diphenhydrAMINE (Benadryl) Low

hydrOXYzine (Atarax, Vistaril) Low-High

Meclizine (Antivert, Bonine) Low

Metoclopramide (Reglan) Low

Ondansetron (Zofran, Zofran ODT) Low

Prochlorperazine (Compazine) Low-High

Promethazine (Phenergan) Low-High

Trimethobenzamide (Tigan) Moderate

Miscellaneous Central Nervous System Agents Cost Index

Megestrol (Megace, Megace ES) Moderate

Antiparkinson Agents Cost Index

Amantadine Low-Moderate

Benztropine (Cogentin) Low-High

Bromocriptine Moderate

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 87 Antiparkinson Agents Cost Index

Entacapone (Comtan) Moderate

Carbidopa-Levodopa (Sinemet) Low

Pramipexole (Mirapex) Low

Rasagiline (Azilect) Moderate

Selegiline (Eldepryl) Moderate-High

Trihexyphenidyl (Artane) Low

Dementia Agents Cost Index

Donepezil (Aricept) Low-Moderate

Galantamine (Razadyne) Low-High

Memantine (Namenda) Low

Rivastigmine (Exelon, Exelon Patches) Low-Moderate

Muscle Relaxants-Antispasticity Agents Cost Index

Baclofen Low

Dantrolene (Dantrium) Low-Moderate

diazePAM (Valium) C-IV Low-High

tiZANidine (Zanaflex) - RESERVE USE Low

Muscle Relaxants-Muscle Relaxant Agents Cost Index

Cyclobenzaprine Low

diazePAM (Valium) C-IV Low-high

Methocarbamol (Robaxin) Low

Psychotropic Agents-Benzodiazepine Anxiolytics and Hypnotics Cost Index

ALPRAZolam (Xanax, Xanax XR) C-IV Low

chlordiazePOXIDE (Librium) C-IV Low

clonazePAM (KlonoPIN) C-IV Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 88 Psychotropic Agents-Benzodiazepine Anxiolytics and Hypnotics Cost Index

Clorazepate (Tranxene) C-IV Low

diazePAM (Valium) C-IV Low-High

LORazepam (Ativan) C-IV Low

Midazolam (Versed) C-IV Moderate

Oxazepam (Serax) C-IV Moderate

Temazepam (Restoril) C-IV Low

Triazolam (Halcion) C-IV Moderate

Psychotropic Agents-Miscellaneous Anxiolytics and Hypnotics Cost Index

busPIRone (BuSpar) Low

diphenhydrAMINE (Benadryl) Low

Eszopiclone (Lunesta) Low

hydrOXYzine (Atarax, Vistaril) Low-High

Prazosin (Minipress) Low

traZODone (Desyrel) Low

Zolpidem (Ambien) C-IV Low

Psychotropic Agents-Antidepressants-Monoamine Oxidase Cost Index Inhibitors (MAOI)

Phenelzine (Nardil) Moderate

Tranylcypromine (Parnate) Moderate

Psychotropic Agents-Antidepressants-Serotonin Selective Reuptake Cost Index Inhibitors (SSRI)

Citalopram (CeleXA) Low

Escitalopram (Lexapro) Low-High

FLUoxetine (PROzac) Low-High

fluvoxaMINE (Luvox) Low-High

PARoxetine (Paxil) Low-High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 89 Psychotropic Agents-Antidepressants-Serotonin Selective Reuptake Cost Index Inhibitors (SSRI)

Sertraline (Zoloft) Low-High

Psychotropic Agents-Antidepressants-Serotonin Norepinephrine Cost Index Reuptake Inhibitors (SNRI)

DULoxetine (Cymbalta) Low

Venlafaxine (Effexor) Low

Psychotropic Agents-Antidepressants-Tricyclic Agents Cost Index

Amitriptyline (Elavil) Moderate

clomiPRAMINE (Anafranil) - for OCD High

Desipramine (Norpramin) Moderate-High

Doxepin (SINEquan) Moderate

Imipramine (Tofranil) Low

Nortriptyline (Pamelor) Low

Psychotropic Agents-Miscellaneous Antidepressants Cost Index

buPROPion (Budeprion, Wellbutrin, Zyban) Low

Mirtazapine (Remeron, Remeron SolTab) Low

traZODone (Desyrel) Low

Esketamine (Spravato) C-III RESERVE USE High

Ketamine (Ketalar) C-III RESERVE USE High

Psychotropic Agents-Antipsychotics Cost Index

ARIPiprazole (Abilify, Abilify discmelt, Abilify Maintena, Aristada, Aristada Low-High Initio -RESERVE USE)

Asenapine (Saphris) High

Brexpiprazole (Rexulti) High

Cariprazine (Vraylar) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 90 Psychotropic Agents-Antipsychotics Cost Index

chlorproMAZINE (Thorazine) High

cloZAPine (Clozaril)- RESERVE USE High

fluPHENAZine (Prolixin) High

Haloperidol (Haldol) Moderate

Iloperidone (Fanapt) RESERVE USE High

Loxapine (Loxitane) Moderate

Lumateperone (Caplyta) High

Lurasidone (Latuda) High

OLANZapine (ZyPREXA) Low

Paliperidone (Invega) High

Perphenazine (Trilafon) Moderate

QUEtiapine (SEROquel) Low

risperiDONE (RisperDAL), RisperDAL M-Tab, RisperDAL Consta Low-High

Thioridazine (Mellaril) - RESERVE USE Moderate

Thiothixene (Navane) High

Trifluoperazine (Stelazine) High

Ziprasidone (Geodon) Moderate

Psychotropic Agents-Mood Stabilizers Cost Index

carBAMazepine (TEGretol) Moderate-High

Divalproex (Depakote) Low

lamoTRIgine (LaMICtal) Low-High

Lithium Carbonate (Eskalith, Lithonate) Low-Moderate

Lithium Citrate Moderate-High

OXcarbazepine (Trileptal) Low

Topiramate (Topamax) Low

Valproic Acid/Valproate (Depakene) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 91 Psychotropic Agents-Stimulants Cost Index

Amphetamine Mixture (Adderall) CII Low-Moderate

atoMOXetine (Strattera) Moderate-High

Dexmethylphenidate, extended release (Focalin XR) CII High

Rarely used in adults Low-Moderate Dextroamphetamine (DexedrineC-II

Lisdexamfetamine (Vyvanse) C-II Reserve Use High

Rarely used in adults Low-Moderate Methylphenidate, immediate release (Ritalin, Methylin, Metadate) C-II

Rarely used in adults Moderate-High Methylphenidate, sustained release (Ritalin SR, Metadate CD Concerta) C-II

Psychotropic Agents-Other ADHD Agents Cost Index

cloNIDine (Catapres) Low

guanFACINE (Tenex, Intuniv) Low

Substance Use Treatments Cost Index

Acamprosate (Campral) High

Buprenorphine (Subutex)- RESERVE USE Moderate

Buprenorphine-naloxone (Suboxone)- RESERVE USE Moderate

Disulfiram (Antabuse) Moderate

Naltrexone (ReVia, Naltrexone microspheres (Vivitrol) RESERVE USE Low-High

Nicotine (Nicoderm, Nicotrol, Nicorette) Low-Moderate

Topiramate (Topamax) Low

Endocrine Agents

Estrogens Cost Index

Estradiol (Estrace, Vivelle, Alora, Climara, Estraderm) Low-High

Estrogens, Conjugated (Premarin) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 92 Progesterones Cost Index

medroxyPROGESTERone (Provera) Low

Combination Products Cost Index

Estrogen-medroxyPROGESTERone (PremPro, Premphase) High

All commercially available oral contraceptive agents are considered to be formulary agents

Androgens Cost Index

Testosterone (Androlan) C-IV Moderate

Osteoporosis Agents Cost Index

Alendronate (Fosamax, Binosto) Low

Calcitonin-Salmon (Miacalcin) Low

Denosumab (Prolia) High

Ibandronate (Boniva) Low-Moderate

Raloxifene (Evista) Low

Risedronate (Actonel) Moderate

Zoledronic Acid (Reclast) High

Adrenal Cortical Steroids Cost Index

Dexamethasone Moderate

Fludrocortisone Low

Low-High Hydrocortisone (Cortef)

methylPREDNISolone (Medrol, DEPO-Medrol, SOLU-Medrol) Low-High

prednisoLONE Moderate-high

predniSONE (Deltasone) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 93 Thyroid Agents Cost Index

Levothyroxine (Synthroid, Levoxyl) Low

methIMAzole (Tapazole) Low

Propylthiouracil Moderate

Miscellaneous Endocrine Agents Cost Index

Allopurinol (Zyloprim) Low

Desmopressin (DDAVP, Stimate) Low-High

Gastrointestinal Agents

Antacids Cost Index

Aluminum Hydroxide Low

Aluminum Hydroxide-Magnesium Trisilicate (Gaviscon) Low

Aluminum Hydroxide-Magnesium Hydroxide (Maalox) Low

Aluminum Hydroxide-Magnesium Hydroxide-Simethicone (Mylanta) Low

Calcium Carbonate (Os-Cal, Os-Cal chewable, Tums ) - 40% elemental Low calcium

Antispasmodics/Anticholinergic Agents Cost Index

Dicyclomine (Bentyl) Low

Glycopyrrolate (Robinul) Low

Histamine (H2) Antagonists-Preferred Agents Cost Index

Famotidine (Pepcid) Low-Moderate

Histamine (H2) Antagonists-Other Agents Cost Index

raNITIdine Low-High

Proton Pump Inhibitors-Preferred Agents Cost Index

Lansoprazole (Prevacid) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 94 Proton Pump Inhibitors-Preferred Agents Cost Index

Pantoprazole (Protonix) Low-High

Proton Pump Inhibitors-Other Agents Cost Index

Esomeprazole (NexIUM) Low-High

Omeprazole (PriLOSEC) Low-High

Antiflatulants Cost Index

Simethicone (Gas-X, Phazyme ) Low

Stimulants Cost Index

Metoclopramide (Reglan) Low

Laxatives-Saline Osmotic Cost Index

Magnesium Citrate Moderate

Magnesium Hydroxide (Milk of Magnesia) Low

Laxatives-Irritant/Stimulant Cost Index

Bisacodyl (Dulcolax) Low

Senna (Senokot) Low

Laxatives-Bulking Agents Cost Index

Cellulose (Unifiber) Low

Methylcellulose (Citrucel) Low

Polycarbophil (Fibercon, Fiber-Lax) Low

Psyllium (Konsyl, Metamucil) Low

All products of psyllium, psyllium husk, and psyllium seed, alone or in combination with dextrose, aspartame, sugar or sucrose are considered to be formulary.

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 95 Laxatives-Osmotic Cost Index

Lactulose (Enulose) Low

Polyethylene Glycol (MiraLax) Low

Polyethylene Glycol Electrolyte Solution (PEG, Co-Lyte, GoLYTELY, ) Moderate

Sorbitol Low

Laxatives-Combination Agents Cost Index

Docusate Sodium-Sennosides (Peri-Colace) Low

Laxatives-Surfactants Cost Index

Docusate Calcium (Surfak) Low

Docusate Sodium (Colace) Low

Laxatives-Calcium Channel Activators Cost Index

Linaclotide (Linzess) RESERVE USE High

Lubiprostone (Amitiza) Moderate

Miscellaneous Laxatives Cost Index

Glycerin Suppository (Sani-Supp) Low

Antidiarrheals Cost Index

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Low

Saccharomyces boulardii (Florastor) Low

Lactobacillus Acidophilus (Lactinex, Bacid, Florajen) Low-High

Loperamide (Imodium) Low

Rectal Agents Cost Index

Hydrocortisone Rectal Foam, suppositories, cream, ointment (Proctofoam- Moderate-High HC, Anusol-HC)

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 96 Rectal Agents Cost Index

Pramoxine–Hydrocortisone (Analpram HC) High

Phenylepherine Rectal cream, ointment, suppositories (Preparation H) Low

Miscellaneous Gastrointestinal Agents Cost Index

Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Low

Mesalamine (Asacol HD, Pentasa, Rowasa, Canasa) Moderate-High

miSOPROStol (Cytotec) Low-Moderate

Pancrelipase (Pancreaze, Creon) Moderate-High

Sucralfate (Carafate) Low

sulfaSALAzine (Azulfidine) Low-Moderate

Genitourinary Agents

Interstitial Cystitis Agents Cost Index

Phenazopyridine (Pyridium) Low

Genitourinary Irrigants Cost Index

Sodium Chloride Moderate-High

Water for Irrigation Moderate-High

Medications for BPH Cost Index

Finasteride (Proscar) Low

Tamsulosin (Flomax) Low

Urinary Alkalinizers Cost Index

Potassium Citrate (Urocit K) Moderate

Potassium Citrate Combinations (Polycitra-LC, Polycitra K) Low

Sodium Bicarbonate Low

Sodium Citrate-Citric Acid (Oracit) Moderate

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 97

Urinary Anticholinergics Cost Index

Darifenacin (Enablex) Moderate

Oxybutynin (Ditropan XL) Low

Solifenacin (Vesicare) Low

Trospium Low

Tolterodine (Detrol, Detrol LA) Moderate

Urinary Cholinergics Cost Index

Bethanechol (Urecholine) Moderate

Vaginal Antifungals Cost Index

Clotrimazole (Gyne-Lotrimin) Low

Miconazole Low

Tioconazole Moderate

Miscellaneous Genitourinary Agents Cost Index

Mirabegron (Myrbetriq) RESERVE USE High

Sevelamer (Renagel) High

Immunological Agents

Immune Serums Cost Index

Hepatitis B Immune Globulin (HBIG) High

Bacterial Vaccines Cost Index

Pneumococcal Vaccine, Polyvalent (Pneumovax 23) High

Pneumococcal Vaccine, Conjugate (Prevnar 13) High

Viral Vaccines Cost Index

Hepatitis A Vaccine (Vaqta, Havrix) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 98 Viral Vaccines Cost Index

Hepatitis A-Hepatitis B Vaccine (Twinrix) High

Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B, High Heplisav-B )

Influenza Virus Vaccine High

Measles-Mumps-Rubella Virus Vaccine, Live (MMR II) High

Varicella Virus Vaccine, Live (Varivax) High

Zoster Vaccine- Recombinant, Adjuvanted (Shingrix) High

Toxoids Cost Index

Diphtheria-Tetanus Toxoids Adsorbed (DT) High

Diphtheria-Tetanus Toxoids Adsorbed for Adult Use (Td) High

Diphtheria-Tetanus-Acellular Pertussis (Tdap) (Boostrix, Adacel) High

In-Vivo Diagnostic Biologicals Cost Index

Tuberculin, Purified Protein Derivative (P.P.D.) High

Infectious Disease Agents

Antibiotics-Penicillins Cost Index

Amoxicillin (Amoxil, Polymox) Low

Amoxicillin-Clavulanate (Augmentin) Low

Ampicillin (Polycillin, Omnipen) Low-High

Nafcillin High

penicillin G Benzathine (Bicillin LA) High

penicillin V Potassium (Pen-Vee K, V-Cillin K) Low

Piperacillin-Tazobactam (Zosyn) High

Antibiotics-Cephalosporins Cost Index

ceFAZolin (Kefzol) Moderate

cefdinir (Omnicef) Moderate

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 99 Antibiotics-Cephalosporins Cost Index

Cefepime (Maxipime) High

cefTRIAXone (Rocephin) Moderate

Cefuroxime Axetil (Ceftin) - Oral form only Low

Cephalexin (Keflex) Low

Antibiotics-Macrolides Cost Index

Azithromycin (Zithromax) Low-Moderate

Clarithromycin (Biaxin) Moderate

Antibiotics-Tetracyclines Cost Index

Doxycycline (Vibramycin) Low

Minocycline Moderate

Tetracycline High

Antibiotics-Quinolones Cost Index

Ciprofloxacin (Cipro) Low-High

levoFLOXacin (Levaquin) Low

Moxifloxacin (Avelox) High

Antibiotics-Aminoglycosides Cost Index

Amikacin High

Gentamicin High

Neomycin High

Tobramycin Moderate

Miscellaneous Antibiotics Cost Index

Clindamycin (Cleocin) Low-Highh

Fosfomycin (Monurol) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 100 Miscellaneous Antibiotics Cost Index

Linezolid (Zyvox) RESERVE USE High

metroNIDAZOLE (Flagyl) Low-Moderate

Sulfamethoxazole -Trimethoprim (Bactrim) Low-High The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage forms

Vancomycin (Vancocin) High

Antifungals Cost Index

Fluconazole (Diflucan) Low-Moderate

Griseofulvin (Fulvicin, Grifulvin V, Gris-Peg) High

Ketoconazole (Nizoral) Low

Nystatin (Mycostatin) Low

Terbinafine (LamISIL) Low

Antituberculars Cost Index

Ethambutol (Myambutol) Low

Ethionamide (Trecator) High

Isoniazid (INH) Low

Pyrazinamide Moderate

Rifabutin (Mycobutin) High

rifAMPin (Rifadin) Moderate

rifAMPin - Isoniazid (Rifamate) High

Antivirals Cost Index

Acyclovir (Zovirax) High

Oseltamivir (Tamiflu) High

valACYclovir (Valtrex) Moderate

Zanamivir (Relenza) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 101 All commercially available antiviral agents used in the treatment of AIDS/HIV are considered to be formulary agents

Antihelmintics Cost Index

Ivermectin (Stromectol) High

Urinary Anti-Infectives Cost Index

Nitrofurantoin (Macrodantin) Moderate

Miscellaneous Anti-Infectives Cost Index

Dapsone Low

Pentamidine (Pentam) - RESERVE USE High

Parenteral Solutions and Additives

Parenteral Solutions Cost Index

Amino Acid Injection (Aminosyn) High

Amino Acid Injection-Dextrose-Electrolytes (Clinimix E) High

Dextrose 5%-Sodium Chloride Intravenous Solution Moderate

Dextrose 5% in Water Moderate

Dextrose 5% in Ringer's Lactate Moderate

Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution Moderate

Dextrose 50% in Water High

Sodium Chloride Intravenous Solution Moderate

Sodium Chloride Moderate

Water for Injection Moderate

Electrolyte Replacement Additives Cost Index

Magnesium Sulfate Moderate

Potassium Chloride Low

Sodium Chloride Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 102 Nutritional Agents

Vitamins Cost Index

Ascorbic Acid (Vitamin C) Low

Cyanocobalamin ( Vitamin B12) Low-High

Folic Acid (Folvite) Low

Niacin Low

Pyridoxine (Vitamin B6) Low

Thiamine (Vitamin B1) Low

Vitamin A (Aquasol A) High

Vitamin D2 (Ergocalciferol, Calciferol, Drisdol) Low-Moderate

Vitamin D3 (Calcitrol, Rocaltrol, Cholecalciferol) Low

Vitamin E (Aquasol E) Low

Minerals, Trace Elements, and Electrolytes Cost Index

Calcium Carbonate (Os-Cal, Os-Cal chewable, Tums) - 40% elemental Low calcium

Calcium Citrate (Citracal) 20% elemental calcium Low

Ferrous Sulfate (Feosol, Fer-In-Sol) -20% elemental iron Low

Potassium Chloride Low

Zinc Sulfate Low

Combination Products Cost Index

Calcium Carbonate-Vitamin D3 (Os-Cal + D) 40% elemental calcium Low

Calcium Citrate-Vitamin D3 (Citracal-D) 20% elemental calcium Low

Iron salts with or without vitamins and/or minerals (Hemocyte Plus, Niferex- Low 150 Forte)

Multivitamin (Unicap, Hexavitamins) Low

Multivitamin-Minerals Low

Multivitamins, Pediatric (Poly-Vi-Sol) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 103 Combination Products Cost Index

Multivitamins, Prenatal Low

Vitamin B Complex Low

Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C, Nephrocaps, Low Nephro-vite)

Vitamin B Complex-Vitamin C-Zinc Low

Miscellaneous nutritional agents Cost Index

Levocarnitine (Carnitor) High

Respiratory Agents

Beta2 Agonist-Short acting (SABA) Cost Index

Albuterol (Proventil, Ventolin) Low-Moderate

Levalbuterol (Xopenex) Moderate

Beta2 Agonist-Long Acting (LABA) Cost Index

Salmeterol (Serevent) High

Anticholinergics-Short Acting (SAMA) Cost Index

Ipratropium (Atrovent) Low-Moderate

Anticholinergics-Long Acting (LAMA) Cost Index

Tiotropium (Spiriva) Moderate

Combination Short-Acting Beta2 Agonists Plus Anticholinergics Cost Index (SABA/SAMA)

Albuterol-Ipratropium (Combivent) Moderate

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 104 Combination Long Acting Beta-2 Agonists Plus Corticosteroids Cost Index (LABA/ICS)

Budesonide-Formoterol (Symbicort) Moderate

Fluticasone-Salmeterol (Advair) High

Inhaled Corticosteroids (ICS) Cost Index

Beclomethasone (QVAR Redihaler) Moderate

Budesonide (Pulmicort) Moderate

Fluticasone (Flovent) Moderate

Miscellaneous Respiratory Drugs Cost Index

Acetylcysteine High

Montelukast (Singulair) Low

Sodium Chloride Low

Antihistamine, Cough and Decongestant Preparations Cost Index

Benzonatate Antitussive Low

Brompheniramine-Phenylephrine (Dimetapp Children’s Cold and Allergy) Low

Brompheniramine-Pseudoephedrine, Rynex PSE) Low

Cetirizine (ZyrTEC) Low

Cetirizine-Pseudoephedrine (ZyrTEC D) Low

Chlorpheniramine Low

Cyproheptadine (Periactin) Low

*Dextromethorphan Antitussive Low

diphenhydrAMINE (Benadryl) Low

Fexofenadine (Allegra) Low

Fexofenadine - Pseudoephedrine (Allegra-D) Low

guaiFENesin-Codeine C-V Low

*guaiFENesin-Dextromethorphan Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 105 Antihistamine, Cough and Decongestant Preparations Cost Index

guaiFENesin-Pseudoephedrine (Mucinex D) Low

hydrOXYzine (Atarax, Vistaril) Low

Loratadine (Claritin) Low

Loratadine-Pseudoephedrine (Claritin D) Low

Pseudoephedrine (Sudafed) Decongestant Low

Triprolidine-Pseudoephedrine (Aprodine) Low

*Any combination of products containing dextromethorphan or guaifenesin are considered formulary if individual ingredients are on formulary AND the dosage form is on formulary.

Expectorants Cost Index

*guaiFENesin (Robitussin, Mucinex) Low

Potassium Iodide (SSKI) High

*ANY COMBINATION OF PRODUCTS CONTAINING DEXTROMETHORPHAN OR DEXTROMETHORPHAN-GUAIFENESIN ARE CONSIDERED FORMULARY IF INDIVIDUAL INGREDIENTS ARE ON FORMULARY AND THE DOSAGE FORM IS ON FORMULARY. Topical Agents

Ophthalmics-Agents for Glaucoma Cost Index

Betaxolol (Betoptic S) High

Bimatoprost (Lumigan) High

Brimonidine (Alphagan P) Low

Latanoprost (Xalatan) Moderate

Pilocarpine (Isopto Carpine) Moderate

Timolol (Timoptic, Timoptic XE) Low

Timolol-Dorzolamide (Cosopt) Low

Travoprost (Travatan Z) High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 106 Ophthalmics-Antibiotics Cost Index

Bacitracin High

Ciprofloxacin (Ciloxan) Moderate

Erythromycin High

Gentamicin Moderate

Moxifloxacin (Moxeza, Vigamox) Reserve Use High

Polymyxin B-Bacitracin (Polysporin) Low

Polymyxin B-Trimethoprim (Polytrim) Low

Sulfacetamide Sodium (Bleph-10) Moderate

Tobramycin (Tobrex) Moderate

Ophthalmics-Mydriatics Cost Index

Atropine Sulfate (Isopto Atropine) Moderate

Homatropine High

Phenylephrine (Neo-Synephrine) Moderate

Tropicamide (Mydriacyl) Low

Ophthalmics-Decongestant/Antiallergy Cost Index

Ketotifen (Zaditor) Low

Naphazoline Low

Olopatadine (Patanol) High

Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing) Low

Tetrahydrozoline-Zinc Sulfate (Visine A.C. ) Low

Miscellaneous Ophthalmics Cost Index

Balanced Salt Solution Ophthalmic Irrigating Solution (BSS, Eye Stream) High

Carboxymethylcellulose Low

Cromolyn (Intal) Low

Dexamethasone - RESERVE USE High

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 107 Miscellaneous Ophthalmics Cost Index

Fluorescein Sodium (Bio Glo, FUL-GLO) Low

Fluorescein-benoxinate (Altafluor Benox) N/A

Mineral Oil-Petrolatum (Akwa Tears, Refresh Lacrilube) Low

Polyvinyl Alcohol (Artifical Tears, Akwa Tears) Moderate

Prednisolone (Pred Mild, Pred Forte) RESERVE USE High

Proparacaine (Alcaine) Moderate

Sodium Chloride Low

Tobramycin-Dexamethasone (TobraDex)- RESERVE USE High

Otics Cost Index

Acetic Acid Low

Acetic Acid-Hydrocortisone (VoSol HC) High

Carbamide Peroxide (Debrox) Low

Ciprofloxacin-Dexamethasone (Ciprodex) High

Ciprofloxacin-Hydrocortisone (Cipro HC Otic) High

Hydrogen Peroxide Low

Mineral Oil Low

Neomycin-Polymyxin B-Hydrocortisone (Cortisporin) Moderate

Mouth and Throat Agents Cost Index

Benzocaine (Orajel, Cepacol) Low

Carbamide Peroxide (Gly-Oxide) Low

Chlorhexidine (Peridex) Low

Clotrimazole Low

Doxycycline N/A

Fluoride (PerioMed) Low

Lidocaine (Viscous Lidocaine) Low

Nystatin Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 108 Mouth and Throat Agents Cost Index

Phenol (Chloraseptic) Low

Saliva Substitute(Biotene) Low

Triamcinolone High

Nasal Agents Cost Index

Azelastine Low

Beclomethasone (Beconase) Moderate

Fluticasone (Flonase) Low

Mometasone (Nasonex) Low

Oxymetazoline (Afrin) Low

Phenylephrine (Neo-Synephrine) Low

Sodium Chloride Low

Triamcinolone (Nasacort) Low

Dermatologicals-Acne Agents Cost Index

Adapalene (Differin) Moderate

Benzoyl Peroxide Low

Benzoyl Peroxide-Clindamycin (BenzaClin) High

Clindamycin (Cleocin T) Moderate

Erythromycin-Benzoyl Peroxide (Benzamycin) Moderate

metroNIDAZOLE (Noritate, MetroGel) Moderate

Salicylic Acid-Sulfur Low

Sulfacetamide Sodium Low

Tazarotene (Tazorac, Avage) High

Tretinoin (Retin-A) High

Dermatologicals-Analgesics Cost Index

Diclofenac Gel (Voltaren Gel)- RESERVE USE Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 109

Dermatologicals-Anesthetics, local Cost Index

Benzocaine (Lanacaine) Low

Ethyl Chloride Low

Lidocaine (Xylocaine) Low

Lidocaine-Prilocaine (EMLA, Lidoderm) Low

Pramoxine Low

Dermatologicals-Anti-Histamine Agents Cost Index

Calamine-Zinc Oxide-Glycerin (Calamine Lotion) Low

Calamine-Pramoxine (Caladryl) Low

diphenhydrAMINE (Benadryl) Low

Pramoxine-Zinc (Caladryl Clear) Low

Dermatologicals-Anti-Infectives-Antibiotics Cost Index

Bacitracin Low

Bacitracin-Polymyxin B (Polysporin) Low

Clindamycin (Cleocin T) Moderate

Gentamicin Moderate

metroNIDAZOLE (Noritate, MetroGel) Moderate

Mupirocin (Bactroban) Low-High

Neomycin-Polymyxin B-Bacitracin (Triple Antibiotic Ointment) Low

Dermatologicals-Anti-Infectives-Antiviral Cost Index

Acyclovir (Zovirax) High

Dermatologicals-Anti-Infectives-Antifungals Cost Index

Ciclopirox Low

Clotrimazole Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 110 Dermatologicals-Anti-Infectives-Antifungals Cost Index

Clotrimazole-Betamethasone dipropionate (Lotrisone ) Low

Ketoconazole Low

Miconazole Low

Nystatin Low

Terbinafine Low

Tolnaftate Low

Dermatologicals-Antipsoriatics Cost Index

Calcipotriene (Dovonex) High

Coal Tar Low

Selenium Sulfide Low

Tazarotene (Tazorac, Avage) High

Dermatologicals-Antiseborrheic Agents Cost Index

Coal Tar Low

Salicylic Acid-Sulfur Low

Selenium Sulfide Low

Sulfacetamide Sodium Low

Dermatologicals-Antiseptics & Germacides Cost Index

Chlorhexidine Low

Hexachlorophene Low

Povidone-Iodine (Betadine) Low

Dermatologicals-Burn Agents Cost Index

Bacitracin Low

Silver SulfADIAZINE (Silvadene) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 111 Dermatologicals-Corticosteroids-Ultra High Potency Cost Index

Betamethasone dipropionate, augmented (Diprolene A/F) - RESERVE USE Low

Clobetasol (Clobex, Cormax,Temovate) - RESERVE USE Moderate

Dermatologicals-Corticosteroids- High Potency Cost Index

Betamethasone dipropionate (Diprolene) Moderate

Fluocinonide Low

Dermatologicals-Corticosteroids- Medium Potency Cost Index

Betamethasone Valerate (Valisone) Moderate

Fluocinolone (Capex, Derma-Smooth/FS, Synalar) Moderate

Triamcinolone Low

Dermatologicals-Corticosteroids- Low Potency Cost Index

Desonide (Desowen, Tridesilon) Low-High

Hydrocortisone (Lanacort, Corticaine) Low

Dermatologicals-Diaper Rash Agents Cost Index

Diaper Rash Ointment Low

Diaper Rash Powder (Mexsana) Low

Zinc Oxide Low

Dermatologicals-Emollients Cost Index

Emollient Gel Low

Emollient Lotion-Cream (Lubriderm, Keri Lotion, Cetaphil, Eucerin, Low Nutraderm)

Emollient Ointment (Lanolin, Aquaphor) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 112 Dermatologicals-Keratolytics Cost Index

Podophyllum Resin (Podocon-25) High

Salicylic Acid Low-High All available salicylic acid products as a single agent are considered to be on formulary

Urea Low

Dermatologicals-Ointments Cost Index

Petrolatum, White (Vaseline) Low

Oxybenzone-PDO-Pet Hy-Phl (Vaseline Lip Therapy) Low

Dermatologicals-Rubs and Liniments Cost Index

Menthol Low

Menthol-Methyl Salicylate (Ben-Gay) Low

Dermatologicals-Skin Cleansers Cost Index

Abrasive Cleanser (Brasivol, Pernox, Salac, Seba-Nil) Low

Non-Soap Cleanser (Cetaphil) Low

Salicylic Acid-Sulfur Low All commercially available salicylic acid sulfur forms are on formulary

Dermatologicals-Scabicides & Pediculicides Cost Index

Permethrin 1% Liquid (NIX) Low

Permethrin 5% Cream (Elimite) Low

Pyrethins 0.33%-Piperonyl Butoxide 4% (Pronto, RID) Low

Dermatologicals-Skin Protectants Cost Index

Benzoin, Compound Tincture Low

Menthol-Zinc Oxide (Calmoseptine, Risamine) Low

Silver SulfADIAZINE (Silvadene) Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 113 Dermatologicals-Skin Protectants Cost Index

Zinc Oxide Low

Dermatologicals-Sunscreens Cost Index

Sunscreen-Block- Contains minimum SPF 15 Low

Dermatologicals-Tar-Containing Agents Cost Index

Coal Tar Low

Dermatologicals-Wound Agents Cost Index

Collagenase (Santyl) High

Trypsin-Balsam Peru-Castor Oil (Granulex, Revina, TBC) Low

Wound Cleanser (Carrington Clara-Klenz) Low

Miscellaneous Dermatologicals Cost Index

Aluminum Chloride Hexahydrate (Drysol) Low

Camphor-Phenol (Campho-Phenique) Low

Hydrogen Peroxide Low

Pimecrolimus (Elidel) High

Silver Nitrate Low

Tacrolimus (Protopic) High

Trypsin-Balsam Peru-Castor Oil (Granulex) Low

Irrigation Solutions Cost Index

Sodium Chloride Solution, irrigation: 0.45%, 0.9% Moderate-High

Water for Irrigation Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 114 Nutritional Supplements

Certification Process Used Product Line Certified

Good Manufacturer Practices (GMP) Nature’s Way

Good Manufacturer Practices (GMP) Country Life

Good Manufacturer Practices (GMP) Twin

Consumer Labs (CL) Good Neighbor Pharmacy

Consumer Labs (CL) Sundown

United States Pharmacopoeia (USP) Nature Made

National Sanitation Foundation (NSF) GNC Nutritional Supplements

Supplement Cost Index

Fish Oil (Nature Made Fish Oil) Low

Glucosamine Low

Magnesium L-lactate dihydrate (Mag-Tab SR) Low

Melatonin Low

Texas HHS Psychiatric Drug Formulary 2021

Therapeutic Classification/Cost Index 115 Index

A Adderall XR ...... 19, 34

Abilify ...... 13, 35, 90 Adenocard ...... 23, 33, 83

Abilify discmelt ...... 35, 90 Adenosine ...... 23, 33, 83

Abilify Maintena ...... 13, 35, 90 Adrenalin ...... 48, 84

Abrasive Cleanser ...... 113 Advair ...... 51, 105

Acamprosate ...... 32, 92 Afrin ...... 65, 109

Acetaminophen ...... 32, 85 Akwa Tears ...... 61, 67, 108

Acetaminophen-Codeine ...... 32, 85 Albuterol ...... 33, 104

Acetaminophen-HYDROcodone ...... 32, 85 Albuterol-Ipratropium ...... 33, 104 acetaZOLAMIDE ...... 32, 82 Alcaine ...... 69, 108

Acetic Acid ...... 32, 108 Aldactazide ...... 73, 82

Acetic Acid-Hydrocortisone ...... 32, 108 Aldactone ...... 73, 82

Acetylcysteine ...... 32, 105 Alendronate ...... 33, 93

Actonel ...... 70, 93 Allbee with C ...... 78, 104

Actos ...... 67, 80 Allegra ...... 49, 105

Acyclovir ...... 32, 101, 110 Allegra-D ...... 49, 105

Adacel ...... 46, 99 Allopurinol ...... 33, 94

Adalat CC ...... 63, 83 Alora ...... 48, 92

Adapalene ...... 33, 109 Alphagan P...... 38, 106

Adderall ...... 19, 34, 92 ALPRAZolam...... 21, 33, 88

Texas HHS Psychiatric Drug Formulary 2021

Index 116 Altafluor Benox ...... 50, 108 Analpram HC ...... 68, 97

Aluminum Chloride Hexahydrate ...... 33, 114 Androlan ...... 74, 93

Aluminum Hydroxide ...... 33, 94 Antabuse ...... 46, 92

Aluminum Hydroxide-Magnesium Hydroxide Antara ...... 49, 83 ...... 33, 94 Antineoplastic Agents ...... 35 Aluminum Hydroxide-Magnesium Hydroxide- Simethicone ...... 34, 94 Antivert ...... 59, 87

Aluminum Hydroxide-Magnesium Trisilicate Antiviral Agents ...... 35 ...... 33, 94 Anusol-HC ...... 53, 96 Amantadine ...... 34, 87 Apixaban ...... 35, 81 Ambien ...... 22, 79, 89 Aprodine ...... 76, 106 Amikacin ...... 34, 100 Aquaphor ...... 47, 112 Amino Acid Injection ...... 34, 102 Aquasol A ...... 77, 103 Amino Acid Injection-Dextrose-Electrolytes Aquasol E ...... 78, 103 ...... 34, 102 Aricept ...... 47, 88 Aminosyn ...... 34, 102 ARIPiprazole ...... 13, 35, 90 Amiodarone ...... 34, 83 ARIPiprazole Extended Release ...... 13 Amitiza ...... 58, 96 ARIPiprazole Initio...... 13, 23 Amitriptyline ...... 15, 30, 34, 84, 90 ARIPiprazole lauroxil ...... 13 amLODIPine ...... 34, 83 Aristada ...... 13, 35, 90 Amoxicillin ...... 34, 99 Aristada Initio ...... 13, 23, 35, 90 Amoxicillin-Clavulanate ...... 34, 99 Arixtra ...... 51, 81 Amoxil ...... 34, 99 Artane ...... 76, 88 Amphetamine Mixture ...... 19, 34, 92 Artifical Tears ...... 67, 108 Ampicillin ...... 34, 99 Asacol HD ...... 59, 97 Anafranil ...... 16, 42, 90

Texas HHS Psychiatric Drug Formulary 2021

Index 117 Ascorbic Acid ...... 35, 103 Bactroban ...... 62, 110

Asenapine ...... 13, 35, 90 Balanced Salt Solution Ophthalmic Irrigating Solution ...... 36, 107 Aspirin ...... 35, 81, 85 Banzel ...... 71, 87 Aspirin-Acetaminophen-Caffeine ...... 35, 84 Beclomethasone ...... 36, 105, 109 Atarax ...... 22, 54, 87, 89, 106 Beconase ...... 36, 109 Atenolol ...... 35, 83, 84 Benadryl ...... 22, 46, 87, 89, 105, 110 Ativan ...... 21, 58, 86, 89 Benazepril ...... 36, 84 atoMOXetine ...... 20, 35, 92 Ben-Gay ...... 59, 113 atorvaSTATin ...... 35, 83 Benicar ...... 29, 64, 84 Atropine Sulfate ...... 36, 107 Bentyl ...... 45, 94 Atrovent ...... 55, 104 BenzaClin ...... 37, 109 Augmentin ...... 34, 99 Benzamycin ...... 48, 109 Avage ...... 74, 109, 111 Benzocaine ...... 36, 108, 110 Avelox ...... 62, 100 Benzodiazepines ...... 31, 86, 88 Azelastine ...... 36, 109 Benzoin, Compound Tincture ...... 36, 113 Azilect ...... 70, 88 Benzonatate ...... 37, 105 Azithromycin ...... 36, 100 Benzoyl Peroxide ...... 37, 109 Azulfidine ...... 73, 97 Benzoyl Peroxide-Clindamycin...... 37, 109 B Benztropine ...... 37, 87 Bacid ...... 56, 96 Betadine ...... 68, 111 Bacitracin ...... 36, 107, 110, 111 Betamethasone dipropionate ...... 37, 112 Bacitracin-Polymyxin B ...... 36, 110 Betamethasone dipropionate, augmented 23, Baclofen ...... 36, 88 37

Bactrim ...... 73, 101 Betamethasone Valerate ...... 37, 112

Texas HHS Psychiatric Drug Formulary 2021

Index 118 Betaxolol ...... 37, 106 Budeprion ...... 38, 90

Bethanechol ...... 37, 98 Budesonide ...... 38, 105

Betoptic S ...... 37, 106 Budesonide-Formoterol ...... 38, 105

Biaxin ...... 42, 100 Buprenorphine ...... 23, 38, 92

Bicillin LA ...... 65, 99 Buprenorphine-naloxone ...... 23, 38, 92

Bicitra ...... 97 buPROPion ...... 15, 38, 90

Bimatoprost ...... 37, 106 buPROPion SR ...... 16

Binosto ...... 33, 93 buPROPion XL ...... 16

Bio Glo ...... 50, 108 BuSpar ...... 21, 38, 89

Biotene ...... 71, 109 busPIRone ...... 21, 38, 89

Bisacodyl ...... 37, 95 C

Bismatrol ...... 38, 96, 97 Caladryl ...... 39, 110

Bismuth Subsalicylate ...... 38, 96, 97 Caladryl Clear ...... 68, 110

Bleph-10 ...... 73, 107 Calamine Lotion ...... 38, 110

Bonine ...... 59, 87 Calamine-Pramoxine ...... 39, 110

Boniva ...... 54, 93 Calamine-Zinc Oxide-Glycerin ...... 38, 110

Boostrix ...... 46, 99 Calan ...... 77, 83, 85

Brasivol ...... 113 Calan SR ...... 77, 83

Brexpiprazole ...... 13, 38, 90 Calciferol ...... 48, 78, 103

Brimonidine ...... 38, 106 Calcipotriene ...... 39, 111

Bromocriptine ...... 38, 87 Calcitonin-Salmon ...... 39, 93

Brompheniramine-Phenylephrine ..... 38, 105 Calcitrol ...... 41, 78, 103

Brompheniramine-Pseudoephedrine . 38, 105 Calcium Carbonate ...... 39, 94, 103

BSS ...... 36, 107 Calcium Carbonate-Vitamin D3 ...... 39

Texas HHS Psychiatric Drug Formulary 2021

Index 119 Calcium Carbonate-Vitamin DR3R ...... 103 Carrington Clara-Klenz ...... 78, 114

Calcium Citrate ...... 39, 103 Carvedilol ...... 40, 83

Calcium Citrate-Vitamin D3 ...... 39 Catapres ...... 20, 42, 84, 92

Calcium Citrate-Vitamin DR3R ...... 103 ceFAZolin ...... 40, 99

Calmoseptine ...... 59, 113 Cefdinir ...... 40, 99

Campho-Phenique ...... 39, 114 Cefepime ...... 40, 100

Camphor-Phenol ...... 39, 114 Ceftin ...... 40, 100

Campral ...... 32, 92 cefTRIAXone ...... 40, 100

Canagliflozin ...... 39, 80 Cefuroxime Axetil ...... 40, 100

Canasa ...... 59, 97 CeleBREX ...... 24, 40, 85

Cannabidiol ...... 23, 39, 86 Celecoxib ...... 24, 40, 85

Capex ...... 50, 112 CeleXA ...... 16, 42, 89

Caplyta ...... 14, 58, 91 Cellulose ...... 40, 95

Capoten ...... 39, 84 Cepacol ...... 36, 108

Captopril ...... 39, 84 Cephalexin ...... 40, 100

Carafate ...... 73, 97 Cerebyx ...... 51, 86 carBAMazepine ...... 17, 30, 39, 86, 91 Cetaphil ...... 47, 63, 112, 113

Carbamide Peroxide ...... 40, 108 Cetirizine ...... 41, 105

Carbatrol ...... 17, 39 Cetirizine-Pseudoephedrine ...... 41, 105

Carbidopa-Levodopa ...... 40, 88 Chloraseptic ...... 66, 109

Carboxymethylcellulose ...... 40 chlordiazePOXIDE ...... 21, 41, 88

Cardizem ...... 46, 83 Chlorhexidine ...... 41, 108, 111

Cariprazine ...... 13, 40, 90 Chlorpheniramine ...... 41, 105

Carnitor ...... 56, 104 chlorproMAZINE ...... 10, 11, 13, 41, 91

Texas HHS Psychiatric Drug Formulary 2021

Index 120 Chlorthalidone ...... 41, 82 Clinoril ...... 73, 85

Cholecalciferol ...... 41, 78, 103 cloBAZam ...... 24, 31, 42, 86

Cholestyramine ...... 41, 83 Clobetasol ...... 24, 42, 112

Ciclopirox ...... 41, 110 Clobex ...... 42, 112

Ciloxan ...... 41, 107 clomiPRAMINE ...... 16, 42, 90

Cipro ...... 41, 100 clonazePAM ...... 21, 42, 86, 88

Cipro HC Otic ...... 108 cloNIDine ...... 20, 42, 84, 92

Cipro Otic ...... 42 cloNIDine Extended Release ...... 20

Ciprodex ...... 41, 108 Clopidogrel ...... 42, 81

Ciprofloxacin ...... 41, 100, 107 Clorazepate ...... 21, 43, 86, 89

Ciprofloxacin-Dexamethasone ...... 41, 108 Clotrimazole ...... 43, 98, 108, 110

Ciprofloxacin-Hydrocortisone ...... 42, 108 Clotrimazole- Betamethasone dipropionate ...... 43, 111 Citalopram ...... 16, 42, 89 cloZAPine ...... 13, 24, 30, 43, 91 Citracal ...... 39, 103 Clozaril ...... 13, 24, 43, 91 Citracal-D ...... 39, 103 Coal Tar ...... 43, 111, 114 Citrucel ...... 60, 95 Cod Liver Oil-Zinc Oxide-Talc ...... 43 Clarithromycin...... 42, 100 Cogentin ...... 37, 87 Claritin ...... 58, 106 Colace ...... 46, 96 Claritin D ...... 58, 106 Colchicine ...... 43, 85 Cleocin ...... 42, 100 Collagenase ...... 43, 114 Cleocin T ...... 42, 109, 110 Co-Lyte ...... 67, 96 Climara ...... 48, 92 Combivent ...... 33, 104 Clindamycin ...... 42, 100, 109, 110 Compazine ...... 69, 87 Clinimix E ...... 34, 102

Texas HHS Psychiatric Drug Formulary 2021

Index 121 Comtan ...... 47, 88 Darifenacin ...... 44, 98

Concerta ...... 19, 60, 92 DDAVP ...... 44, 94

Cordarone ...... 34, 83 Debrox ...... 40, 108

Coreg ...... 40, 83 Deltason ...... 69

Coreg CR ...... 40, 83 Deltasone ...... 93

Cormax ...... 42, 112 Denosumab ...... 44, 93

Cortef ...... 53, 93 Depakene ...... 18, 77, 85, 87, 91

Corticaine ...... 53 Depakote ...... 18, 46, 84, 86, 91

Cortisporin ...... 63, 108 Depakote ER ...... 18, 46, 84

Cosopt ...... 75, 106 DEPO-Medrol ...... 60, 93

Coumadin ...... 78, 81 Derma-Smooth/FS ...... 50, 112

Cozaar ...... 58, 84 Desipramine ...... 16, 30, 44, 90

Creon ...... 65, 97 Desitin ...... 43

Crestor...... 71, 83 Desmopressin ...... 44, 94

Cromolyn ...... 43, 107 Desonide ...... 44, 112

Cyanocobalamin ...... 43, 103 Desowen ...... 44, 112

Cyclobenzaprine ...... 43, 88 Desyrel ...... 17, 22, 76, 89, 90

Cymbalta ...... 16, 47, 90 Detrol...... 75, 98

Cyproheptadine ...... 44, 105 Detrol LA ...... 75, 98

Cytotec ...... 61, 97 Dexamethasone ...... 44, 93, 107

D Dexedrine ...... 19, 44, 92

Dantrium ...... 44, 88 Dexedrine spansules...... 44

Dantrolene ...... 44, 88 Dexedrine Spansules ...... 19

Dapsone ...... 44, 102 Dexmethylphenidate XR ...... 19, 44, 92

Texas HHS Psychiatric Drug Formulary 2021

Index 122 Dextroamphetamine ...... 19, 44 diphenhydrAMINE ..... 10, 12, 22, 46, 87, 89, 105, 110 Dextroamphetamine XR ...... 92 Diphtheria-Tetanus Toxoids Adsorbed . 46, 99 Dextromethorphan ...... 44, 105 Diphtheria-Tetanus Toxoids Adsorbed for Dextrose 5% in Ringer's Lactate ...... 45, 102 Adult Use ...... 46, 99

Dextrose 5% in Water ...... 45, 102 Diphtheria-Tetanus-Acellular Pertussis 46, 99

Dextrose 5%-Sodium Chloride Intravenous Diprolene ...... 37, 112 Solution ...... 45, 102 Diprolene A/F ...... 23, 37, 112 Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution ...... 45, 102 Disulfiram ...... 46, 92

Dextrose 50% in Water ...... 45, 102 Ditropan XL ...... 65, 98

Diamox ...... 32, 82 Divalproex ...... 18, 31, 46, 84, 86, 91

Diaper Rash Ointment ...... 45, 112 Docusate Calcium ...... 46, 96

Diaper Rash Powder ...... 45, 112 Docusate Sodium ...... 46, 96

Diaperene ...... 78 Docusate Sodium-Sennosides ...... 47, 96

Diastat ...... 45, 86 Dolophine ...... 60, 85 diazePAM ...... 21, 45, 86, 88, 89 Donepezil...... 47, 88

Diclofenac Gel ...... 24, 45, 109 DOPamine ...... 24, 47, 84

Dicyclomine ...... 45, 94 Dovonex ...... 39, 111

Differin ...... 33, 109 Doxepin ...... 16, 30, 47, 90

Diflucan ...... 50, 101 Doxycycline ...... 47, 100, 108

Digoxin ...... 45, 82 Drisdol ...... 48, 78, 103

Dilantin ...... 66, 86 Drysol ...... 33, 114 dilTIAZem ...... 46, 83 DT ...... 46, 99

Dimetapp Children’s Cold and Allergy 38, 105 Dulcolax ...... 37, 95

Diovan ...... 77, 84 DULoxetine ...... 16, 47, 90

Texas HHS Psychiatric Drug Formulary 2021

Index 123 Duragesic ...... 49 EpiPen ...... 48, 80

Dyazide ...... 76, 82 Epoetin alfa ...... 24, 48, 82

E Epogen ...... 24, 48, 82

E.E.S...... 48 Epsom Salt ...... 59

Effexor ...... 17, 77, 85, 90 Ergocalciferol ...... 48, 78, 103

Effexor XR ...... 17 Eryc ...... 48

Elavil ...... 15, 34, 84, 90 EryPed ...... 48

Eldepryl ...... 71, 88 Erythrocin ...... 48

Elidel ...... 67, 114 Erythromycin ...... 48, 107

Elimite ...... 66, 113 Erythromycin base ...... 48

Eliquis ...... 35, 81 Erythromycin Ethylsuccinate ...... 48

EMLA ...... 57, 110 Erythromycin-Benzoyl Peroxide ...... 48, 109

Emollient Gel ...... 47, 112 Escitalopram ...... 16, 48, 89

Emollient Lotion-Cream ...... 47, 112 Eskalith ...... 18, 57, 91

Emollient Ointment ...... 47, 112 Esketamine ...... 24, 48, 90

Empagliflozin ...... 47, 80 Esomeprazole ...... 48, 95

Enablex ...... 44, 98 Estrace ...... 48, 92

Enalapril ...... 47, 84 Estraderm ...... 48, 92

Engerix-B ...... 53, 99 Estradiol ...... 48, 92

Enoxaparin ...... 47, 81 Estrogen-medroxyPROGESTERone ...... 48, 93

Entacapone ...... 47, 88 Estrogens, Conjugated ...... 48, 92

Enulose ...... 56, 96 Eszopiclone ...... 22, 58, 89

Epidiolex ...... 23, 39, 86 Ethambutol ...... 49, 101

EPINEPHrine ...... 48, 80, 84 Ethionamide ...... 49, 101

Texas HHS Psychiatric Drug Formulary 2021

Index 124 Ethosuximide ...... 30, 49, 86 Fibercon ...... 67, 95

Ethyl Chloride ...... 49, 110 Fiber-Lax ...... 67, 95

Eucerin ...... 47, 112 Filibon ...... 62

Evista ...... 70, 93 Finasteride ...... 50, 97

Excedrine Migraine...... 35, 84 Fish Oil ...... 50, 115

Exelon ...... 71, 88 Flagyl ...... 61, 101

Exelon Patches ...... 71, 88 Flomax ...... 74, 97

Eye Stream ...... 36, 107 Flonase ...... 51, 109

F Florajen ...... 56, 96

Famotidine ...... 49, 94 Florastor ...... 71, 96

Fanapt ...... 14, 25, 54, 91 Flovent ...... 51, 105

Fazaclo ...... 13, 24, 43 Fluconazole ...... 50, 101

Felbamate ...... 25, 49, 86 Fludrocortisone ...... 50, 93

Felbatol ...... 25, 49, 86 Fluocinolone ...... 50, 112

Fenofibrate ...... 49, 83 Fluocinonide ...... 50, 112 fentaNYL ...... 49 Fluorescein Sodium ...... 50, 108

Feosol ...... 49, 82, 103 Fluorescein-benoxinate ...... 50, 108

Fer-In-Sol ...... 49, 82, 103 Fluoride ...... 50, 108

Ferro-Sequels ...... 49, 82 FLUoxetine ...... 16, 50, 89

Ferrous Fumarate-Docusate Sodium ... 49, 82 fluPHENAZine ...... 12, 13, 30, 50, 91

Ferrous Sulfate ...... 49, 82, 103 fluPHENAZine Decanoate ...... 13

Fexofenadine ...... 49, 105 Fluticasone...... 51, 105, 109

Fexofenadine - Pseudoephedrine ...... 49 Fluticasone-Salmeterol ...... 51, 105

Fexofenadine-Pseudoephedrine ...... 105 fluvoxaMINE ...... 16, 51, 89

Texas HHS Psychiatric Drug Formulary 2021

Index 125 Focalin XR ...... 19, 44, 92 Glucotrol ...... 52, 80

Folic Acid ...... 51 Glycerin ...... 52, 96

Folvite ...... 51 Glycopyrrolate ...... 52, 94

Fondaparinux ...... 51, 81 Gly-Oxide ...... 40, 108

Fosamax ...... 33, 93 GoLYTELY ...... 67, 96

Fosfomycin ...... 51, 100 Granulex...... 77, 114

Fosphenytoin ...... 51, 86 Grifulvin V ...... 52, 101

FUL-GLO ...... 50, 108 Griseofulvin ...... 52, 101

Fulvicin ...... 52, 101 Gris-Peg ...... 52, 101

Furosemide ...... 51, 82 guaiFENesin ...... 52, 106

G guaiFENesin-Codeine ...... 52, 105

Gabapentin ...... 31, 51, 86 guaiFENesin-Dextromethorphan ...... 52, 105

Gabatril ...... 74, 87 guaiFENesin-Pseudoephedrine ...... 52, 106

Galantamine ...... 51, 88 guanFACINE ...... 20, 53, 92

Gas-X ...... 72, 95 guanFACINE Extended Release ...... 20

Gaviscon ...... 33, 94 Gyne-Lotrimin ...... 43, 98

Gentamicin ...... 51, 100, 107, 110 H

Geodon ...... 15, 79, 91 Halcion ...... 22, 76, 89 glipiZIDE ...... 52, 80 Haldol ...... 14, 53, 91

Glucagon ...... 52, 81 Haldol Decanoate ...... 14

Glucophage ...... 60, 80 Haloperidol ...... 10, 12, 14, 30, 53, 91

Glucophage XR ...... 60, 80 Haloperidol Decanoate ...... 14

Glucosamine ...... 52, 115 Havrix ...... 53, 98

Glucose, oral ...... 52, 81 HBIG ...... 53, 98

Texas HHS Psychiatric Drug Formulary 2021

Index 126 Hemocyte Plus ...... 55, 103 Iloperidone ...... 14, 25, 54, 91

Heparin ...... 53, 81 Imipramine ...... 16, 30, 54, 90

Hepatitis A Vaccine ...... 53, 98 Imitrex ...... 73, 85

Hepatitis A-Hepatitis B Vaccine ...... 53, 99 Imodium ...... 58, 96

Hepatitis B Immune Globulin ...... 53, 98 Inderal ...... 20, 69, 83, 85

Hepatitis B Virus Vaccine, Recombinant ... 53, Influenza Virus Vaccine ...... 54, 99 99 INH ...... 55, 101 Heplisav-B ...... 53, 99 Inotropin ...... 24 Hexachlorophene ...... 53, 111 Insulin, Aspart ...... 54, 80 Hexavitamins ...... 62, 103 Insulin, Combination (70/30) ...... 54, 80 Homatropine ...... 53, 107 Insulin, Combination, lispro protamine HumaLOG ...... 54, 80 suspension-insulin lispro ...... 80

HumaLOG Mix 50/50 ...... 55, 80 Insulin, Detemir ...... 54, 80

HumaLOG Mix 75/25 ...... 55, 80 Insulin, Glargine ...... 54, 80

HumuLIN ...... 55, 80 Insulin, Lispro ...... 54, 80 hydrALAZINE ...... 53, 84 Insulin, lispro protamine suspension- insulin lispro ...... 55 hydroCHLOROthiazide ...... 53, 82 Insulin, NPH ...... 55, 80 Hydrocortisone ...... 53, 93, 112 Insulin, Regular ...... 55, 80 Hydrocortisone ...... 96 Intal ...... 107 Hydrogen Peroxide...... 54, 108, 114 Intropin ...... 47, 84 hydrOXYzine ...... 10, 12, 22, 54, 87, 89, 106 Intuniv ...... 20, 53, 92 I Invega ...... 14, 65, 91 Ibandronate ...... 54, 93 Invega Sustenna ...... 14, 65 Ibuprofen ...... 54, 85 Invega Trinza ...... 14

Texas HHS Psychiatric Drug Formulary 2021

Index 127 Invokana ...... 39, 80 Ketamine ...... 26, 55, 90

Ipratropium ...... 55, 104 Ketoconazole ...... 55, 101, 111

Iron salts with or without vitamins and/or Ketorolac ...... 56, 85 minerals ...... 55, 103 Ketotifen ...... 56, 107 Isoniazid ...... 55, 101 KlonoPIN ...... 21, 42, 86, 88 Isoptin ...... 77, 83, 85 Konsyl ...... 69, 95 Isoptin SR ...... 77, 83 L Isopto Atropine ...... 36, 107 Labetalol ...... 56, 83 Isopto Carpine ...... 67, 106 Lacosamide ...... 31, 56, 86 Isordil ...... 55, 82 Lactinex...... 56, 96 Isosorbide Dinitrate ...... 55, 82 Lactobacillus Acidophilus ...... 56, 96 Isosorbide Mononitrate ...... 55, 82 Lactulose ...... 56, 96 Ivermectin ...... 55, 102 LaMICtal ...... 18, 56, 87, 91 J LamISIL ...... 74, 101 Januvia ...... 72, 80 lamoTRIgine ...... 18, 30, 56, 87, 91 Jardiance ...... 47, 80 Lanacaine ...... 36, 110 K Lanacort ...... 53 Kaopectate ...... 38, 96, 97 Lanolin ...... 47, 112 Kapvay ...... 20 Lanoxin ...... 45, 82 Keflex ...... 40, 100 Lansoprazole ...... 56, 94 Kefzol ...... 40, 99 Lantus ...... 54, 80 Keppra ...... 56, 87 Lasix ...... 51, 82 Keri Lotion ...... 47, 112 Latanoprost ...... 56, 106 Ketalar ...... 26, 55, 90 Latuda ...... 14, 58, 91

Texas HHS Psychiatric Drug Formulary 2021

Index 128 Levalbuterol ...... 56, 104 Lithium Citrate ...... 57

Levaquin ...... 57, 100 Lithobid ...... 18, 57

Levarterenol ...... 28, 56, 64, 84 Lithonate ...... 57, 91

Levemir ...... 54, 80 Lofibra ...... 49, 83 levETIRAcetam ...... 31, 56, 87 Loperamide ...... 58, 96

Levocarnitine ...... 56, 104 Lopressor ...... 60, 83, 84 levoFLOXacin ...... 57, 100 Loprox ...... 41

Levophed ...... 28, 56, 64, 84 Loratadine ...... 58, 106

Levothyroxine ...... 57, 94 Loratadine-Pseudoephedrine ...... 58, 106

Levoxyl ...... 57, 94 LORazepam ...... 10, 12, 21, 58, 86, 89

Lexapro ...... 16, 48, 89 Lortab ...... 32, 85

Librium ...... 21, 41, 88 Losartan ...... 58, 84

Lidocaine ...... 57, 108, 110 Lotensin ...... 36, 84

Lidocaine-Prilocaine ...... 57, 110 Lotrimin ...... 43

Lidoderm ...... 57, 110 Lotrisone ...... 43, 111

Linaclotide ...... 27, 57, 96 Lovaza ...... 64, 83

Linezolid ...... 27, 57, 101 Lovenox ...... 47, 81

Linzess ...... 27, 57, 96 Loxapine ...... 14, 58, 91

Lipitor ...... 35, 83 Loxitane ...... 14, 58, 91

Liraglutide ...... 57, 80 Lubiprostone ...... 58, 96

Lisdexamfetamine...... 19, 27, 57, 92 Lubriderm ...... 47, 112

Lisinopril ...... 57, 84 Lumateperone ...... 14, 58, 91

Lithium ...... 18, 30, 91 Lumigan ...... 37, 106

Lithium Carbonate ...... 57 Luminal ...... 66, 86

Texas HHS Psychiatric Drug Formulary 2021

Index 129 Lunesta ...... 22, 58, 89 Meloxicam ...... 59, 85

Lurasidone ...... 14, 58, 91 Memantine ...... 59, 88

Luvox ...... 16, 51, 89 Menthol ...... 59, 113

Lyrica ...... 69, 87 Menthol-Methyl Salicylate ...... 59, 113

M Menthol-Zinc Oxide ...... 59, 113

Maalox ...... 33, 94 Mephyton ...... 66, 81

Macrodantin ...... 63, 102 Mesalamine ...... 59, 97

Magnesium Citrate ...... 58, 95 Metadate ...... 19, 60, 92

Magnesium Hydroxide ...... 58, 95 Metadate CD ...... 60, 92

Magnesium L-lactate dihydrate ...... 59, 115 Metamucil ...... 69, 95

Magnesium Sulfate ...... 59, 102 metFORMIN ...... 60, 80

Mag-Tab SR ...... 59, 115 Methadone ...... 60, 85

Maxipime ...... 40, 100 methIMAzole ...... 60, 94

Maxzide ...... 76, 82 Methocarbamol ...... 60, 88

Measles-Mumps-Rubella Virus Vaccine, Live Methylcellulose ...... 60, 95 ...... 59, 99 Methyldopa ...... 60, 84 Meclizine ...... 59, 87 Methylin ...... 19, 60, 92 Medrol ...... 60, 93 Methylphenidate, immediate release .. 19, 60, medroxyPROGESTERone ...... 59, 93 92

Megace ...... 59, 87 Methylphenidate, sustained release ... 19, 60, 92 Megace ES ...... 59, 87 Methylphenidate, sustained release, osmotic Megestrol ...... 59, 87 release ...... 19

Melatonin ...... 59, 115 methylPREDNISolone ...... 60, 93

Mellaril ...... 15, 29, 74, 91 Metoclopramide ...... 60, 87, 95

Texas HHS Psychiatric Drug Formulary 2021

Index 130 Metoprolol ...... 60, 83, 84 Moxeza ...... 27, 62, 107

MetroGel ...... 61, 109, 110 Moxifloxacin ...... 27, 62, 100, 107 metroNIDAZOLE ...... 61, 101, 109, 110 Mucinex ...... 52, 106

Mexsana ...... 45, 112 Mucinex D ...... 52, 106

Miacalcin ...... 39, 93 Multivitamin ...... 62, 103

Miconazole ...... 61, 98, 111 Multivitamin, Prenatal ...... 62, 104

Midazolam ...... 61, 86, 89 Multivitamin-Minerals ...... 62, 103

Milk of Magnesia ...... 58, 95 Multivitamins, Pediatric ...... 62, 103

Mineral Oil ...... 61, 108 Mupirocin ...... 62, 110

Mineral Oil-Petrolatum ...... 61, 108 Myambutol ...... 49, 101

Minipress ...... 68, 89 Mycobutin ...... 70, 101

Minocycline ...... 61, 100 Mycostatin ...... 64, 101

Mirabegron ...... 27, 61, 98 Mydriacyl ...... 76, 107

MiraLax ...... 67, 96 Mylanta ...... 34, 94

Mirapex ...... 68, 88 Myrbetriq ...... 27, 61, 98

Mirtazapine ...... 16, 61, 90 Mysoline ...... 69, 86 miSOPROStol ...... 61, 97 N

MMR II ...... 59, 99 Nabumetone ...... 27, 62, 85

Mobic ...... 59, 85 Nafcillin ...... 62, 99

Mometasone ...... 61, 109 Naloxone ...... 27, 62, 81

Montelukast ...... 61, 105 Naltrexone ...... 20, 27, 62, 92

Monurol ...... 51, 100 Naltrexone microspheres ...... 20, 28, 62, 92

Morphine ...... 62, 85 Namenda ...... 59, 88

Motrin ...... 54, 85 Naphazoline ...... 63, 107

Texas HHS Psychiatric Drug Formulary 2021

Index 131 Naprosyn ...... 63, 84, 85 Nicotrol ...... 63, 92

Naproxen ...... 63, 84, 85 NIFEdipine ...... 63, 83

Narcan ...... 27, 62, 81 Niferex-150 ...... 55

Nardil ...... 16, 66, 89 Niferex-150 Forte ...... 55, 103

Nasacort ...... 76, 109 Nitrofurantoin ...... 63, 102

Nasonex ...... 61, 109 Nitroglycerin ...... 63, 83

Nature Made Fish Oil ...... 50, 115 NIX ...... 66, 113

Navane ...... 15, 74, 91 Nizoral ...... 55, 101

Nayzilam ...... 61, 86 Non-Soap Cleanser ...... 63, 113

Neomycin ...... 63, 100 Norepinephrine ...... 28, 56, 64, 84

Neomycin-Polymyxin B-Bacitracin .... 63, 110 Noritate ...... 61, 109, 110

Neomycin-Polymyxin B-Hydrocortisone .... 63, Normodyne ...... 56, 83 108 Norpramin ...... 16, 44, 90 Neo-Synephrine ...... 66, 107, 109 Nortriptyline ...... 16, 31, 64, 90 Nephrocaps ...... 78, 104 Norvasc ...... 34, 83 Nephro-vite ...... 78, 104 NovoLIN ...... 55, 80 Neurontin ...... 51, 86 NovoLOG ...... 54, 80 Neutra-Phos-K ...... 68 Nutraderm ...... 47, 112 NexIUM ...... 48, 95 Nystatin ...... 64, 101, 108, 111 Niacin-Nicotinamide ...... 63, 83 O Nicobid...... 63, 83 OLANZapine ...... 10, 12, 14, 31, 64, 91 Nicoderm...... 63, 92 OLANZapine pamoate ...... 14, 28 Nicorette ...... 63, 92 Olmesartan ...... 29, 64, 84 Nicotine ...... 63, 92 Olopatadine ...... 64, 107

Texas HHS Psychiatric Drug Formulary 2021

Index 132 Omega-3-acid ethyl esters ...... 64, 83 Pamelor ...... 16, 64, 90

Omeprazole ...... 64, 95 Pancreaze ...... 65, 97

Omnicef ...... 40, 99 Pancrelipase ...... 65, 97

Omnipen ...... 34, 99 Pantoprazole ...... 65, 95

Ondansetron ...... 64, 87 Parnate ...... 16, 75, 89

Onfi ...... 24, 42, 86 PARoxetine ...... 16, 65, 89

Oracit ...... 72, 97 Patanol ...... 64, 107

Orajel ...... 36, 108 Paxil ...... 16, 65, 89

Os-Cal ...... 39, 94, 103 PEG ...... 67, 96

Os-Cal + D ...... 39, 103 penicillin G Benzathine ...... 65, 99

Os-Cal chewable ...... 39, 94, 103 penicillin V Potassium ...... 65, 99

Oseltamivir ...... 64, 101 Penlac ...... 41

Oxazepam ...... 21, 64, 89 Pentam ...... 29, 65, 102

OXcarbazepine ...... 18, 31, 65, 87, 91 Pentamidine ...... 29, 65, 102

Oxybenzone-PDO-Pet Hy-Phl ...... 65, 113 Pentasa ...... 59, 97

Oxybutynin ...... 65, 98 Pen-Vee K ...... 65, 99 oxyCODONE ...... 65, 85 Pepcid ...... 49, 94

OxyCONTIN ...... 65, 85 Pepto-Bismol ...... 38, 96, 97

Oxymetazoline ...... 65, 109 Periactin ...... 44, 105

P Peri-Colace ...... 47, 96

P.P.D...... 77, 99 Peridex ...... 41, 108

Pacerone ...... 34, 83 PerioMed ...... 50, 108

Paliperidone ...... 14, 65, 91 Permethrin ...... 66, 113

Paliperidone palmitate ...... 14 Pernox ...... 113

Texas HHS Psychiatric Drug Formulary 2021

Index 133 Perphenazine ...... 14, 31, 66, 91 Polycitra-LC ...... 68, 97

Petrolatum, White ...... 66, 113 Polyethylene Glycol ...... 67, 96

Phazyme ...... 72, 95 Polyethylene Glycol Electrolyte Solution .. 67, 96 Phenazopyridine ...... 66, 97 Polymox ...... 34, 99 Phenelzine ...... 16, 66, 89 Polymyxin B-Bacitracin ...... 67, 107 Phenergan ...... 69, 87 Polymyxin B-Trimethoprim ...... 67, 107 PHENobarbital ...... 31, 66, 86 Polysporin ...... 36, 67, 107, 110 Phenol ...... 66, 109 Polytrim ...... 67, 107 Phenylephrine ...... 66, 97, 107, 109 Polyvinyl Alcohol ...... 67, 108 Phenytoin ...... 31, 66, 86 Poly-Vi-Sol ...... 62, 103 Phytonadione ...... 66, 81 Potassium Chloride ...... 67, 102, 103 Pilocarpine ...... 67, 106 Potassium Citrate ...... 68, 97 Pimecrolimus ...... 67, 114 Potassium Citrate Combinations ...... 68, 97 Pioglitazone ...... 67, 80 Potassium Iodide ...... 68, 106 Piperacillin-Tazobactam ...... 67, 99 Potassium Phosphate ...... 68 Plavix ...... 42, 81 Povidone-Iodine ...... 68, 111 Pneumococcal Vaccine, Conjugate ...... 67, 98 Pramipexole ...... 68, 88 Pneumococcal Vaccine, Polyvalent ...... 67, 98 Pramoxine ...... 68, 110 Pneumovax 23 ...... 67, 98 Pramoxine–Hydrocortisone ...... 68, 97 Podocon-25 ...... 67, 113 Pramoxine-Zinc ...... 68, 110 Podophyllum Resin ...... 67, 113 Prandin ...... 70, 80 Polycarbophil ...... 67, 95 Pravachol ...... 68, 83 Polycillin ...... 34, 99 Pravastatin ...... 68, 83 Polycitra K ...... 68, 97

Texas HHS Psychiatric Drug Formulary 2021

Index 134 Prazosin ...... 68, 89 Prolixin Decanoate ...... 13

Pred Forte ...... 69, 108 Promethazine ...... 69, 87

Pred Mild ...... 69, 108 Pronto ...... 70, 113 prednisoLONE ...... 69, 93 Proparacaine ...... 69, 108

Prednisolone ...... 108 Propranolol ...... 20, 69, 83, 85 predniSONE ...... 69, 93 Propylthiouracil ...... 69, 94

Pregabalin ...... 31, 69, 87 Proscar ...... 50, 97

Premarin ...... 48, 92 Protonix ...... 65, 95

Premphase ...... 48, 93 Protopic ...... 73, 114

PremPro ...... 48, 93 Protriptyline ...... 16

Preparation H ...... 66, 97 Proventil ...... 33, 104

Prevacid ...... 56, 94 Provera ...... 59, 93

Prevnar 13...... 67, 98 PROzac ...... 16, 50, 89

PriLOSEC ...... 64, 95 Pseudoephedrine ...... 69, 106

Primidone ...... 69, 86 Psyllium ...... 69, 95

Prinivil ...... 57, 84 Pulmicort ...... 38, 105

ProAir Respiclick ...... 33 Pyrazinamide ...... 70, 101

Procardia ...... 63, 83 Pyrethins 0.33%-Piperonyl Butoxide 4% . 70, 113 Procardia XL ...... 63, 83 Pyridium ...... 66, 97 Prochlorperazine ...... 69, 87 Pyridoxine ...... 70, 103 Procrit ...... 24, 48, 82 Q Proctofoam-HC ...... 53, 96 QUEtiapine ...... 14, 70, 91 Prolia ...... 44, 93 QVAR Redihaler ...... 36, 105 Prolixin ...... 13, 50, 91

Texas HHS Psychiatric Drug Formulary 2021

Index 135 R rifAMPin ...... 70, 101

Raloxifene ...... 70, 93 rifAMPin - Isoniazid ...... 101 raNITIdine ...... 70, 94 rifAMPin-Isoniazid ...... 70

Rasagiline ...... 70, 88 Risamine ...... 59, 113

Razadyne ...... 51, 88 Risedronate ...... 70, 93

Reclast ...... 79, 93 RisperDAL ...... 14, 70, 91

Recombivax HB ...... 53, 99 RisperDAL Consta ...... 14, 70, 91

Refresh Lacrilube ...... 61, 108 RisperDAL M-Tab ...... 14, 70, 91

Reglan ...... 60, 87, 95 risperiDONE ...... 14, 70, 91

Relafen ...... 27, 62, 85 Ritalin ...... 19, 60, 92

Relenza ...... 78, 101 Ritalin SR ...... 60, 92

Remeron ...... 16, 61, 90 Ritalin XR ...... 19

Remeron SolTab ...... 61, 90 Rivaroxaban ...... 71, 81

Renagel ...... 72, 98 Rivastigmine ...... 71, 88

Repaglinide ...... 70, 80 Robaxin ...... 60, 88

Restoril ...... 22, 74, 89 Robinul ...... 52, 94

Retin-A ...... 76, 109 Robitussin ...... 52, 106

ReVia ...... 20, 27, 62, 92 Rocaltrol ...... 41, 78, 103

Revina ...... 77, 114 Rocephin ...... 40, 100

Rexulti ...... 13, 38, 90 Rosuvastatin ...... 71, 83

RID ...... 70, 113 Rowasa ...... 59, 97

Rifabutin ...... 70, 101 Rufinamide ...... 31, 71, 87

Rifadin ...... 70, 101 Rynex PSE ...... 38, 105

Rifamate ...... 70, 101

Texas HHS Psychiatric Drug Formulary 2021

Index 136 S Simethicone ...... 72, 95

Saccharomyces boulardii ...... 71, 96 Simvastatin ...... 72, 83

Salac ...... 113 Sinemet ...... 40, 88

Salicylic Acid ...... 71, 113 SINEquan ...... 16, 47, 90

Salicylic Acid-Sulfur ...... 71, 109, 111, 113 Singulair ...... 61, 105

Saliva Substitute ...... 71, 109 Sitagliptin ...... 72, 80

Salmeterol ...... 71, 104 Sodium Bicarbonate ...... 72, 97

Sani-Supp ...... 52, 96 Sodium Chloride 72, 97, 102, 105, 108, 109, 114 Santyl ...... 43, 114 Sodium Chloride Intravenous Solution ..... 72, Saphris ...... 13, 35, 90 102

Seba-Nil ...... 113 Sodium Citrate-Citric Acid ...... 72, 97

Selegiline ...... 71, 88 Sodium Polystyrene Sulfonate ...... 72, 81

Selenium Sulfide ...... 71, 111 solifenacin ...... 73, 98

Senna ...... 71, 95 SOLU-Medrol ...... 60, 93

Senokot ...... 71, 95 Sorbitol ...... 73, 96

Serax ...... 21, 64, 89 Spiriva ...... 75, 104

Serevent ...... 71, 104 Spironolactone ...... 73, 82

SEROquel ...... 14, 70, 91 Spironolactone-hydroCHLOROthiazide . 73, 82

Sertraline ...... 16, 71, 90 Spravato ...... 24, 48, 90

Sevelamer ...... 72, 98 SSKI ...... 68, 106

Shingrix ...... 79, 99 Stelazine ...... 15, 76, 91

Silvadene ...... 72, 111, 113 Stimate ...... 44, 94

Silver Nitrate ...... 72, 114 Strattera ...... 20, 35, 92

Silver SulfADIAZINE ...... 72, 111, 113 Stresscaps ...... 78, 104

Texas HHS Psychiatric Drug Formulary 2021

Index 137 Stromectol ...... 55, 102 Td ...... 46, 99

Suboxone ...... 23, 38, 92 Tdap ...... 46, 99

Subutex ...... 23, 38, 92 TEGretol ...... 17, 39, 86, 91

Sucralfate ...... 73, 97 TEGretol XR ...... 17, 39

Sudafed ...... 69, 106 Temazepam ...... 22, 74, 89

Sulfacetamide Sodium ...... 73, 107, 109, 111 Temovate ...... 24, 42, 112

Sulfamethoxazole-Trimethoprim ...... 73, 101 Tenex ...... 20, 53, 92 sulfaSALAzine ...... 73, 97 Tenormin ...... 35, 83, 84

Sulindac ...... 73, 85 Terbinafine ...... 74, 101, 111

SUMAtriptan ...... 73, 85 Testosterone ...... 74, 93

Sunscreen-Block ...... 73, 114 Tetracycline ...... 74, 100

Surfak ...... 46, 96 Tetrahydrozoline ...... 74, 107

Symbicort ...... 38, 105 Tetrahydrozoline-Zinc Sulfate ...... 74, 107

Synalar ...... 50, 112 Thiamine ...... 74, 103

Synthroid ...... 57, 94 Thioridazine ...... 15, 29, 31, 74, 91

T Thiothixene ...... 15, 74, 91

Tacrolimus ...... 73, 114 Thorazine ...... 13, 41, 91

Tamiflu ...... 64, 101 tiaGABine ...... 31, 74, 87

Tamoxifen ...... 74, 81 Tigan ...... 76, 87

Tamsulosin ...... 74, 97 Timolol ...... 74, 106

Tapazole ...... 60, 94 Timolol-Dorzolamide ...... 75, 106

Tazarotene ...... 74, 109, 111 Timoptic ...... 74, 106

Tazorac ...... 74, 109, 111 Timoptic XE ...... 74, 106

TBC ...... 77, 114 Tinactin ...... 75

Texas HHS Psychiatric Drug Formulary 2021

Index 138 Tioconazole ...... 75, 98 Triazolam...... 22, 76, 89

Tiotropium ...... 75, 104 Tricor ...... 49, 83 tiZANidine ...... 29, 75, 88 Tridesilon ...... 44, 112

TobraDex ...... 75, 108 Trifluoperazine...... 15, 76, 91

Tobramycin...... 75, 100, 107 Triglide ...... 49, 83

Tobramycin-Dexamethasone ...... 75, 108 Trihexyphenidyl ...... 76, 88

Tobrex ...... 75, 107 Trilafon ...... 14, 66, 91

Tofranil ...... 16, 54, 90 Trileptal ...... 18, 65, 87, 91

Tolnaftate ...... 75, 111 Trimethobenzamide ...... 76, 87

Tolterodine ...... 75, 98 Triple Antibiotic Ointment ...... 63, 110

Topamax ...... 75, 85, 87, 91, 92 Triprolidine-Pseudoephedrine ...... 76, 106

Topiramate ...... 31, 75, 85, 87, 91, 92 Tropicamide ...... 76, 107

Toprol XL ...... 60, 83, 84 Trospium ...... 76, 98

Toradol ...... 56, 85 Trypsin-Balsam Peru-Castor Oil ...... 77, 114 traMADol ...... 75, 86 Tuberculin, Purified Protein Derivative . 77, 99

Tranxene ...... 21, 43, 86, 89 Tums ...... 39, 94, 103

Tranylcypromine ...... 16, 75, 89 Twinrix ...... 53, 99

Travatan Z...... 76, 106 Tylenol ...... 32, 85

Travoprost ...... 76, 106 U traZODone...... 17, 22, 76, 89, 90 Ultram ...... 75, 86

Trecator ...... 49, 101 Unicap ...... 62, 103

Tretinoin ...... 76, 109 Unifiber ...... 40, 95

Triamcinolone ...... 76, 109, 112 Urea ...... 77, 113

Triamterene-hydroCHLOROthiazide .... 76, 82 Urecholine ...... 37, 98

Texas HHS Psychiatric Drug Formulary 2021

Index 139 Urocit K ...... 68, 97 Versacloz ...... 13, 24, 43

V Versed ...... 61, 89

Vagifem ...... 48 Vesicare ...... 73, 98 valACYclovir ...... 77, 101 Vibramycin ...... 47, 100

Valisone ...... 37, 112 Vicodin ...... 32, 85

Valium ...... 21, 45, 86, 88, 89 Vicodin ES ...... 32, 85

Valproic Acid/Valproate ... 18, 31, 77, 85, 87, Victoza ...... 57, 80 91 Vigamox ...... 27, 62, 107 Valsartan ...... 77, 84 Vimpat ...... 56, 86 Valtrex ...... 77, 101 Viscous Lidocaine ...... 108 Vancocin ...... 77, 101 Visine A.C...... 74, 107 Vancomycin ...... 77, 101 Visine Allergy Relief ...... 74, 107 Vaqta ...... 53, 98 Visine Moisturizing ...... 74, 107 Varicella Virus Vaccine, Live ...... 77, 99 Vistaril ...... 22, 54, 87, 89, 106 Varivax ...... 77, 99 Vitamin A ...... 77, 103 Vaseline ...... 66, 113 Vitamin A&D Topical ...... 77 Vaseline Lip Therapy ...... 65, 113 Vitamin B Complex ...... 78, 104 Vasotec ...... 47, 84 Vitamin B Complex-Vitamin C ...... 78, 104 V-Cillin K ...... 65, 99 Vitamin B Complex-Vitamin C-Zinc ... 78, 104 Venlafaxine ...... 17, 77, 85, 90 Vitamin B1 ...... 74, 103 Ventolin ...... 33, 104 Vitamin B12 ...... 43, 103 Verapamil ...... 77, 83, 85 Vitamin B6 ...... 70, 103 Verelan ...... 77, 83, 85 Vitamin C ...... 35, 103 Verelan PM ...... 77, 83, 85 Vitamin D2 ...... 78, 103

Texas HHS Psychiatric Drug Formulary 2021

Index 140 Vitamin D3 ...... 78, 103 Xylocaine ...... 57, 110

Vitamin E ...... 78, 103 Z

Vitamin K1 ...... 66, 81 Zaditor ...... 56, 107

Vivactil ...... 16 Zanaflex ...... 29, 75, 88

Vivelle ...... 48, 92 Zanamivir ...... 78, 101

Vivitrol ...... 20, 28, 62, 92 Zarontin ...... 49, 86

Voltaren Gel ...... 24, 45, 109 Zestril ...... 57, 84

VoSol HC ...... 32, 108 Zinc Oxide ...... 78, 112, 114

Vraylar ...... 13, 40, 90 Zinc Oxide-Petrolatum-Imidazolidinyl Urea 78

Vyvanse ...... 19, 27, 57, 92 Zinc Sulfate...... 79, 103

W Ziprasidone ...... 10, 12, 15, 79, 91

Warfarin ...... 78, 81 Zithromax ...... 36, 100

Water for Injection...... 78, 102 Zocor ...... 72, 83

Water for Irrigation ...... 78, 97, 114 Zofran ...... 64, 87

Wellbutrin ...... 15, 38, 90 Zofran ODT ...... 64, 87

Wellbutrin SR ...... 16 Zoledronic Acid ...... 79, 93

Wellbutrin XL ...... 16 Zoloft ...... 16, 71, 90

Wound Cleanser ...... 78, 114 Zolpidem ...... 22, 79, 89

X Zonalon ...... 47

Xalatan ...... 56, 106 Zonegran ...... 79, 87

Xanax ...... 21, 33, 88 Zonisamide ...... 31, 79, 87

Xanax XR ...... 33, 88 Zoster Vaccine- Recombinant, Adjuvanted 79, 99 Xarelto ...... 71, 81 Zosyn ...... 67, 99 Xopenex ...... 56, 104

Texas HHS Psychiatric Drug Formulary 2021

Index 141 Zovirax ...... 32, 101, 110 ZyPREXA Zydis ...... 14, 64

Zyban ...... 38, 90 ZyrTEC ...... 41, 105

Zyloprim ...... 33, 94 ZyrTEC D ...... 41, 105

ZyPREXA ...... 14, 64, 91 Zyvox ...... 27, 57, 101

ZyPREXA Relprevv ...... 14, 28, 64

Texas HHS Psychiatric Drug Formulary 2021

Index 142 Appendix A. New Drug Application Form

New Drug Application for inclusion in the Texas HHSC Psychiatric Drug Formulary **(The new drug application process is described on the back of this form)**

Texas HHS Psychiatric Drug Formulary 2021

A-1 Section 306.357 of HHSC rules governing the use and maintenance of the HHSC Psychiatric Drug Formulary (26 TAC, Part 1, Chapter 306, Subchapter G) describes the procedures for applying to have a drug added to the formulary, which are: (1) Any member of the PEFC, any service system component* practitioner, or any contract practitioner may apply to have a drug added to the HHSC Psychiatric Drug Formulary by completing the New Drug Application form found in the HHSC Psychiatric Drug Formulary on the HHSC Psychiatric Formulary website. (2 Include the following with the New Drug Application form: (A) published articles in biomedical literature that substantiate the efficacy and safety of the proposed drug; (B) information on the advantages of the proposed drug compared with similar formulary drugs; (C) a list of formulary drugs that the proposed drug would replace or supplement; and (D) cost effectiveness data. (b) Submitting the application. (1) An HHSC facility** practitioner or HHSC facility contract practitioner shall submit the application to the facility's pharmacy and therapeutics committee for approval. If the committee approves the application, the committee forwards the application to the PEFC. (2) A non-facility service system component practitioner or non-facility service system component contract practitioner shall submit the application to the component's clinical/medical director or designee who determines if the application is appropriate and complete, and if so, shall forward the application to the PEFC. (3) A member of the PEFC shall submit the application directly to the PEFC. (c) Considering the application. The PEFC considers the drug application and shall: (1) approve the proposed drug's inclusion and, if appropriate, approve audit criteria and recommend dosage guidelines; (2) approve the proposed drug on a trial basis for a specified period of time; (3) approve the proposed drug as a reserve drug, with guidelines; (4) postpone the decision until a later meeting; or (5) deny the proposed drug's inclusion.

* The term “service system component” refers to HHSC, an HHSC facility, and a local authority. ** The term “facility” refers to a facility operated by HHSC, including state hospitals and state supported living centers.

Texas HHS Psychiatric Drug Formulary 2021

A-2 Appendix B. PEFC Conflict of Interest Policy

Policy

The HHSC Psychiatric Executive Formulary Committee (PEFC) must ensure balance, independence, objectivity and scientific rigor in determining which drugs should be on the formulary and their use in special populations. It is the policy of the PEFC to prohibit any apparent or actual conflict of interest. As such, each member of the PEFC, individuals preparing drug monographs, each requesting practitioner, and those appointed to work groups that report to the PEFC shall abide by this policy and submit a Conflict of Interest Disclosure Statement. The intent of this disclosure is not to prevent those with a significant financial interest or other relationship from participating in the formulary process, but rather to provide information to committee members and to the public so that conflicts can be resolved prior to the decision making process. It remains for the members of the committee to determine whether the individual’s interests or relationships may influence them with regard to exposition or conclusions. A conflict of interest for these purposes includes any situation in which a Committee member, individual preparing a drug monograph, individual submitting a request to the PEFC, work group member or a first degree relative of said person has a private or personal interest sufficient to appear to influence the objective exercise of his/her duties for the agency. An apparent conflict of interest is one in which a reasonable person would think that the person’s judgment is potentially compromised.

All committee members, individuals submitting drug monographs, individuals requesting drugs for addition to the formulary, and work group members are expected to disclose any financial interest or other relationship with (a) the manufacturer(s) of any commercial product and/or provider of commercial services for drugs on the formulary or being considered for the formulary (b) any commercial support for these drugs. Significant financial interest or other relationship can include such things as grants or research support, employee, consultant, major stockholder, member of speaker’s bureau, etc. The disclosure shall include any conflict of interest of a first degree relative.

PEFC members shall also abide by the HHS Ethics Policy.

Definitions “Companies” – includes pharmaceutical and biotechnology companies. “Compensation” - includes direct and indirect remuneration or royalties, and may also include, among other things, items and services at reduced prices, or with discounts or rebates. “Controlling Interest” - a direct or indirect ownership or beneficial interest, individually or in conjunction with members of your family, which permits election or selection of a majority of the governing body of a company and/or which permits the exercise of control over the affairs of such company. “Financial Interest” – a direct or indirect, through business, investment or family: (a) Ownership Interest or investment interest in a company; (b) Compensation arrangement with a company or any of its affiliates; or

Texas HHS Psychiatric Drug Formulary 2021

B-1 (c) Ownership Interest or investment interest in, or compensation arrangement with, any company or individual with which that company or any of its affiliates is negotiating a transaction or arrangement. “First Degree Relative” – spouse, parent, siblings, children “Gifts” or “Gratuities” - includes, among other things, meals, entertainment or recreational items, subsidies given directly to a healthcare professional for continuing medical education (CME), educational (i.e. anatomical models) and non-educational and practice-related items (i.e. items that do not advance disease or treatment education). “Ownership Interest” - owning or controling directly, indirectly, or beneficially through such person’s family, in excess of five percent (5%) of the total value of all securities of a Company.

Procedure

1. Committee members shall submit Disclosure Statements at least annually and as needed as their situation changes. See Appendix C for the “HHSC Psychiatric Executive Formulary Committee Disclosure Form.” 2. Individuals submitting requests for addition to the formulary or completing drug monographs shall submit the “HHSC Psychiatric Executive Formulary Committee Disclosure Form” along with the New Drug Application or drug monograph, respectively. 3. Members of work groups appointed by the PEFC shall submit Disclosure Statements no later than the first meeting and then annually if the work group exists for more than a year. The work group shall forward each work group members’ conflict of interest to the PEFC for their review. 4. A review of committee members’ conflict of interest shall be completed for all individuals present at each meeting. This information shall be documented in the minutes of each meeting. 5. Each facility Pharmacy and Therapeutics Committee or similarly functioning committee is encouraged to adopt a similar policy. 6. New Drug Applications submitted without the HHSC Psychiatric Executive Formulary Committee Disclosure Form will be considered incomplete and returned to the requestor. 7. Failure to disclose will result in written notification and may be reported to the individual’s facility. The determination of the action shall be based on the nature on the non- disclosure.

Determining Conflict of Interest: Committee members present at the meeting shall determine if a conflict of interest exists and if it exists, the degree of conflict. The degree of conflict shall be determined based on the involvement of the individual with the manufacturer(s) as well as the role the individual plays within the Committee membership or meeting. For example, conflicts by an individual preparing a monograph for presentation at a meeting maybe viewed differently than a Committee member voting on a formulary addition.

Determination of conflict of interest is not limited to the manufacturer of the drug in the New Drug Application but shall include all relationships with manufacturers. For example, individuals

Texas HHS Psychiatric Drug Formulary 2021

B-2 shall be identified with a conflict of interest for any activities related to the products of any manufacturer that paid them, and any competing products.

Action Taken for Conflict of Interest: Action taken to minimize bias from the individual identified as having a conflict of interest shall be based on the individual’s role and relationship to the committee and the degree of conflict. Actions taken may include but are not limited to:

Committee Member identified with a significant conflict of interest

● Removal from the room during the discussion and voting on a formulary addition ● Removal from the Committee ● Having no communication with other committee members regarding the specific New Drug Application prior to any deliberations and voting.

Individual completing a monograph that is identified with a significant conflict of interest

● Identifying the specific conflict in relationship regarding the monograph verbally prior to and after the presentation of the monograph at the meeting ● Identifying the specific conflict in relationship regarding the monograph in writing at the end of monograph ● Not allowing the individual to develop a monograph Individual submitting a New Drug Application that is identified with a significant conflict of interest

● Declining to review the New Drug Application request Identification of conflict of interest and action taken regarding conflict of interest shall be documented in the minutes.

This policy applies to members of work groups as appointed by PEFC. Work groups will follow the same procedure and consequences for reporting, determining and action taken for conflict of interest.

Texas HHS Psychiatric Drug Formulary 2021

B-3 Appendix C. PEFC Disclosure Form

HHSC Psychiatric Executive Formulary Committee (PEFC) Disclosure Form

Texas HHS Psychiatric Drug Formulary 2021

C-1 Appendix D. Non-Formulary Drug Justification Form

Texas HHS

Non-Formulary Drug Justification

Texas HHS Psychiatric Drug Formulary 2021

D-1

Texas HHS Psychiatric Drug Formulary 2021

G-1