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Texas Health and Human Services
Commission
Psychiatric Drug Formulary
State Hospitals
&
State Supported Living Centers
&
Community Mental Health Centers
18T2020
Approved October 2019
Updated April 2020
Texas HHS Psychiatric Drug Formulary 2020
Table of Contents 2
Table of Contents
Table of Contents ................................................................................... 2
Introduction ........................................................................................... 4
Members of the HHSC Psychiatric Executive Formulary Committee........ 7
Ex-Officio Members ................................................................................ 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 ..................................................................................... 12
Antidepressants ................................................................................... 15 Mood Stabilizers .................................................................................. 17
Stimulants .......................................................................................... 19 Miscellaneous Drugs Used for Psychotropic Purposes ................................ 20 Anxiolytics .......................................................................................... 21
Hypnotics ........................................................................................... 21
Reserve Drugs ...................................................................................... 23
Therapeutic Serum Concentrations of Some Anticonvulsants ............... 31
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 ............................................................ 85 Endocrine Agents ................................................................................. 93
Gastrointestinal Agents ........................................................................ 94 Genitourinary Agents ........................................................................... 97 Immunological Agents .......................................................................... 99
Infectious Disease Agents ................................................................... 100 Parenteral Solutions and Additives ....................................................... 103
Nutritional Agents .............................................................................. 103 Respiratory Agents ............................................................................ 105
Topical Agents ................................................................................... 107 Nutritional Supplements ..................................................................... 115
Texas HHS Psychiatric Drug Formulary 2020
Table of Contents 3
Index ................................................................................................. 117
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
Appendix E. Adverse Drug Reaction Reporting (MedWatch) Form ........ E1
Appendix F. Foods Containing Tyramine............................................... F1
Appendix G. Oral Morphine Conversion Table ....................................... G1
Texas HHS Psychiatric Drug Formulary 2020
Introduction 4
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.
Texas HHS Psychiatric Drug Formulary 2020
Introduction 5
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
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.
Texas HHS Psychiatric Drug Formulary 2020
Introduction 6
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
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.
Mark Messer, D.O. Chairperson
HHSC Psychiatric Executive Formulary Committee October 2019
Texas HHS Psychiatric Drug Formulary 2020
Introduction 7
Members of the HHSC Psychiatric Executive Formulary
Committee
Angela Babin, RPh
The Harris Center for Mental Health & IDD
Jean Baemayr, PharmD
State Hospitals
John Bennett, MD
Dallas Metrocare Services
Bonnie Burroughs, PharmD
Abilene State Supported Living Center
German Corso, MD
Tropical Texas Behavioral Health
Catherine S. Hall, PharmD, BCPP, BCACP
San Antonio State Hospital
Jeanna Heidel, PharmD
Rusk State Hospital
Dana Hopkins, RN
Austin State Hospital
Jeffery Matthews, MD
UT Health Science Center Tyler
Mark Messer, DO
Terrell State Hospital
David Moron, MD
Rio Grand State Center
Kenda Pittman, PharmD
State Supported Living Centers
Rishi Sawhney, MD
BHS Community Behavioral Health
Glenn Shipley, DO
State Supported Living Centers
Ashton Wickramasinghe, MD
Austin State Supported Living Center
Ex-Officio Members
Tim Bray
Associate Commissioner
State Hospitals
Mike Maples
Deputy Executive Commissioner
HHS Facilities
Brad Fitzwater, MD
Medical Director
HHSC Substance Use
Nina Muse, MD
Chief Medical Officer
State Hospitals
Connie Horton, RNP
HHSC Nursing Services Coordinator
State Supported Living Centers
Peggy Perry
Director of Quality Management
State Hospitals
Raul Luna, RN, MSN
Chief of Nursing
State Hospitals
Rachel Samsel
Director of Policy and Projects
State Hospitals
HHS Psychiatric Drug Formulary editor
Jean Baemayr, PharmD
Texas HHS Psychiatric Drug Formulary 2020
Procedure for Addition of Drugs to the Formulary 8
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 2020
Psychotropic Dosage Guidelines 9
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 2020
Psychotropic Dosage Guidelines 10
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
dose (mg)
Minimum Interval
(hrs)
Maximum Total
Dose per day (mg)
chlorproMAZINE1,2,4,7 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
dose (mg)
Minimum Interval
(hrs)
Maximum Total
Dose per day (mg)
chlorproMAZINE1,2,4,7 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
LORazepamP1,2,3,4,5 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 2020
Psychotropic Dosage Guidelines 11
*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. Lexicomp® Drug Information Handbook, 27PthP Edition, American Pharmacist Association.
Tables added February 2009; Reviewed October 2019
Adult Treatment of Behavioral Emergencies
Intramuscular Short-Acting Agents
Drug Maximum Single
dose (mg)
Minimum Interval
(hrs)
Maximum Total
Dose per day (mg)
IM chlorproMAZINE1 100* 2 400
IM diphenhydrAMINE2,3 100 1 400
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
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 12
Drug Maximum Single
dose (mg)
Minimum Interval
(hrs)
Maximum Total
Dose per day (mg)
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. Lexicomp® Drug Information Handbook, 27PthP Edition, American Pharmacists Association
3. Micromedex® [electronic version]. Truven Health Analytics, Greenwood Village, CO, USA
(cited 07-15-19)
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.
Reviewed October 2019
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)
Tourette’s (FDA)
6 - < 12 y/o
104 (<50 kg)
204 (≥50 kg)
30
Tourette’s (FDA)
104 (<50 kg)
204 (≥50 kg)
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 13
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
ARIPiprazole Extended
Release
(Abilify Maintena)
400 per 4 weeks ID ID
ARIPiprazole lauroxil
(Aristada)
882 per 4 weeks
1064 per 8 weeks
ID ID
Asenapine (Saphris) 20 10 to < 12 y/o: 20 20
Brexpiprazole (Rexulti) 4 ID ID
Cariprazine (Vraylar) 6 ID ID
chlorproMAZINE
(Thorazine)
2,000 5 – 12 y/o: 75 (Lit) 800 (Lit)
cloZAPine (Clozaril,
Fazaclo, Versacloz)
RESERVE USE
900 8 – 11 y/o: 300 (Lit) 600 (Lit)
fluPHENAZine (oral)
(Prolixin)
40 ID ID
fluPHENAZine Decanoate
(Prolixin Decanoate)
400 per 4 weeks ID ID
Haloperidol (oral)
(Haldol)
40 3 – 12 y/o:
Lesser of 0.15 mg/kg
or 6 (Lit)
> 12 y/o:
Acute agitation 10
Psychosis 15
Tourette 15 (Lit)4
Haloperidol Decanoate
(Haldol Decanoate)
450 per month ID ID
Iloperidone (Fanapt)
RESERVE USE
24 ID ID
Loxapine (Loxitane) 250 ID ID
Lurasidone (Latuda) 160 10 – 11 y/o: 805 (Lit) 13 – 17 y/o: 80
OLANZapine (ZyPREXA,
ZyPREXA Zydis)
30 4 – 5 y/o: 12.5 (Lit)
6 – 12 y/o: 20 (Lit)
13 – 17 y/o: 20
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 14
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
OLANZapine pamoate
(ZyPREXA Relprevv)
RESERVE USE
300 per 2 weeks
405 per 4 weeks
ID ID
Paliperidone (Invega) 12
ID 6 (< 51 kg)
12 (≥ 51 kg)
Paliperidone palmitate
(Invega Sustenna)
234 per 4 weeks ID ID
Paliperidone palmitate
(Invega Trinza)
NON-Formulary
819 per 3 months ID ID
Perphenazine (Trilafon) 64 ID > 12 y/o: 64 (Lit)
QUEtiapine (SEROquel) 800 5 – 9 y/o: 400 (Lit)
10–12 y/o: 800 (Lit)
13 – 17 y/o: 800
risperiDONE (RisperDAL,
RisperDAL M-Tab)
81 *5 to < 12 y/o: 3 6
RisperDAL Consta 50 per 2 weeks ID ID
Thioridazine (Mellaril)2
RESERVE USE
(ABSOLUTE) 800 ID ID
Thiothixene (Navane) 60 ID ID
Trifluoperazine
(Stelazine)
40 ID ID
Ziprasidone (Geodon) 240 10 – 11 y/o:
803 (≤ 45 kg)
1603 (> 45 kg) (Lit)
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
ID- insufficient data Lit- Literature support
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 15
Reviewed October 2019
Drug Therapeutic reference
range/Recommended drug
concentration
cloZAPine 350 – 600 ng/mL
fluPHENAZine 1 – 10 ng/mL
Haloperidol 1 – 10 ng/mL
OLANZapine 20 – 80 ng/mL
Perphenazine 0.6 – 2.4 ng/mL
Thioridazine 100 – 200 ng/mL
Reviewed October 2019
Antidepressants
Suggested maximum doses (mg/day)
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
Amitriptyline (Elavil) 300 Not Recommended Not Recommended
buPROPion (Wellbutrin) 450 (with no
single dose > 150)
6 to < 12 y/o: Lesser of
6 mg/kg or 300 (Lit)1
(with no single dose >
150)
Lesser of 6 mg/kg
or 300 (Lit)1
(with no single
dose > 150)
buPROPion SR
(Wellbutrin SR)
400 (with no
single dose > 200)
ID 400 (Lit)1
buPROPion XL
(Wellbutrin XL)
450 ID 450 (Lit)1
Citalopram** (CeleXA) 40
120 (OCD)
6 to < 12 y/o: 40 (Lit) 40 (Lit)
clomiPRAMINE
(Anafranil)
250 10 – 11 y/o: Lesser of 3
mg/kg or 200 mg (OCD)
Lesser of 3 mg/kg
or 200 mg (OCD)
Desipramine
(Norpramin)
300* Not Recommended Not Recommended
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 16
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
Doxepin (SINEquan) 300 Not Recommended Not Recommended
DULoxetine (Cymbalta) 120 7 – 12 y/o: 1203 1203
Escitalopram**
(Lexapro)
20
60 (OCD)
6 – 11 y/o: 20 (Lit) ≥ 12 y/o: 30 (Lit)
FLUoxetine** (PROzac) 80
120 (OCD – Lit)
6 to < 12 y/o: 60 (Lit) 60
fluvoxaMINE (Luvox) 300
450 (OCD)
8 – 11 y/o: 200 (OCD) 12 – 17 y/o: 300
(OCD)
Imipramine (Tofranil) 300* Not Recommended Not Recommended
Mirtazapine (Remeron) 45 3 to < 12 y/o: 45 (Lit) 45 (Lit)
Nortriptyline (Pamelor) 150* Not Recommended Not Recommended
PARoxetine (Paxil) 60
100 (OCD)
Not Recommended
Possible Harm
Not Recommended
Possible Harm
Phenelzine (Nardil) 90 Not Recommended Not Recommended
Protriptyline (Vivactil)
NON-Formulary
60 Not Recommended Not Recommended
Sertraline** (Zoloft) 200
400 (OCD – Lit)
≥ 6 y/o 200 200
Tranylcypromine
(Parnate)
60 Not Recommended Not recommended
traZODone (Desyrel) 600 ID 100 (Lit)2
Venlafaxine (Effexor) 375 Not Recommended
Possible Harm
Not Recommended
Possible Harm
Venlafaxine XR (Effexor
XR)
225 Not Recommended
Possible Harm
Not Recommended
Possible Harm
*Plasma concentration monitoring is recommended if these doses are exceeded
**Dose varies with diagnosis 1For ADHD 2For sedative hypnotic 3FDA approved GAD 120
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 17
ID- insufficient data to suggest support regarding its efficacy or to provide maximum dosing guidelines in this patient group
Lit- Literature support OCD- Obessive Compulsive Disorder
Reviewed October 2019
Drug Therapeutic reference range
Amitriptyline 120 – 250 ng/mL
Desipramine 100 – 300 ng/mL
Doxepin 30 – 150 ng/mL
Imipramine 150 – 250 ng/mL
Nortriptyline 50 – 150 ng/mL
Reviewed October 2019
Mood Stabilizers
Suggested maximum doses (mg/day)
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
carBAMazepine
(TEGretol, TEGretol XR,
Carbatrol)
1,600 < 6 y/o: 35 mg/kg
6 to < 12 y/o: 1,000 mg (6
– 12 mcg/ml)
#
12 – 15 y/o: 1,000
> 15 y/o: 1,200
lamoTRIgine (LaMICtal) With VPA: 100
Monotherapy:
200
With EIAED:
400
6 to < 12 y/o:
With VPA: 1 - 3 mg/kg
With VPA & EIAED: 1 - 5
mg/kg
Monotherapy: 4.5 - 7.5
mg/kg
With EIAED: 5 - 15 mg/kg
With VPA: 200
With VPA & EIAED:
400
Monotherapy: 375
With EIAED: 500
Lithium (Lithobid,
Eskalith)
< 65 y/o:
3,600
≥ 65 y/o:
1,800
#
7 to < 12 y/o
20 – 30 kg:
Acute: 1,500
Maintenance: 1,200
#
> 30 kg
1,800 or 1.2 mEq/L
(Lit)
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 18
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
OXcarbazepine
(Trileptal)
2,400 ID ID
Valproic Acid/Valproate,
Divalproex (Depakene,
Depakote, Depakote
ER)
60 mg/kg 6 to < 10 y/o: 60 mg/kg
(Lit)
≥ 10 y/o: 60 mg/kg #
60 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)
ID- insufficient data to suggest support regarding its efficacy or to provide maximum dosing guidelines in this patient group VPA- valproic acid-valproate
Reviewed October 2019
Drug Therapeutic reference range
carBAMazepine Adult: 4 – 12 mcg/mL
Adol Max: 12 mcg/mL
lamoTRIgine Bipolar Disorder: 1 – 6 mcg/mL
Epilepsy: 3 – 15 mcg/mL
Lithium Acute: 0.5 – 1.2 mEq/L
Maintenance: 0.6 – 1.0 mEq/L
Child & Adol Max: 1.2 mEq/L (Lit)
OXcarbazepine nd
Valproic
Acid/Valproate,
Divalproex
50 – 125 mcg/mL
Adol Max: 125 mcg/mL (Lit)
Divalproex ER: 85 – 125 mcg/mL
nd= not yet determined
Reviewed October 2019
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 19
Stimulants
Suggested maximum doses (mg/day)
Drug Adult Child (< 12 y/o) Adolescent
(12 y/o to < 18
y/o)
Amphetamine Mixture
(Adderall)
60 3-5 y/o: 30 (Lit)
≥ 6 y/o:
≤ 50 kg: 40
> 50 kg: 60 (Lit)
≤ 50 kg: 40
> 50 kg: 60 (Lit)
Amphetamine Mixture
(Adderall XR)
60 ≥ 6 y/o:
≤ 50 kg: 30
> 50 kg: 60 (Lit)
≤ 50 kg: 30
> 50 kg: 60 (Lit)
Dexmethylphenidate,
extended release
(Focalin XR)
40 ≥ 6 y/o: 50 (Lit) 50 (Lit)
Dextroamphetamine
(Dexedrine, Dexedrine
Spansules, Zenzedi)
60 3 – 5 y/o: 30 (Lit)
≥ 6 y/o:
≤ 50 kg: 40
> 50 kg: 60 (Lit)
≤ 50 kg: 40
> 50 kg: 60 (Lit)
Lisdexamfetamine
(Vyvanse)
70 6 – 12 y/o: 70 70
Methylphenidate,
immediate release
(Ritalin, Methylin,
Metadate), sustained
release (Ritalin XR)
60 3 – 5 y/o: 32.5 (Lit)
≥ 6 y/o:
≤ 50 kg: 60
> 50 kg: 100 (Lit)*
≤ 50 kg: 60
> 50 kg: 100 (Lit)*
Methylphenidate,
sustained release,
osmotic release
(Concerta)
72 3-5 y/o: 36 (Lit)
≥ 6 y/o: 72 (Lit)
12 y/o: 72 (Lit)
≥ 13 y/o: 72
* Any dose exceeding 60 mg/day should be used with caution and with attentive monitoring
Reviewed October 2019
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 20
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
less 1.8 mg/kg or 100
(Lit)
Whichever is less 1.8
mg/kg or 100 (Lit)
cloNIDine (Catapres) 0.4 ≥ 6 y/o:
(27 – 40.5 kg) 0.2
(40.5 – 45 kg) 0.3
# (Lit)
(> 45 kg) 0.4
# (Lit)
cloNIDine Extended
Release (Kapvay) NON-
Formulary
0.4 ≥ 6 y/o: 0.4* 0.4
guanFACINE (Tenex) 4 ≥ 6 y/o:
(27 – 40.5 kg) 2
(40.5 – 45 kg) 3
# (Lit)
(> 45 kg) 4
# (Lit)
guanFACINE Extended
Release (Intuniv)
ID 6 - 12 y/o: 4* ≥ 13 y/o: 7
Naltrexone (ReVia) 200 ID ID
Naltrexone microspheres
(Vivitrol) RESERVE USE
380 per 4 weeks ID ID
Propranolol (Inderal) 160
(anxiety)***
ID ID
*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
Reviewed October 2019
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 21
Anxiolytics
Suggested maximum doses (mg/day)
Drug Under 65 years
(mg/day)
65 years and over
(mg/day)
ALPRAZolam (Xanax)
(exception: for panic
disorder)
4
10
2
N/A
busPIRone (BuSpar) 60 60
chlordiazePOXIDE (Librium) 100* 40*
clonazePAM (KlonoPIN) 4^ 4^
ClorazepateP1P (Tranxene) 60 30
diazePAMP1P (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 2019
Hypnotics
Suggested maximum doses (mg/day)
Drug Under 65
years
(mg/day)
65 years and
older
(mg/day)
Child
(< 12 y/o)
Adolescent
(12 y/o to <
18 y/o)
∆*diphenhydrAMINE
(Benadryl)
300 300 25 – 37 lb:
12.5
38-49 lb: 19
50 – 99 lb: 25
≥ 100 lb: 50
(Lit)
50 – 99 lb: 25
≥ 100 lb: 50
(Lit)
Texas HHS Psychiatric Drug Formulary 2020
Psychotropic Dosage Guidelines 22
Drug Under 65
years
(mg/day)
65 years and
older
(mg/day)
Child
(< 12 y/o)
Adolescent
(12 y/o to <
18 y/o)
∆hydrOXYzine
(Atarax, Vistaril)
400 300 3 – 5 y/o: 25
6 – 12 y/o: 50
(Lit)
> 12 y/o: 100
(Lit)
∆Temazepam
(Restoril)
30 15 Not
Recommended
Possible Harm
Not
Recommended
Possible Harm
traZODone
(Desyrel)
200 150 ID 100 (Lit)
∆Triazolam
(Halcion)
(Conscious sedation
dosing)
0.25
(0.5)
0.125
(0.25)
ID ID
∆Zolpidem
(Ambien)
Males: 10
Females: 5
5 Not
Recommened
Possible Harm
Not
Recommended
Possible Harm
*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 ID- Insufficient data to suggest support regarding its efficacy or to provide maximum dose
guidelines for this patient population
Reviewed October 2019
Texas HHS Psychiatric Drug Formulary 2020
Reserve Drugs 23
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
lauroxil (Aristada
Initio)
To be used if the patient has demonstrated tolerability to ARIPiprazole
through either a two-week trial of oral ARIPiprazole or a history of
ARIPiprazole LAI use
Adenosine
(Adenocard)
To be used in an ECT suite or under the direction of an anesthesiologist
Betamethasone
dipropionate,
augmented
(Diprolene A/F)
To be used under the direction of a dermatologist
Buprenorphine
(Subutex)
1. Admitted on the drug and the medication is continued. Use must
be 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-
naloxone
(Suboxone)
1. Admitted on the drug and the medication is continued. Use must
be 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).
Cannabidiol
(Epidiolex)
1. To be used in patients with a diagnosis of Lennox-Gastaut
syndrome or 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 2020
Reserve Drugs 24
Drug Guidelines for Use
Celecoxib
(CeleBREX)
1. Patients with a history of serious gastrointestinal complications with
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
(Temovate)
To be used under the direction of a dermatologist
cloZAPine
(Clozaril, Fazaclo,
Versacloz)
1. For use in patients with refractory schizophrenia or schizoaffective
disorder [defined as failure on two antipsychotics from two different
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
(Voltaren Gel)
1. Oral therapy is deemed too risky due to cardiac and gastrointestinal
complications, or;
2. Other topical therapies have proven to be ineffective
DOPamine
(Inotropin)
To be used in an ECT Suite or under the direction of an anesthesiologist
Epoetin alfa
(Epogen, Procrit)
When recommended by a consultant physician
Texas HHS Psychiatric Drug Formulary 2020
Reserve Drugs 25
Drug Guidelines for Use
Esketamine
(Spravato)
1. All REMS requirements must be followed.
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.
Felbamate
(Felbatol)
Weekly progress note by physician monitoring for response and adverse
effects for at least two weeks following initiation of therapy
Iloperidone
(Fanapt)
1. For use in patients that have failed on two antipsychotics given for
a sufficient time; or
2. For patients who cannot tolerate other antipsychotics due to
akathisia
Insulin, Detemir
(Levemir)
For those who are unable to tolerate Insulin, glargine.
Texas HHS Psychiatric Drug Formulary 2020
Reserve Drugs 26
Ketamine
(Ketalar)
1. A comprehensive diagnostic assessment should be completed to
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 2020
Reserve Drugs 27
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
(Linzess)
Patients who are receiving enteral nutrition or who require a modified diet
texture
Linezolid (Zyvox) When recommended by a consultant physician
Lisdexamfetamine
(Vyvanse)
1. Continued therapy on admission; or
2. Failed other stimulants
Mirabegron
(Myrbetriq)
Unable to tolerate anticholinergic medications
Moxifloxacin
(Moxeza,
Vigamox)
For bacterial conjunctivitis where MRSA or gram negative microorganisms
is identified or suspected.
Nabumetone
(Relafen)
For the treatment of chronic osteoarthritis or chronic rheumatoid arthritis
Naloxone
(Narcan) Nasal
spray
To be dispensed only as a discharge medication for patients that have
been determined to be at risk of an opiate overdose.
Texas HHS Psychiatric Drug Formulary 2020
Reserve Drugs 28
Drug Guidelines for Use
Naltrexone
microspheres
(Vivitrol)-
Alcohol Use
Disorders
1. For those that are not candidates for or who have not responded to
or tolerated other available formulary therapies for alcohol use
disorders and do not have a contraindication to the use of extended
release naltrexone.
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.
Texas HHS Psychiatric Drug Formulary 2020
Reserve Drugs 29
Drug Guidelines for Use
Naltrexone
microspheres
(Vivitrol)-
Opioid Use
Disorders
1. 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
indicate treatment with extended release naltrexone in case of
emergency.
11.Hospital use requires MHA approval prior to initiation.
Norepinephrine or
Levarterenol
(Levophed)
To be used in an ECT Suite or under the direction of an anesthesiologist.
OLANZapine
pamoate
(ZyPREXA
Relprevv)
1. Written approval by the Hospital Clinical Director and the local
mental health authority clinical director prior to initiation of therapy
with olanzapine pamoate
2. Compliance with the Risk Evaluation and Mitigation Strategy (REMS)
Olmesartan
(Benicar)
Prior failure to ACE inhibitor therapy due to intolerable side effects or in
cases of drug shortages of formulary ARBs.
Texas HHS Psychiatric Drug Formulary 2020
Reserve Drugs 30
Drug Guidelines for Use
Ophthalmic
agents containing
a steroid
Consultation with an Ophthalmologist or Therapeutic Optometrist prior to
initiation.
Pentamidine
(Pentam)
1. Prophylaxis post-treatment of documented Pneumocystis carinii
pneumonia; or
2. Prophylaxis of Pneumocystis carinii in patients with CD4 counts less
than 200
Thioridazine
(Mellaril)
1. Indicated only for patients with refractory schizophrenia (failed
other 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
(Zanaflex)
1. Documented failure or intolerance to baclofen
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 2020
Therapeutic Serum Concentrations of Some Anticonvulsants 31
Therapeutic Serum Concentrations of Some Anticonvulsants
Drug (mcg/ml)
carBAMazepine (TEGretol, TEGretol XR,
Carbatrol)
4 – 12
Ethosuximide (Zarontin) 40 – 100
lamoTRIgine Bipolar Disorder: 1 – 6 mcg/mL
Epilepsy: 3 – 15 mcg/mL
PHENobarbital (Luminal) 10 – 40
Phenytoin (Dilantin) 10 – 20
Valproic Acid/Valproate, Divalproex
(Depakene, Depakote, Depakote ER)
Seizure Disorder: 50 – 100
Bipolar Disorder: 50 – 125
Aggression: not established
Depakote ER
Seizure Disorder: 50 – 100
Bipolar Disorder: 85 - 125
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:
1. Lexicomp® Drug Information Handbook, 27PthP Edition, American Pharmacists Association
2. Micromedex® [electronic version], Truven Health Analytics, Greenwood Village, CO, USA
(cited 8-20-2019)
3. Facts & Comparison® [electronic version], Walters Kluwer (cited 8-20-19)
Reviewed October 2019
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 32
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 (Acetasol, VoSol)
Solution, otic
Acetic Acid-Aluminum Acetate (Domeboro Otic)
Solution, otic: 2% acetic acid in aluminum acetate
Acetic Acid-Hydrocortisone-Propylene Glycol-Sodium Acetate-Benzethonium (VoSol
HC)
Solution, otic: 1% Hydrocortisone, 2% Acetic Acid, 3% Propylene Glycol, 0.015% Sodium Acetate, and .02%Benzethonium
Acetylcysteine
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 33
Solution, inhalation
Acyclovir (Zovirax)
Capsule, oral Cream, topical
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 34
Aluminum Hydroxide-Magnesium Hydroxide (Maalox)
Suspension, oral
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 35
Ampicillin (Polycillin, Omnipen)
Capsule, oral
Powder for suspension, oral
Powder for injection
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
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 36
atoMOXetine (Strattera)
Capsule, oral
atorvaSTATin (Lipitor)
Tablet, oral
Atropine Sulfate (Isopto Atropine)
Ointment, ophthalmic
Solution, ophthalmic
Azelastine (Astelin)
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
Beclomethasone, (QVAR)
Aerosol, oral inhalation
Suspension, nasal inhalation
Benazepril (Lotensin)
Tablet, oral
Benzocaine (Lanacaine, Cepacol, Orajel)
Topical, for mucous membranes:
Gel: 6%, 20% Liquid: 20%
Topical, dermatologic:
Cream, topical: 5%, 6% Ointment: 5%
Spray: 20% Mouth-Throat preparations:
Gel: 6.3%, 7.5%, 10%, 15%, 20%
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 37
Liquid: 5%, 6.3%, 10%, 20%
Benzoin, Compound Tincture
Tincture, topical (may also contain aloe, storax, tolu balsam, 74% to 80% alcohol)
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 38
Bisacodyl (Dulcolax)
Suppository, rectal
Tablet, enteric coated, oral
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 39
Calamine-Zinc Oxide-Glycerin (Calamine Lotion)
Lotion, topical
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]
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 2020
Alphabetical Listing 40
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 2020
Alphabetical Listing 41
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 42
Ciprofloxacin-Dexamethasone (Ciprodex)
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 2020
Alphabetical Listing 43
Clorazepate (Tranxene) C-IV
Tablet, oral
Clotrimazole (Lotrimin, Gyne-Lotrimin, Fungoid)
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
Cyclobenzaprine
Tablet, oral
Cyproheptadine (Periactin)
Syrup, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 44
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, ophthalmicRESERVE USE Tablet, oral
Dexmethylphenidate, extended release (Focalin XR) CII
Capsule, oral, extended release
Dextroamphetamine (Dexedrine, Dexedrine spansules, Dextrostat) C-II
Capsule, extended release 24 hr, oral
Tablet, oral (5 mg tablet contain tartrazine)
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.
Capsule, oral Liquid, oral
Liquid, sustained release, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 45
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
dilTIAZem (Cardizem)
Capsule, extended release 12 hr:
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 46
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
Syrup, oral
Docusate Sodium-Sennosides (Peri-Colace)
Tablet, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 47
Donepezil (Aricept)
Tablet, oral
Tablet, oral disintegrating
DOPamine (Intropin)- RESERVE USE
Infusion in D5W
Injection
Doxepin (SINEquan, Zonalon)
Capsule, oral
Concentrate, oral
Doxycycline (Vibramycin, Periostat)
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
Enalapril (Vasotec)
Tablet, oral
Enoxaparin (Lovenox)
Injection
Entacapone (Comtan)
Tablet, oral
EPINEPHrine (Adrenalin)
Auto-injector
Injection
Epoetin alfa (Epogen, Procrit)- RESERVE USE
Injection
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 48
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
Intravenous
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 Tablet, oral
Ethambutol (Myambutol)
Tablet, oral
Ethionamide (Trecator)
Tablet, sugar coated, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 49
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
Felodipine
Tablet, extended release, 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
Tablet, extended release 24 hour, oral
Finasteride (Proscar)
Tablet, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 50
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
Injection
Strip, ophthalmic
Fluorescein-benoxinate (Flurox)
Solution, ophthalmic: fluorescein sodium 0.25% and benoxinate hydrochloride 0.4%
Fluoride(OmniMed, PerioMed)
Liquid, oral
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 Injection, as hydrochloride Tablet, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 51
Fluticasone (Flonase, Flovent)
Aerosol, oral inhalation
Solution, nasal inhalation
Powder, oral inhalation diskus
Fluticasone-Salmeterol (Advair)
Aerosol, oral inhalation (HFA)
Powder, oral inhalation
Fluvastatin
Capsule, oral
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
Gemfibrozil (Lopid)
Tablet, film coated, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 52
Gentamicin
Cream, topical
Infusion, premixed in NS
Injection Injection, intrathecal, preservative free
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 53
guaiFENesin-Dextromethorphan
Liquid, oral
Tablet, sustained release
guaiFENesin-Pseudoephedrine (Mucinex D)
Tablet, oral
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 (Isopto Homatropine)
Solution, ophthalmic
hydrALAZINE
Tablet, oral
hydroCHLOROthiazide
Capsule, oral
Tablet, oral
Hydrocortisone (Cortef, Lanacort, Corticaine, Anusol-HC, Proctofoam-HC)
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 54
Injection, as sodium succinate Cream, topical
Lotion, topical Ointment, topical
Cream, rectal Foam, rectal Suppositories, rectal
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)- RESERVE USE
Injection: 100 units/mL
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 55
Insulin, Glargine (Lantus)
Injection: 100 units/mL
Insulin, Lispro (HumaLOG)
Injection: 100 units/mL
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
Kaolin-Pectin
Suspension, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 56
Ketamine (Ketalar) C-III RESERVE USE
Intravenous
Ketoconazole (Nizoral)
Cream, topical
Shampoo, topical
Tablet, oral
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 57
Levarterenol (Levophed)or Norepinephrine -RESERVE USE
Injection
levETIRAcetam (Keppra)
Solution, oral
Tablet, oral
Levocarnitine (Carnitor)
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 58
Lithium Carbonate (Eskalith, Lithonate, Lithobid)
Capsule, oral
Tablet, oral
Tablet, controlled release, oral Tablet, slow release, oral
Lithium Citrate
Syrup, oral
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
Loxapine (Loxitane)
Capsule, 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 2020
Alphabetical Listing 59
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 2020
Alphabetical Listing 60
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, with sucrose and maltodextrin
Powder, oral, sugar free, with phenylalanine
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 61
Tablet, extended release, oral
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
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 2020
Alphabetical Listing 62
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, Vivitrol)
Tablet, oral
Injection, long-acting - RESERVE USE
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 63
Naphazoline (Naphcon, AK-Con)
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 2020
Alphabetical Listing 64
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)
Tablet, oral
Tablet, oral disintegrating
Ophthalmic Irrigating Solution (BSS, Eye Stream, AK-Rinse)
Solution, ophthalmic
Ophthalmic Lubricant (HypoTears, HypoTears PF Artifical Tears, Liquitears)
Ointment, ophthalmic
Solution, ophthalmic
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 65
Oseltamivir (Tamiflu)
Capsule, oral
Suspension, oral
Oxazepam (Serax) C-IV
Capsule, oral
Tablet, oral
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 66
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
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 67
Phenytoin (Dilantin)
Capsule, extended release, oral
Injection
Suspension, oral Tablet, chewable, oral
Phytonadione (Vitamin K1, Mephyton
Tablet, oral
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 68
Potassium Chloride
Capsule, oral
Capsule, sustained release, oral
Liquid, oral 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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 69
Prazosin (Minipress)
Capsule, oral
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)
Injection
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 70
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.
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 (Zantac)
Injection
Syrup, oral Tablet, oral
Rasagiline (Azilect)
Tablet, oral
Rectal Hemorrhoidal Suppositories (Wyanoids, Anusol)
Suppository, rectal
Repaglinide (Prandin)
Tablet, oral
Rifabutin (Mycobutin)
Capsule, oral
rifAMPin (Rifadin)
Capsule, oral
Injection
rifAMPin-Isoniazid (Rifamate)
Capsule, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 71
Risedronate (Actonel)
Tablet, oral
risperiDONE (RisperDAL, RisperDAL M-Tab, RisperDAL Consta)
Injection, long acting
Solution, oral Tablet, oral
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
Gel
Mouthwash Spray Toothpaste
Salmeterol (Serevent)
Powder, oral inhalation
Scopolamine (Isopto Hyoscine)
Solution, ophthalmic
Selegiline (Eldepryl)
Capsule, oral
Tablet, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 72
Selenium Sulfide
Shampoo, topical
Senna (Senokot)
Tablet, oral
Sertraline (Zoloft)
Concentrate, oral
Tablet, oral
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
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 73
Sodium Citrate-Citric Acid (Oracit)
Solution, oral
Sodium Polystyrene Sulfonate
Powder for suspension, oral Suspension, oral (with sorbitol and alcohol)
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 74
Sunscreen-Block
Cream-Lotion, topical: contains a minimum SPF of 15
Tacrolimus (Protopic)
Ointment, topical
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
Thiamine (Vitamin B1)
Injection
Tablet, oral
Thioridazine (Mellaril)- RESERVE USE
Tablet, oral
Thiothixene (Navane)
Capsule, oral
tiaGABine (Gabatril)
Tablet, oral
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 75
Timolol (Timoptic)
Gel, ophthalmic Solution, as maleate, ophthalmic 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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 76
Tranylcypromine (Parnate)
Tablet, oral
Travoprost (Travatan Z)
Solution, ophthalmic
traZODone (Desyrel)
Tablet, oral
Tretinoin (Retin-A)
Cream, topical
Gel, topical
Triamcinolone (Azmacort, Nasacort)
Aerosol, topical
Cream, topical
Lotion, topical Ointment, topical Paste, dental
Spray, nasal inhalation
Triamterene (Dyrenium)
Capsule, oral
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 77
Tropicamide (Mydriacyl)
Solution, ophthalmic
Trospium
Tablet, oral
Capsule, extended release 24 hour, oral
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, oral
Syrup, 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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 78
Vitamin A (Aquasol A)
Capsule, oral
Vitamin A&D Topical
Ointment, topical
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
Texas HHS Psychiatric Drug Formulary 2020
Alphabetical Listing 79
Paste, topical
Zinc Oxide-Petrolatum-Imidazolidinyl Urea (Diaperene)
Ointment, topical
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 2020
Therapeutic Classification/Cost Index 80
Therapeutic Classification/Cost Index
Antidiabetic Agents
Insulins, Human Cost Index
Insulin, Aspart (NovoLOG) High
Insulin, Combination (70/30) High
Insulin, Detemir (Levemir) RESERVE USE High
Insulin, Glargine (Lantus) High
Insulin, Lispro (HumaLOG) Moderate
Insulin, Combination, lispro protamine suspension-insulin lispro,
(HumaLOG Mix 75/25, HumaLOG Mix 50/50) Moderate
Insulin, NPH Moderate
Insulin, Regular (HumuLIN, NovoLIN) Moderate
Sulfonylureas Cost Index
glipiZIDE (Glucotrol) Low
Miscellaneous Antidiabetic Agents Cost Index
Liraglutide (Victoza) High
metFORMIN (Glucophage, Glucophage XR) Low
Pioglitazone (Actos) Low
Repaglinide (Prandin) Low
Antidotes
Antidotes Cost Index
Glucagon High
Glucose, oral Moderate
Naloxone (Narcan) High
Phytonadione (Vitamin K1, Mephyton) High
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 81
Antidotes Cost Index
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
Miscellaneous Blood Modifying Agents Cost Index
Epoetin alfa (Epogen, Procrit) RESERVE USE High
Ferrous Fumarate-Docusate Sodium (Ferro-Sequels) [33% elemental iron] Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 82
Miscellaneous Blood Modifying Agents Cost Index
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
Triamterene (Dyrenium) High
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 2020
Therapeutic Classification/Cost Index 83
Antianginals Cost Index
Nitroglycerin Low
Antiarrhythmics Cost Index
Adenosine (Adenocard) Reserve Use High
Amiodarone (Pacerone, Cordarone) Low
Calcium Channel Blockers Cost Index
amLODIPine (Norvasc) Low
dilTIAZem (Cardizem) Low
Felodipine 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-High
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
Fluvastatin Moderate
Gemfibrozil (Lopid) Low
Niacin-Nicotinamide (Nicobid) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 84
Antihyperlipidemics Cost Index
Pravastatin (Pravachol) Low
Rosuvastatin (Crestor) Low
Simvastatin (Zocor) Low
Omega-3-acid ethyl esters (Lovaza) Moderate
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-High
hydrALAZINE Low
Methyldopa Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 85
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
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) Low-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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 86
Analgesics-Opiate Agonists Cost Index
morphine-II Low-Moderate
oxyCODONE (OxyCONTIN) C-II 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
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 Low-moderate
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) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 87
Miscellaneous Anticonvulsants Cost Index
Cannabidiol (Epidiolex) C-V RESERVE USE High
carBAMazepine (TEGretol) Moderate-High
Divalproex (Depakote) Low
Felbamate (Felbatol) - RESERVE USE Moderate
Gabapentin (Neurontin) Low
Lacosamide (Vimpat) C-V High
lamoTRIgine (LaMICtal) Low-High
levETIRAcetam (Keppra) Low
OXcarbazepine (Trileptal) Low
Pregabalin (Lyrica) C-V Low
Rufinamide (Banzel) High
tiaGABine (Gabatril) High
Topiramate (Topamax) Low
Valproic Acid/Valproate
(Depakene)
Low
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 88
Miscellaneous Central Nervous System Agents Cost Index
Megestrol (Megace, Megace ES) Moderate
Antiparkinson Agents Cost Index
Amantadine Moderate
Benztropine (Cogentin) Low-High
Bromocriptine Moderate
Entacapone (Comtan) Low
Carbidopa-Levodopa (Sinemet) Low
Pramipexole (Mirapex) Low
Rasagiline (Azilect) High
Selegiline (Eldepryl) Low
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) Moderate
diazePAM (Valium) C-IV Low-High
tiZANidine (Zanaflex) - RESERVE USE Low
Muscle Relaxants-Muscle Relaxant Agents Cost Index
Cyclobenzaprine Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 89
Muscle Relaxants-Muscle Relaxant Agents Cost Index
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) Uoral onlyU C-IV Low
clonazePAM (KlonoPIN) C-IV Low
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
hydrOXYzine (Atarax, Vistaril) Low-High
Prazosin (Minipress) Low
traZODone (Desyrel) Low
Zolpidem (Ambien) C-IV Low
Psychotropic Agents-Antidepressants-Monoamine Oxidase
Inhibitors (MAOI)
Cost Index
Phenelzine (Nardil) Moderate
Tranylcypromine (Parnate) Moderate
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 90
Psychotropic Agents-Antidepressants-Serotonin Selective Reuptake
Inhibitors (SSRI)
Cost Index
Citalopram (CeleXA) Low
Escitalopram (Lexapro) Low-High
FLUoxetine (PROzac) Low-High
fluvoxaMINE (Luvox) Low-High
PARoxetine (Paxil) Low-High
Sertraline (Zoloft) Low-High
Psychotropic Agents-Antidepressants-Serotonin Norepinephrine
Reuptake Inhibitors (SNRI)
Cost Index
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 91
Psychotropic Agents-Antipsychotics Cost Index
ARIPiprazole (Abilify, Abilify discmelt, Abilify Maintena, Aristada, Aristada
Initio -RESERVE USE)
Low-High
Asenapine (Saphris) High
Brexpiprazole (Rexulti) High
Cariprazine (Vraylar) High
chlorproMAZINE (Thorazine) High
cloZAPine (Clozaril)- RESERVE USE Moderate-High
fluPHENAZine (Prolixin) High
Haloperidol (Haldol) Low-High
Iloperidone (Fanapt) RESERVE USE High
Loxapine (Loxitane) Moderate
Lurasidone (Latuda) High
OLANZapine (ZyPREXA) Low
Paliperidone (Invega) High
Perphenazine (Trilafon) Low-Moderate
QUEtiapine (SEROquel) Low
risperiDONE (RisperDAL) Low-High
Thioridazine (Mellaril) - RESERVE USE Moderate
Thiothixene (Navane) Moderate
Trifluoperazine (Stelazine) Moderate
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 92
Psychotropic Agents-Mood Stabilizers Cost Index
OXcarbazepine (Trileptal) Low
Topiramate (Topamax) Low
Valproic Acid/Valproate (Depakene) Low
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
Dextroamphetamine (Dexedrine, Dextrostat) C-II
Low-Moderate
Lisdexamfetamine (Vyvanse) C-II Reserve Use High
Rarely used in adults
Methylphenidate, immediate release (Ritalin, Methylin, Metadate) C-II
Low-Moderate
Rarely used in adults
Methylphenidate, sustained release (Ritalin SR, Metadate CD Concerta) C-II
Moderate-High
Psychotropic Agents-Other ADHD Agents Cost Index
cloNIDine (Catapres) Low
guanFACINE (Tenex, Intuniv) Low
Substance Use Treatments Cost Index
Acamprosate (Campral) High
Buprenorphine (Subutex) C-II- RESERVE USE Moderate
Buprenorphine-naloxone (Suboxone) C-II- RESERVE USE Moderate
Disulfiram (Antabuse) Moderate
Naltrexone (ReVia, Vivitrol- RESERVE USE) Low-High
Nicotine (Nicoderm, Nicotrol, Nicorette) Low-Moderate
Topiramate (Topamax) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 93
Endocrine Agents
Estrogens Cost Index
Estradiol (Estrace, Vivelle, Alora, Climara, Estraderm) Low-High
Estrogens, Conjugated (Premarin) High
Progesterones Cost Index
medroxyPROGESTERone (Provera) Low-High
Combination Products Cost Index
Estrogen-medroxyPROGESTERone (PremPro, Premphase) Low
All commercially available oral contraceptive agents are considered to be formulary agents
Androgens Cost Index
Testosterone (Androlan) C-IV Low
Osteoporosis Agents Cost Index
Alendronate (Fosamax, Binosto) Low
Calcitonin-Salmon (Miacalcin) Low
Denosumab (Prolia) High
Ibandronate (Boniva) Moderate
Raloxifene (Evista) Moderate
Risedronate (Actonel) Low
Zoledronic Acid (Reclast) High
Adrenal Cortical Steroids Cost Index
Dexamethasone Moderate
Fludrocortisone Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 94
Adrenal Cortical Steroids Cost Index
Hydrocortisone (Cortef) Low-High
methylPREDNISolone (Medrol, DEPO-Medrol, SOLU-Medrol) Low-High
prednisoLONE Moderate-high
predniSONE (Deltasone) Low
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
calcium
Low
Antispasmodics/Anticholinergic Agents Cost Index
Dicyclomine (Bentyl) Low
Glycopyrrolate (Robinul) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 95
Histamine (H2) Antagonists-Preferred Agents Cost Index
Famotidine (Pepcid) Low-Moderate
Histamine (H2) Antagonists-Other Agents Cost Index
raNITIdine (Zantac) Low-High
Proton Pump Inhibitors-Preferred Agents Cost Index
Lansoprazole (Prevacid) Low
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 96
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.
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) High
Miscellaneous Laxatives Cost Index
Glycerin Suppository (Sani-Supp) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 97
Antidiarrheals Cost Index
Bismuth Subsalicylate (Pepto-Bismol, Bismatrol, Kaopectate) Low
Kaolin-Pectin Low
Lactobacillus Acidophilus (Lactinex, Bacid, Florajen) Low-High
Loperamide (Imodium) Low
Rectal Agents Cost Index
Hydrocortisone Rectal Foam, suppositories, cream, ointment (Proctofoam-
HC, Anusol-HC)
High
Pramoxine – Hydrocortisone (Analpram HC) High
Pramoxine (Anusol) Rectal ointment, suppository Low
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) High
miSOPROStol (Cytotec) Moderate
Pancrelipase (Pancreaze, Creon) High
Saccharomyces boulardii (Florastor) Moderate
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 Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 98
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
Urinary Anticholinergics Cost Index
Darifenacin (Enablex) Moderate
Oxybutynin (Ditropan XL) Low
Solifenacin (Vesicare) Low
Trospium Moderate
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 99
Miscellaneous Genitourinary Agents Cost Index
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
Hepatitis A-Hepatitis B Vaccine (Twinrix) High
Hepatitis B Virus Vaccine, Recombinant (Recombivax HB, Engerix-B,
Heplisav-B )
High
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 100
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
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 101
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
Linezolid (Zyvox) RESERVE USE High
metroNIDAZOLE (Flagyl) Low-Moderate
Sulfamethoxazole -Trimethoprim (Bactrim)
The 5:1 ratio of Sulfamethoxazole to Trimethoprim is constant in all dosage
forms
Low-High
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 102
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
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 103
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 High
Dextrose 5% in Water Moderate
Dextrose 5% in Ringer's Lactate Moderate
Dextrose 5%-Sodium Chloride-Potassium Chloride Intravenous Solution High
Dextrose 50% in Water High
Sodium Chloride Intravenous Solution High
Sodium Chloride Low
Water for Injection Low
Electrolyte Replacement Additives Cost Index
Magnesium Sulfate Low
Potassium Chloride Low
Sodium Chloride Low
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 104
Vitamins Cost Index
Vitamin E (Aquasol E) Low
Minerals, Trace Elements, and Electrolytes Cost Index
Calcium Carbonate (Os-Cal, Os-Cal chewable, Tums) - 40% elemental
calcium
Low
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-
150 Forte)
Low
Multivitamin (Unicap, Hexavitamins) Low
Multivitamin-Minerals Low
Multivitamins, Pediatric (Poly-Vi-Sol) Low
Multivitamins, Prenatal Low
Vitamin B Complex Low
Vitamin B Complex-Vitamin C (Stresscaps, Allbee with C, Nephrocaps,
Nephro-vite)
Low
Vitamin B Complex-Vitamin C-Zinc Low
Miscellaneous nutritional agents Cost Index
Levocarnitine (Carnitor) High
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 105
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
(SABA/SAMA)
Cost Index
Albuterol-Ipratropium (Combivent) Moderate
Combination Long Acting Beta-2 Agonists Plus Corticosteroids
(LABA/ICS)
Cost Index
Budesonide-Formoterol (Symbicort) Moderate
Fluticasone-Salmeterol (Advair) High
Inhaled Corticosteroids (ICS) Cost Index
Beclomethasone (QVAR) Moderate
Budesonide (Pulmicort) Moderate
Fluticasone (Flovent) Moderate
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 106
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
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.
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 107
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
Ophthalmics-Antibiotics Cost Index
Bacitracin High
Ciprofloxacin (Ciloxan) Moderate
Erythromycin High
Gentamicin (Garamycin) 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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 108
Ophthalmics-Mydriatics Cost Index
Atropine Sulfate (Isopto Atropine) Moderate
Homatropine (Isopto Homatropine) High
Phenylephrine (Neo-Synephrine) Moderate
Scopolamine (Isopto Hyoscine) N/A
Tropicamide (Mydriacyl) Low
Ophthalmics-Decongestant/Antiallergy Cost Index
Ketotifen (Zaditor) Low
Naphazoline (Naphcon, AK-Con) Low
Olopatadine (Patanol) High
Tetrahydrozoline (Visine Allergy Relief, Visine Moisturizing) Low
Miscellaneous Ophthalmics Cost Index
Carboxymethylcellulose Low
Cromolyn (Intal) Low
Dexamethasone - RESERVE USE High
Fluorescein Sodium Low
Fluorescein-benoxinate (Flurox) N/A
Ophthalmic Irrigating Solution (BSS, Eye Stream, AK-Rinse) Low
Ophthalmic Lubricant (Artifical Tears, Liquitears, HypoTears, HypoTears PF) 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 (Acetasol, VoSol) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 109
Otics Cost Index
Acetic Acid-Aluminum Acetate (Domeboro Otic) Low
Acetic Acid-Hydrocortisone-Propylene Glycol-Sodium Acetate-Benzethonium
(VoSol HC)
High
Carbamide Peroxide-Glycerin-Propylene Glycol-Sodium Stannate (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 ( Fungoid) Low
Doxycycline (Periostat) N/A
Fluoride (OmniMed, PerioMed) Low
Lidocaine (Viscous Lidocaine) Low
Nystatin (Mycostatin) Low
Phenol (Chloraseptic) Low
Saliva Substitute OTC Low
Saliva Substitute Rx Low
Sodium Chloride Low
Triamcinolone High
Nasal Agents Cost Index
Azelastine (Astelin) 0.1% nasal spray 137 mcg/spray Low
Fluticasone (Flonase) Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 110
Nasal Agents Cost Index
Mometasone (Nasonex) Low
Oxymetazoline (Afrin) Low
Phenylephrine (Neo-Synephrine) Low
Sodium Chloride Low
Triamcinolone (Azmacort, 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
Dermatologicals-Anesthetics, local Cost Index
Benzocaine (Lanacaine) Low
Ethyl Chloride Low
Lidocaine (Xylocaine) Low
Lidocaine-Prilocaine (EMLA, Lidoderm) Low
Pramoxine Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 111
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 (Garamycin) 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
Clotrimazole-Betamethasone dipropionate (Lotrisone ) Low
Ketoconazole Low
Miconazole Low
Nystatin Low
Terbinafine Low
Tolnaftate Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 112
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
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 113
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,
Nutraderm)
Low
Emollient Ointment (Lanolin, Aquaphor) Low
Dermatologicals-Keratolytics Cost Index
Podophyllum Resin (Podocon-25) High
Salicylic Acid
All available salicylic acid products as a single agent are considered to be on
formulary
Low-High
Urea Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 114
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
All commercially available salicylic acid sulfur forms are on formulary
Low
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
Zinc Oxide Low
Dermatologicals-Sunscreens Cost Index
Sunscreen-Block- Contains minimum SPF 15 Low
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 115
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
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
Texas HHS Psychiatric Drug Formulary 2020
Therapeutic Classification/Cost Index 116
Certification Process Used Product Line Certified
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 2020
Index 117
Index
A
Abilify ........................................ 12, 35, 91
Abilify discmelt ................................ 35, 91
Abilify Maintena .......................... 13, 35, 91
Abrasive Cleanser ................................ 114
Acamprosate ................................... 32, 92
Acetaminophen ................................ 32, 86
Acetaminophen-Codeine ................... 32, 85
Acetaminophen-HYDROcodone ........... 32, 85
Acetasol ........................................ 32, 108
acetaZOLAMIDE ............................... 32, 82
Acetic Acid .................................... 32, 108
Acetic Acid-Aluminum Acetate ......... 32, 109
Acetic Acid-Hydrocortisone-Propylene Glycol-
Sodium Acetate-Benzethonium ..... 32, 109
Acetylcysteine ............................... 32, 106
Actonel ........................................... 71, 93
Actos .............................................. 67, 80
Acyclovir ................................ 33, 102, 111
Adacel ............................................ 46, 99
Adalat CC ........................................ 63, 83
Adapalene ..................................... 33, 110
Adderall .................................... 19, 34, 92
Adderall XR ..................................... 19, 34
Adenocard ................................. 23, 33, 83
Adenosine ................................. 23, 33, 83
Adrenalin......................................... 47, 84
Advair ........................................... 51, 105
Afrin ............................................. 65, 110
AK-Con ......................................... 63, 108
AK-Rinse ....................................... 64, 108
Albuterol ....................................... 33, 105
Albuterol-Ipratropium ..................... 33, 105
Alcaine .......................................... 69, 108
Aldactazide ...................................... 73, 82
Aldactone ........................................ 73, 82
Alendronate ..................................... 33, 93
Allbee with C ................................. 78, 104
Allegra .......................................... 49, 106
Allegra-D ....................................... 49, 106
Allopurinol ....................................... 33, 94
Texas HHS Psychiatric Drug Formulary 2020
Index 118
Alora .............................................. 48, 93
Alphagan P .................................... 38, 107
ALPRAZolam ............................... 21, 33, 89
Aluminum Chloride Hexahydrate ...... 33, 115
Aluminum Hydroxide ........................ 33, 94
Aluminum Hydroxide-Magnesium Hydroxide
................................................... 34, 94
Aluminum Hydroxide-Magnesium Hydroxide-
Simethicone ................................. 34, 94
Aluminum Hydroxide-Magnesium Trisilicate
................................................... 33, 94
Amantadine ..................................... 34, 88
Ambien ...................................... 22, 79, 89
Amikacin ....................................... 34, 101
Amino Acid Injection ....................... 34, 103
Amino Acid Injection-Dextrose-Electrolytes
................................................. 34, 103
Aminosyn ...................................... 34, 103
Amiodarone ..................................... 34, 83
Amitiza ........................................... 58, 96
Amitriptyline ....................15, 17, 34, 85, 90
amLODIPine .................................... 34, 83
Amoxicillin .................................... 34, 100
Amoxicillin-Clavulanate ................... 34, 100
Amoxil .......................................... 34, 100
Amphetamine Mixture .................. 19, 34, 92
Ampicillin ...................................... 35, 100
Anafranil ................................... 15, 42, 90
Analpram HC ................................... 68, 97
Androlan ......................................... 74, 93
Antabuse ......................................... 46, 92
Antara ............................................ 49, 83
Antineoplastic Agents ............................. 35
Antivert ........................................... 59, 87
Antiviral Agents ..................................... 35
Anusol ............................................ 70, 97
Anusol-HC ..................................... 53, 97
Apixaban ......................................... 35, 81
Aprodine ....................................... 76, 106
Aquaphor ...................................... 47, 113
Aquasol A ...................................... 78, 103
Aquasol E ...................................... 78, 104
Aricept ............................................ 47, 88
ARIPiprazole .............................. 12, 35, 91
ARIPiprazole Extended Release ............... 13
ARIPiprazole lauroxil ......................... 13, 23
Aristada .................................... 13, 35, 91
Aristada Initio ............................ 23, 35, 91
Arixtra ............................................ 51, 81
Artane ............................................ 76, 88
Texas HHS Psychiatric Drug Formulary 2020
Index 119
Artifical Tears ................................ 64, 108
Asacol HD ....................................... 59, 97
Ascorbic Acid ................................. 35, 103
Asenapine .................................. 13, 35, 91
Aspirin ....................................... 35, 81, 85
Aspirin-Acetaminophen-Caffeine ........ 35, 85
Astelin .......................................... 36, 109
Atarax .......................... 22, 54, 87, 89, 106
Atenolol ..................................... 35, 83, 85
Ativan .................................. 21, 58, 86, 89
atoMOXetine ............................... 20, 36, 92
atorvaSTATin ................................... 36, 83
Atropine Sulfate ............................. 36, 108
Atrovent ....................................... 55, 105
Augmentin .................................... 34, 100
Avage .................................... 74, 110, 112
Avelox .......................................... 62, 101
Azelastine ..................................... 36, 109
Azilect ............................................ 70, 88
Azithromycin ................................. 36, 100
Azmacort ...................................... 76, 110
Azulfidine ........................................ 73, 97
B
Bacid .............................................. 56, 97
Bacitracin ....................... 36, 107, 111, 112
Bacitracin-Polymyxin B .................... 36, 111
Baclofen .......................................... 36, 88
Bactrim ......................................... 73, 101
Bactroban ...................................... 62, 111
Banzel ............................................ 71, 87
Beclomethasone ............................. 36, 105
Benadryl ............... 21, 46, 87, 89, 106, 111
Benazepril ....................................... 36, 84
Ben-Gay ........................................ 59, 114
Benicar ..................................... 29, 64, 84
Bentyl ............................................. 45, 94
BenzaClin ...................................... 37, 110
Benzamycin ................................... 48, 110
Benzocaine ............................. 36, 109, 110
Benzodiazepines ......................... 31, 86, 89
Benzoin, Compound Tincture ........... 37, 114
Benzonatate .................................. 37, 106
Benzoyl Peroxide ............................ 37, 110
Benzoyl Peroxide-Clindamycin .......... 37, 110
Benztropine ..................................... 37, 88
Betadine ....................................... 68, 112
Betamethasone dipropionate............ 37, 112
Texas HHS Psychiatric Drug Formulary 2020
Index 120
Betamethasone dipropionate, augmented. 23,
37
Betamethasone Valerate ................. 37, 113
Betaxolol ....................................... 37, 107
Bethanechol .................................... 37, 98
Betoptic S ..................................... 37, 107
Biaxin ........................................... 42, 100
Bicillin LA ...................................... 66, 100
Bicitra ................................................... 98
Bimatoprost .................................. 37, 107
Binosto ........................................... 33, 93
Bisacodyl ........................................ 38, 95
Bismatrol ........................................ 38, 97
Bismuth Subsalicylate ....................... 38, 97
Bleph-10 ....................................... 73, 107
Bonine ............................................ 59, 87
Boniva ............................................ 54, 93
Boostrix .......................................... 46, 99
Brasivol .............................................. 114
Brexpiprazole ............................. 13, 38, 91
Brimonidine ................................... 38, 107
Bromocriptine .................................. 38, 88
Brompheniramine-Phenylephrine...... 38, 106
Brompheniramine-Pseudoephedrine . 38, 106
BSS .............................................. 64, 108
Budeprion........................................ 38, 90
Budesonide .................................... 38, 105
Budesonide-Formoterol ................... 38, 105
Buprenorphine ................................. 23, 38
Buprenorphine-naloxone ................... 23, 38
buPROPion ................................. 15, 38, 90
buPROPion SR ....................................... 15
buPROPion XL ....................................... 15
BuSpar ...................................... 21, 38, 89
busPIRone ................................. 21, 38, 89
C
Caladryl ........................................ 39, 111
Caladryl Clear ................................ 68, 111
Calamine Lotion ............................. 39, 111
Calamine-Pramoxine ....................... 39, 111
Calamine-Zinc Oxide-Glycerin .......... 39, 111
Calan ........................................ 77, 83, 85
Calan SR ......................................... 77, 83
Calciferol ..................................48, 78, 103
Calcipotriene .................................. 39, 112
Calcitonin-Salmon ............................ 39, 93
Calcitrol ...................................41, 78, 103
Calcium Carbonate ....................39, 94, 104
Texas HHS Psychiatric Drug Formulary 2020
Index 121
Calcium Carbonate-Vitamin D3 ................ 39
Calcium Carbonate-Vitamin DR3R .......... 104
Calcium Citrate .............................. 39, 104
Calcium Citrate-Vitamin D3 ..................... 39
Calcium Citrate-Vitamin DR3R ............... 104
Calmoseptine ................................. 59, 114
Campho-Phenique .......................... 39, 115
Camphor-Phenol ............................ 39, 115
Campral .......................................... 32, 92
Canasa ........................................... 59, 97
Cannabidiol ................................ 23, 39, 87
Capex ........................................... 50, 113
Capoten .......................................... 39, 84
Captopril ......................................... 39, 84
Carafate .......................................... 73, 97
carBAMazepine .......... 17, 18, 31, 39, 87, 91
Carbamide Peroxide ....................... 40, 109
Carbamide Peroxide-Glycerin-Propylene
Glycol-Sodium Stannate ..................... 109
Carbatrol.................................... 17, 31, 39
Carbidopa-Levodopa ......................... 40, 88
Carboxymethylcellulose .......................... 40
Cardizem ........................................ 45, 83
Cariprazine ................................. 13, 40, 91
Carnitor ........................................ 57, 104
Carrington Clara-Klenz .................... 78, 115
Carvedilol ........................................ 40, 83
Catapres .............................. 20, 42, 84, 92
ceFAZolin ...................................... 40, 100
Cefdinir ......................................... 40, 100
Cefepime ....................................... 40, 100
Ceftin............................................ 40, 100
cefTRIAXone .................................. 40, 100
Cefuroxime Axetil ........................... 40, 100
CeleBREX .................................. 24, 40, 85
Celecoxib .................................. 24, 40, 85
CeleXA ...................................... 15, 42, 90
Cellulose ......................................... 40, 96
Cepacol ......................................... 36, 109
Cephalexin .................................... 40, 100
Cerebyx .......................................... 51, 86
Cetaphil ........................... 47, 63, 113, 114
Cetirizine ....................................... 41, 106
Cetirizine-Pseudoephedrine .............. 41, 106
Chloraseptic ................................... 66, 109
chlordiazePOXIDE ....................... 21, 41, 89
Chlorhexidine .......................... 41, 109, 112
Chlorpheniramine ........................... 41, 106
Texas HHS Psychiatric Drug Formulary 2020
Index 122
chlorproMAZINE ...............10, 11, 13, 41, 91
Chlorthalidone ................................. 41, 82
Cholecalciferol .......................... 41, 78, 103
Cholestyramine ................................ 41, 83
Ciclopirox ...................................... 41, 111
Ciloxan ......................................... 41, 107
Cipro ............................................ 41, 101
Cipro HC Otic ....................................... 109
Cipro Otic .............................................. 42
Ciprodex ....................................... 42, 109
Ciprofloxacin .......................... 41, 101, 107
Ciprofloxacin-Dexamethasone .......... 42, 109
Ciprofloxacin-Hydrocortisone ........... 42, 109
Citalopram ................................. 15, 42, 90
Citracal ......................................... 39, 104
Citracal-D ..................................... 39, 104
Citrucel ........................................... 60, 96
Clarithromycin ............................... 42, 100
Claritin ......................................... 58, 106
Claritin D ...................................... 58, 106
Cleocin ......................................... 42, 101
Cleocin T ................................ 42, 110, 111
Climara ........................................... 48, 93
Clindamycin .................... 42, 101, 110, 111
Clinimix E ...................................... 34, 103
Clinoril ............................................ 73, 85
cloBAZam ............................. 24, 31, 42, 86
Clobetasol ................................24, 42, 112
Clobex .......................................... 42, 112
clomiPRAMINE ........................... 15, 42, 90
clonazePAM .......................... 21, 42, 86, 89
cloNIDine ............................. 20, 42, 84, 92
cloNIDine Extended Release ................... 20
Clopidogrel ...................................... 42, 81
Clorazepate .......................... 21, 43, 86, 89
Clotrimazole ..................... 43, 98, 109, 111
Clotrimazole- Betamethasone
dipropionate ............................. 43, 111
cloZAPine ....................... 13, 15, 24, 43, 91
Clozaril ................................ 13, 24, 43, 91
Coal Tar ................................. 43, 112, 115
Cod Liver Oil-Zinc Oxide-Talc .................. 43
Cogentin ......................................... 37, 88
Colace ............................................. 46, 96
Colchicine ........................................ 43, 86
Collagenase ................................... 43, 115
Co-Lyte ........................................... 67, 96
Combivent ..................................... 33, 105
Texas HHS Psychiatric Drug Formulary 2020
Index 123
Compazine ...................................... 69, 87
Comtan ........................................... 47, 88
Concerta .................................... 19, 60, 92
Cordarone ....................................... 34, 83
Coreg ............................................. 40, 83
Coreg CR ........................................ 40, 83
Cormax ......................................... 42, 112
Cortef ............................................. 53, 94
Corticaine ............................................. 53
Cortisporin .................................... 63, 109
Cosopt .......................................... 75, 107
Coumadin ....................................... 78, 81
Cozaar ............................................ 58, 84
Creon ............................................. 65, 97
Crestor ........................................... 71, 84
Cromolyn ...................................... 43, 108
Cyanocobalamin ............................. 43, 103
Cyclobenzaprine ............................... 43, 88
Cymbalta ................................... 16, 47, 90
Cyproheptadine ............................. 43, 106
Cytotec ........................................... 61, 97
D
Dantrium ........................................ 44, 88
Dantrolene ...................................... 44, 88
Dapsone ........................................ 44, 102
Darifenacin ...................................... 44, 98
DDAVP ............................................ 44, 94
Debrox .......................................... 40, 109
Deltason .............................................. 69
Deltasone ............................................. 94
Denosumab ..................................... 44, 93
Depakene .................. 18, 31, 77, 85, 87, 92
Depakote .................. 18, 31, 46, 85, 87, 91
Depakote ER ......................... 18, 31, 46, 85
DEPO-Medrol ................................... 60, 94
Derma-Smooth/FS.......................... 50, 113
Desipramine ......................... 15, 17, 44, 90
Desitin ................................................. 43
Desmopressin .................................. 44, 94
Desonide ....................................... 44, 113
Desowen ....................................... 44, 113
Desyrel .......................... 16, 22, 76, 89, 90
Detrol ............................................. 75, 98
Detrol LA ......................................... 75, 98
Dexamethasone ........................44, 93, 108
Dexedrine.................................. 19, 44, 92
Dexedrine spansules .............................. 44
Dexedrine Spansules ............................. 19
Texas HHS Psychiatric Drug Formulary 2020
Index 124
Dexmethylphenidate XR ............... 19, 44, 92
Dextroamphetamine ......................... 19, 44
Dextroamphetamine XR .......................... 92
Dextromethorphan ......................... 44, 106
Dextrose 5% in Ringer's Lactate ...... 45, 103
Dextrose 5% in Water .................... 45, 103
Dextrose 5%-Sodium Chloride Intravenous
Solution ..................................... 45, 103
Dextrose 5%-Sodium Chloride-Potassium
Chloride Intravenous Solution ....... 45, 103
Dextrose 50% in Water ................... 45, 103
Dextrostat ....................................... 44, 92
Diamox ........................................... 32, 82
Diaper Rash Ointment..................... 45, 113
Diaper Rash Powder ....................... 45, 113
Diaperene ............................................. 79
Diastat ............................................ 45, 86
diazePAM ........................21, 45, 86, 88, 89
Diclofenac Gel ........................... 24, 45, 110
Dicyclomine ..................................... 45, 94
Differin ......................................... 33, 110
Diflucan ........................................ 50, 101
Digoxin ........................................... 45, 82
Dilantin ...................................... 31, 67, 86
dilTIAZem ....................................... 45, 83
Dimetapp Children’s Cold and Allergy 38, 106
Diovan ............................................ 77, 84
diphenhydrAMINE ...... 10, 11, 21, 46, 87, 89,
106, 111
Diphtheria-Tetanus Toxoids Adsorbed . 46, 99
Diphtheria-Tetanus Toxoids Adsorbed for
Adult Use ...................................... 46, 99
Diphtheria-Tetanus-Acellular Pertussis 46, 99
Diprolene ...................................... 37, 112
Diprolene A/F ............................23, 37, 112
Disulfiram ........................................ 46, 92
Ditropan XL ..................................... 65, 98
Divalproex ................. 18, 31, 46, 85, 87, 91
Docusate Calcium ............................. 46, 96
Docusate Sodium ............................. 46, 96
Docusate Sodium-Sennosides ............ 46, 96
Dolophine ............................................. 60
Domeboro Otic ............................... 32, 109
Donepezil ........................................ 47, 88
DOPamine ................................. 24, 47, 84
Dovonex ....................................... 39, 112
Doxepin ............................... 16, 17, 47, 90
Doxycycline ............................ 47, 100, 109
Drisdol .....................................48, 78, 103
Drysol ........................................... 33, 115
Texas HHS Psychiatric Drug Formulary 2020
Index 125
DT .................................................. 46, 99
Dulcolax .......................................... 38, 95
DULoxetine ................................ 16, 47, 90
Duragesic .............................................. 49
Dyazide .......................................... 76, 82
Dyrenium ........................................ 76, 82
E
E.E.S. ................................................... 48
Effexor ................................. 16, 77, 85, 90
Effexor XR ............................................. 16
Elavil ................................... 15, 34, 85, 90
Eldepryl .......................................... 71, 88
Elidel ............................................ 67, 115
Elimite .......................................... 66, 114
Eliquis ............................................ 35, 81
EMLA ............................................ 57, 110
Emollient Gel ................................. 47, 113
Emollient Lotion-Cream ................... 47, 113
Emollient Ointment ........................ 47, 113
Enablex .......................................... 44, 98
Enalapril ......................................... 47, 84
Engerix-B ........................................ 53, 99
Enoxaparin ...................................... 47, 81
Entacapone ..................................... 47, 88
Enulose ........................................... 56, 96
Epidiolex ................................... 23, 39, 87
EPINEPHrine .................................... 47, 84
Epoetin alfa ............................... 24, 47, 81
Epogen ..................................... 24, 47, 81
Epsom Salt ........................................... 59
Ergocalciferol ............................48, 78, 103
Eryc ..................................................... 48
EryPed ................................................. 48
Erythrocin ............................................ 48
Erythromycin ................................. 48, 107
Erythromycin base ................................. 48
Erythromycin Ethylsuccinate ................... 48
Erythromycin-Benzoyl Peroxide ........ 48, 110
Escitalopram .............................. 16, 48, 90
Eskalith ..................................... 17, 58, 91
Esketamine ................................ 25, 48, 90
Esomeprazole .................................. 48, 95
Estrace ........................................... 48, 93
Estraderm ....................................... 48, 93
Estradiol .......................................... 48, 93
Estrogen-medroxyPROGESTERone ...... 48, 93
Estrogens, Conjugated ...................... 48, 93
Ethambutol .................................... 48, 102
Texas HHS Psychiatric Drug Formulary 2020
Index 126
Ethionamide .................................. 48, 102
Ethosuximide .............................. 31, 49, 86
Ethyl Chloride ................................ 49, 110
Eucerin ......................................... 47, 113
Evista ............................................. 70, 93
Excedrine Migraine ........................... 35, 85
Exelon ............................................ 71, 88
Exelon Patches ................................ 71, 88
Eye Stream ................................... 64, 108
F
Famotidine ...................................... 49, 95
Fanapt ................................. 13, 25, 54, 91
Fazaclo ...................................... 13, 24, 43
Felbamate .................................. 25, 49, 87
Felbatol ..................................... 25, 49, 87
Felodipine ....................................... 49, 83
Fenofibrate ...................................... 49, 83
fentaNYL ............................................... 49
Feosol ...................................... 49, 82, 104
Fer-In-Sol ................................ 49, 82, 104
Ferro-Sequels .................................. 49, 81
Ferrous Fumarate-Docusate Sodium ... 49, 81
Ferrous Sulfate ......................... 49, 82, 104
Fexofenadine ................................. 49, 106
Fexofenadine - Pseudoephedrine ............. 49
Fexofenadine-Pseudoephedrine .............. 106
Fibercon .......................................... 67, 96
Fiber-Lax ......................................... 67, 96
Filibon .................................................. 62
Finasteride ...................................... 49, 98
Fish Oil ......................................... 50, 116
Flagyl ............................................ 61, 101
Flomax ............................................ 74, 98
Flonase ......................................... 51, 109
Florajen .......................................... 56, 97
Florastor ......................................... 71, 97
Flovent.......................................... 51, 105
Fluconazole ................................... 50, 101
Fludrocortisone ................................ 50, 93
Fluocinolone .................................. 50, 113
Fluocinonide .................................. 50, 112
Fluorescein Sodium ........................ 50, 108
Fluorescein-benoxinate ................... 50, 108
Fluoride ......................................... 50, 109
FLUoxetine ................................ 16, 50, 90
fluPHENAZine .................. 11, 13, 15, 50, 91
fluPHENAZine Decanoate ........................ 13
Flurox ........................................... 50, 108
Texas HHS Psychiatric Drug Formulary 2020
Index 127
Fluticasone ............................. 51, 105, 109
Fluticasone-Salmeterol ................... 51, 105
Fluvastatin ...................................... 51, 83
fluvoxaMINE ............................... 16, 51, 90
Focalin XR .................................. 19, 44, 92
Folic Acid .............................................. 51
Folvite .................................................. 51
Fondaparinux .................................. 51, 81
Fosamax ......................................... 33, 93
Fosfomycin .................................... 51, 101
Fosphenytoin ................................... 51, 86
Fulvicin ......................................... 52, 101
Fungoid ........................................ 43, 109
Furosemide ..................................... 51, 82
G
Gabapentin ................................ 31, 51, 87
Gabatril .......................................... 74, 87
Galantamine .................................... 51, 88
Garamycin ................................... 107, 111
Gas-X ............................................. 72, 95
Gaviscon ......................................... 33, 94
Gemfibrozil ...................................... 51, 83
Gentamicin ...................... 52, 101, 107, 111
Geodon ...................................... 14, 79, 91
glipiZIDE ......................................... 52, 80
Glucagon ......................................... 52, 80
Glucophage ..................................... 60, 80
Glucophage XR ................................. 60, 80
Glucosamine .................................. 52, 116
Glucose, oral ................................... 52, 80
Glucotrol ......................................... 52, 80
Glycerin .......................................... 52, 96
Glycopyrrolate ................................. 52, 94
Gly-Oxide ...................................... 40, 109
GoLYTELY ........................................ 67, 96
Granulex ....................................... 77, 115
Grifulvin V ..................................... 52, 101
Griseofulvin ................................... 52, 101
Gris-Peg ........................................ 52, 101
guaiFENesin ................................... 52, 107
guaiFENesin-Codeine ...................... 52, 106
guaiFENesin-Dextromethorphan ....... 53, 106
guaiFENesin-Pseudoephedrine .......... 53, 106
guanFACINE .............................. 20, 53, 92
guanFACINE Extended Release ................ 20
Gyne-Lotrimin .................................. 43, 98
H
Halcion...................................... 22, 76, 89
Texas HHS Psychiatric Drug Formulary 2020
Index 128
Haldol ........................................ 13, 53, 91
Haldol Decanoate ................................... 13
Haloperidol ................ 10, 11, 13, 15, 53, 91
Haloperidol Decanoate ............................ 13
Havrix ............................................ 53, 99
HBIG .............................................. 53, 99
Hemocyte Plus ............................... 55, 104
Heparin ........................................... 53, 81
Hepatitis A Vaccine ........................... 53, 99
Hepatitis A-Hepatitis B Vaccine .......... 53, 99
Hepatitis B Immune Globulin ............. 53, 99
Hepatitis B Virus Vaccine, Recombinant ... 53,
99
Heplisav-B....................................... 53, 99
Hexachlorophene ........................... 53, 112
Hexavitamins ................................. 62, 104
Homatropine ................................. 53, 108
HumaLOG ....................................... 55, 80
HumaLOG Mix 50/50 ........................ 55, 80
HumaLOG Mix 75/25 ........................ 55, 80
HumuLIN ........................................ 55, 80
hydrALAZINE ................................... 53, 84
hydroCHLOROthiazide ....................... 53, 82
Hydrocortisone ......................... 53, 94, 113
Hydrocortisone ...................................... 97
Hydrogen Peroxide .................. 54, 109, 115
hydrOXYzine ...... 10, 11, 22, 54, 87, 89, 106
HypoTears ..................................... 64, 108
HypoTears PF ................................. 64, 108
I
Ibandronate ..................................... 54, 93
Ibuprofen ........................................ 54, 85
Iloperidone ........................... 13, 25, 54, 91
Imipramine ........................... 16, 17, 54, 90
Imitrex ........................................... 73, 85
Imodium ......................................... 58, 97
Inderal ................................. 20, 69, 83, 85
Influenza Virus Vaccine ..................... 54, 99
INH .............................................. 55, 102
Inotropin .............................................. 24
Insulin, Aspart ................................. 54, 80
Insulin, Combination (70/30) ............. 54, 80
Insulin, Combination, lispro protamine
suspension-insulin lispro ...................... 80
Insulin, Detemir ......................... 25, 54, 80
Insulin, Glargine ............................... 55, 80
Insulin, Lispro .................................. 55, 80
Insulin, lispro protamine suspension-
insulin lispro .................................... 55
Texas HHS Psychiatric Drug Formulary 2020
Index 129
Insulin, NPH .................................... 55, 80
Insulin, Regular ............................... 55, 80
Intal ................................................... 108
Intropin .......................................... 47, 84
Intuniv ...................................... 20, 53, 92
Invega ....................................... 14, 65, 91
Invega Sustenna .............................. 14, 65
Invega Trinza ........................................ 14
Ipratropium ................................... 55, 105
Iron salts with or without vitamins and/or
minerals ..................................... 55, 104
Isoniazid ....................................... 55, 102
Isoptin ....................................... 77, 83, 85
Isoptin SR ....................................... 77, 83
Isopto Atropine .............................. 36, 108
Isopto Carpine ............................... 67, 107
Isopto Homatropine ........................ 53, 108
Isopto Hyoscine ............................. 71, 108
Isordil ............................................. 55, 82
Isosorbide Dinitrate .......................... 55, 82
Isosorbide Mononitrate ..................... 55, 82
Ivermectin .................................... 55, 102
K
Kaolin-Pectin ................................... 55, 97
Kaopectate ...................................... 38, 97
Kapvay ................................................ 20
Keflex ........................................... 40, 100
Kefzol ........................................... 40, 100
Keppra ............................................ 57, 87
Keri Lotion ..................................... 47, 113
Ketalar ...................................... 26, 56, 90
Ketamine .................................. 26, 56, 90
Ketoconazole .......................... 56, 101, 111
Ketorolac ......................................... 56, 85
Ketotifen ....................................... 56, 108
KlonoPIN .............................. 21, 42, 86, 89
Konsyl ............................................ 70, 96
L
Labetalol ......................................... 56, 83
Lacosamide ............................... 31, 56, 87
Lactinex .......................................... 56, 97
Lactobacillus Acidophilus ................... 56, 97
Lactulose ......................................... 56, 96
LaMICtal............................... 17, 56, 87, 91
LamISIL ........................................ 74, 101
lamoTRIgine .............. 17, 18, 31, 56, 87, 91
Lanacaine ...................................... 36, 110
Lanacort ............................................... 53
Texas HHS Psychiatric Drug Formulary 2020
Index 130
Lanolin ......................................... 47, 113
Lanoxin ........................................... 45, 82
Lansoprazole ................................... 56, 95
Lantus ............................................ 55, 80
Lasix .............................................. 51, 82
Latanoprost ................................... 56, 107
Latuda ....................................... 13, 58, 91
Levalbuterol .................................. 56, 105
Levaquin ....................................... 57, 101
Levarterenol ......................... 29, 57, 64, 84
Levemir ..................................... 25, 54, 80
levETIRAcetam ........................... 31, 57, 87
Levocarnitine ................................. 57, 104
levoFLOXacin ................................. 57, 101
Levophed ............................. 29, 57, 64, 84
Levothyroxine .................................. 57, 94
Levoxyl ........................................... 57, 94
Lexapro ..................................... 16, 48, 90
Librium ...................................... 21, 41, 89
Lidocaine ............................... 57, 109, 110
Lidocaine-Prilocaine ........................ 57, 110
Lidoderm ...................................... 57, 110
Linaclotide .................................. 27, 57, 96
Linezolid .................................. 27, 57, 101
Linzess ...................................... 27, 57, 96
Lipitor ............................................. 36, 83
Liquitears ...................................... 64, 108
Liraglutide ....................................... 57, 80
Lisdexamfetamine ................. 19, 27, 57, 92
Lisinopril ......................................... 57, 84
Lithium ..................................... 17, 18, 91
Lithium Carbonate ................................. 58
Lithium Citrate ...................................... 58
Lithobid ........................................... 17, 58
Lithonate ......................................... 58, 91
Lofibra ............................................ 49, 83
Loperamide ..................................... 58, 97
Lopid .............................................. 51, 83
Lopressor .................................. 60, 83, 85
Loprox ................................................. 41
Loratadine ..................................... 58, 106
Loratadine-Pseudoephedrine ............ 58, 106
LORazepam ............... 10, 11, 21, 58, 86, 89
Lortab ............................................. 32, 85
Losartan .......................................... 58, 84
Lotensin .......................................... 36, 84
Lotrimin ............................................... 43
Lotrisone ..................................... 43, 111
Texas HHS Psychiatric Drug Formulary 2020
Index 131
Lovaza ............................................ 64, 84
Lovenox .......................................... 47, 81
Loxapine .................................... 13, 58, 91
Loxitane ..................................... 13, 58, 91
Lubiprostone ................................... 58, 96
Lubriderm ..................................... 47, 113
Lumigan ....................................... 37, 107
Luminal ..................................... 31, 66, 86
Lurasidone ................................. 13, 58, 91
Luvox ........................................ 16, 51, 90
Lyrica ............................................. 69, 87
M
Maalox ............................................ 34, 94
Macrodantin .................................. 63, 102
Magnesium Citrate ........................... 58, 95
Magnesium Hydroxide ...................... 58, 95
Magnesium L-lactate dihydrate ........ 59, 116
Magnesium Sulfate ......................... 59, 103
Mag-Tab SR................................... 59, 116
Maxipime ...................................... 40, 100
Maxzide .......................................... 76, 82
Measles-Mumps-Rubella Virus Vaccine, Live
................................................... 59, 99
Meclizine ......................................... 59, 87
Medrol ............................................ 60, 94
medroxyPROGESTERone ................... 59, 93
Megace ........................................... 59, 88
Megace ES ....................................... 59, 88
Megestrol ........................................ 59, 88
Melatonin ...................................... 59, 116
Mellaril ................................. 14, 30, 74, 91
Meloxicam ....................................... 59, 85
Memantine ...................................... 59, 88
Menthol ......................................... 59, 114
Menthol-Methyl Salicylate ................ 59, 114
Menthol-Zinc Oxide ......................... 59, 114
Mephyton .................................. 67, 80, 81
Mesalamine ..................................... 59, 97
Metadate ................................... 19, 60, 92
Metadate CD .................................... 60, 92
Metamucil........................................ 70, 96
metFORMIN ..................................... 60, 80
Methadone ........................................... 60
methIMAzole.................................... 60, 94
Methocarbamol ................................ 60, 89
Methylcellulose................................. 60, 96
Methyldopa ...................................... 60, 84
Methylin .................................... 19, 60, 92
Texas HHS Psychiatric Drug Formulary 2020
Index 132
Methylphenidate, immediate release .. 19, 60,
92
Methylphenidate, sustained release ... 19, 60,
92
Methylphenidate, sustained release, osmotic
release ............................................... 19
methylPREDNISolone ........................ 60, 94
Metoclopramide .......................... 60, 87, 95
Metoprolol .................................. 60, 83, 85
MetroGel ................................ 61, 110, 111
metroNIDAZOLE .............. 61, 101, 110, 111
Mexsana ....................................... 45, 113
Miacalcin ......................................... 39, 93
Miconazole ............................... 61, 98, 111
Midazolam .................................. 61, 86, 89
Milk of Magnesia .............................. 58, 95
Mineral Oil ..................................... 61, 109
Minipress ........................................ 69, 89
Minocycline ................................... 61, 100
Mirabegron ................................. 27, 61, 98
MiraLax ........................................... 67, 96
Mirapex .......................................... 68, 88
Mirtazapine ................................ 16, 61, 90
miSOPROStol ................................... 61, 97
MMR II ........................................... 59, 99
Mobic .............................................. 59, 85
Mometasone .................................. 61, 110
Montelukast ................................... 61, 106
Monurol......................................... 51, 101
morphine ........................................ 62, 86
Motrin ............................................. 54, 85
Moxeza ....................................27, 62, 107
Moxifloxacin ...................... 27, 62, 101, 107
Mucinex ........................................ 52, 107
Mucinex D ..................................... 53, 106
Multivitamin ................................... 62, 104
Multivitamin, Prenatal ..................... 62, 104
Multivitamin-Minerals ...................... 62, 104
Multivitamins, Pediatric ................... 62, 104
Mupirocin ...................................... 62, 111
Myambutol .................................... 48, 102
Mycobutin ..................................... 70, 102
Mycostatin .............................. 64, 101, 109
Mydriacyl....................................... 77, 108
Mylanta ........................................... 34, 94
Myrbetriq .................................. 27, 61, 98
Mysoline .......................................... 69, 86
N
Nabumetone .............................. 27, 62, 85
Texas HHS Psychiatric Drug Formulary 2020
Index 133
Nafcillin ........................................ 62, 100
Naloxone ................................... 27, 62, 80
Naltrexone ................................. 20, 62, 92
Naltrexone microspheres .............. 20, 28, 29
Namenda ........................................ 59, 88
Naphazoline .................................. 63, 108
Naphcon ....................................... 63, 108
Naprosyn ........................................ 63, 85
Naproxen ........................................ 63, 85
Narcan ....................................... 27, 62, 80
Nardil ........................................ 16, 66, 89
Nasacort ....................................... 76, 110
Nasonex ....................................... 61, 110
Nature Made Fish Oil ...................... 50, 116
Navane ...................................... 14, 74, 91
Nayzilam ......................................... 61, 86
Neomycin ...................................... 63, 101
Neomycin-Polymyxin B-Bacitracin .... 63, 111
Neomycin-Polymyxin B-Hydrocortisone .... 63,
109
Neo-Synephrine ...................... 66, 108, 110
Nephrocaps ................................... 78, 104
Nephro-vite ................................... 78, 104
Neurontin ........................................ 51, 87
Neutra-Phos-K ...................................... 68
NexIUM ........................................... 48, 95
Niacin-Nicotinamide .......................... 63, 83
Nicobid ........................................... 63, 83
Nicoderm ........................................ 63, 92
Nicorette ......................................... 63, 92
Nicotine .......................................... 63, 92
Nicotrol ........................................... 63, 92
NIFEdipine ....................................... 63, 83
Niferex-150 .......................................... 55
Niferex-150 Forte ........................... 55, 104
Nitrofurantoin ................................ 63, 102
Nitroglycerin .................................... 63, 83
NIX ............................................... 66, 114
Nizoral .......................................... 56, 101
Non-Soap Cleanser ......................... 63, 114
Norepinephrine ..................... 29, 57, 64, 84
Noritate ................................. 61, 110, 111
Normodyne ...................................... 56, 83
Norpramin ................................. 15, 44, 90
Nortriptyline ......................... 16, 17, 64, 90
Norvasc ........................................... 34, 83
NovoLIN .......................................... 55, 80
NovoLOG ......................................... 54, 80
Texas HHS Psychiatric Drug Formulary 2020
Index 134
Nutraderm .................................... 47, 113
Nystatin .......................... 64, 101, 109, 111
O
OLANZapine .............. 10, 11, 13, 15, 64, 91
OLANZapine pamoate ....................... 14, 29
Olmesartan ................................ 29, 64, 84
Olopatadine ................................... 64, 108
Omega-3-acid ethyl esters ................ 64, 84
Omeprazole ..................................... 64, 95
Omnicef ........................................ 40, 100
OmniMed ...................................... 50, 109
Omnipen ....................................... 35, 100
Ondansetron ................................... 64, 87
Onfi ........................................... 24, 42, 86
Ophthalmic Irrigating Solution ......... 64, 108
Ophthalmic Lubricant ...................... 64, 108
Oracit ............................................. 73, 98
Orajel ........................................... 36, 109
Os-Cal ..................................... 39, 94, 104
Os-Cal + D .................................... 39, 104
Os-Cal chewable ....................... 39, 94, 104
Oseltamivir .................................... 65, 102
Oxazepam .................................. 21, 65, 89
OXcarbazepine .................18, 31, 65, 87, 92
Oxybenzone-PDO-Pet Hy-Phl ........... 65, 114
Oxybutynin ...................................... 65, 98
oxyCODONE .................................... 65, 86
OxyCONTIN ..................................... 65, 86
Oxymetazoline ............................... 65, 110
P
P.P.D. ............................................. 77, 99
Pacerone ......................................... 34, 83
Paliperidone ............................... 14, 65, 91
Paliperidone palmitate ............................ 14
Pamelor .................................... 16, 64, 90
Pancreaze........................................ 65, 97
Pancrelipase .................................... 65, 97
Pantoprazole .................................... 65, 95
Parnate ..................................... 16, 76, 89
PARoxetine ................................ 16, 65, 90
Patanol ......................................... 64, 108
Paxil ......................................... 16, 65, 90
PEG ................................................ 67, 96
penicillin G Benzathine .................... 66, 100
penicillin V Potassium ..................... 66, 100
Penlac .................................................. 41
Pentam ....................................30, 66, 102
Pentamidine .............................30, 66, 102
Texas HHS Psychiatric Drug Formulary 2020
Index 135
Pentasa .......................................... 59, 97
Pen-Vee K ..................................... 66, 100
Pepcid ............................................ 49, 95
Pepto-Bismol ................................... 38, 97
Periactin ....................................... 43, 106
Peri-Colace ...................................... 46, 96
Peridex ......................................... 41, 109
PerioMed ....................................... 50, 109
Periostat ....................................... 47, 109
Permethrin .................................... 66, 114
Pernox ................................................ 114
Perphenazine ........................ 14, 15, 66, 91
Petrolatum, White .......................... 66, 114
Phazyme ......................................... 72, 95
Phenazopyridine ............................... 66, 97
Phenelzine.................................. 16, 66, 89
Phenergan ....................................... 69, 87
PHENobarbital ............................. 31, 66, 86
Phenol .......................................... 66, 109
Phenylephrine ................... 66, 97, 108, 110
Phenytoin ................................... 31, 67, 86
Phytonadione .............................. 67, 80, 81
Pilocarpine .................................... 67, 107
Pimecrolimus ................................. 67, 115
Pioglitazone ..................................... 67, 80
Piperacillin-Tazobactam ................... 67, 100
Plavix .............................................. 42, 81
Pneumococcal Vaccine, Conjugate ...... 67, 99
Pneumococcal Vaccine, Polyvalent ...... 67, 99
Pneumovax 23 ................................. 67, 99
Podocon-25 ................................... 67, 113
Podophyllum Resin ......................... 67, 113
Polycarbophil ................................... 67, 96
Polycillin ........................................ 35, 100
Polycitra K ....................................... 68, 98
Polycitra-LC ..................................... 68, 98
Polyethylene Glycol........................... 67, 96
Polyethylene Glycol Electrolyte Solution .. 67,
96
Polymox ........................................ 34, 100
Polymyxin B-Bacitracin .................... 67, 107
Polymyxin B-Trimethoprim .............. 67, 107
Polysporin ........................ 36, 67, 107, 111
Polytrim ........................................ 67, 107
Poly-Vi-Sol .................................... 62, 104
Potassium Chloride .................. 68, 103, 104
Potassium Citrate ............................. 68, 98
Potassium Citrate Combinations ......... 68, 98
Texas HHS Psychiatric Drug Formulary 2020
Index 136
Potassium Iodide ........................... 68, 107
Potassium Phosphate .............................. 68
Povidone-Iodine ............................. 68, 112
Pramipexole .................................... 68, 88
Pramoxine ................................ 68, 97, 110
Pramoxine – Hydrocortisone .................... 97
Pramoxine–Hydrocortisone ...................... 68
Pramoxine-Zinc .............................. 68, 111
Prandin ........................................... 70, 80
Pravachol ........................................ 68, 84
Pravastatin ...................................... 68, 84
Prazosin .......................................... 69, 89
Pred Forte ..................................... 69, 108
Pred Mild ....................................... 69, 108
prednisoLONE .................................. 69, 94
predniSONE ..................................... 69, 94
Pregabalin .................................. 31, 69, 87
Premarin ......................................... 48, 93
Premphase ...................................... 48, 93
PremPro .......................................... 48, 93
Preparation H .................................. 66, 97
Prevacid .......................................... 56, 95
Prevnar 13 ...................................... 67, 99
PriLOSEC ........................................ 64, 95
Primidone ........................................ 69, 86
Prinivil ............................................ 57, 84
ProAir Respiclick .................................... 33
Procardia ......................................... 63, 83
Procardia XL .................................... 63, 83
Prochlorperazine .............................. 69, 87
Procrit ....................................... 24, 47, 81
Proctofoam-HC ................................. 53, 97
Prolia .............................................. 44, 93
Prolixin ..................................... 13, 50, 91
Prolixin Decanoate ................................. 13
Promethazine ................................... 69, 87
Pronto ........................................... 70, 114
Proparacaine .................................. 69, 108
Propranolol ........................... 20, 69, 83, 85
Propylthiouracil ................................ 69, 94
Proscar ........................................... 49, 98
Protonix .......................................... 65, 95
Protopic ........................................ 74, 115
Protriptyline .......................................... 16
Proventil ....................................... 33, 105
Provera ........................................... 59, 93
PROzac ..................................... 16, 50, 90
Pseudoephedrine ............................ 69, 106
Texas HHS Psychiatric Drug Formulary 2020
Index 137
Psyllium .......................................... 70, 96
Pulmicort ...................................... 38, 105
Pyrazinamide ................................. 70, 102
Pyrethins 0.33%-Piperonyl Butoxide 4% .. 70,
114
Pyridium ......................................... 66, 97
Pyridoxine ..................................... 70, 103
Q
QUEtiapine ................................. 14, 70, 91
QVAR............................................ 36, 105
R
Raloxifene ....................................... 70, 93
raNITIdine ....................................... 70, 95
Rasagiline ....................................... 70, 88
Razadyne ........................................ 51, 88
Reclast ........................................... 79, 93
Recombivax HB ................................ 53, 99
Rectal Hemorrhoidal Suppositories ........... 70
Reglan ....................................... 60, 87, 95
Relafen ...................................... 27, 62, 85
Relenza ......................................... 78, 102
Remeron .................................... 16, 61, 90
Remeron SolTab .............................. 61, 90
Renagel .......................................... 72, 99
Repaglinide ...................................... 70, 80
Restoril ..................................... 22, 74, 89
Retin-A ......................................... 76, 110
ReVia ........................................ 20, 62, 92
Revina .......................................... 77, 115
Rexulti ...................................... 13, 38, 91
RID .............................................. 70, 114
Rifabutin ....................................... 70, 102
Rifadin .......................................... 70, 102
Rifamate ....................................... 70, 102
rifAMPin ........................................ 70, 102
rifAMPin - Isoniazid ............................... 102
rifAMPin-Isoniazid .................................. 70
Risamine ....................................... 59, 114
Risedronate ..................................... 71, 93
RisperDAL ................................. 14, 71, 91
RisperDAL Consta ............................. 14, 71
RisperDAL M-Tab .............................. 14, 71
risperiDONE ............................... 14, 71, 91
Ritalin ....................................... 19, 60, 92
Ritalin SR ........................................ 60, 92
Ritalin XR ............................................. 19
Rivaroxaban .................................... 71, 81
Rivastigmine .................................... 71, 88
Texas HHS Psychiatric Drug Formulary 2020
Index 138
Robaxin .......................................... 60, 89
Robinul ........................................... 52, 94
Robitussin ..................................... 52, 107
Rocaltrol .................................. 41, 78, 103
Rocephin ....................................... 40, 100
Rosuvastatin ................................... 71, 84
Rowasa ........................................... 59, 97
Rufinamide ................................. 31, 71, 87
Rynex PSE .................................... 38, 106
S
Saccharomyces boulardii ................... 71, 97
Salac .................................................. 114
Salicylic Acid ................................. 71, 113
Salicylic Acid-Sulfur .......... 71, 110, 112, 114
Saliva Substitute ............................ 71, 109
Salmeterol .................................... 71, 105
Sani-Supp ....................................... 52, 96
Santyl ........................................... 43, 115
Saphris ...................................... 13, 35, 91
Scopolamine .................................. 71, 108
Seba-Nil .............................................. 114
Selegiline ........................................ 71, 88
Selenium Sulfide ............................ 72, 112
Senna ............................................. 72, 95
Senokot .......................................... 72, 95
Serax ........................................ 21, 65, 89
Serevent ....................................... 71, 105
SEROquel .................................. 14, 70, 91
Sertraline .................................. 16, 72, 90
Sevelamer ....................................... 72, 99
Shingrix .......................................... 79, 99
Silvadene ............................... 72, 112, 114
Silver Nitrate ................................. 72, 115
Silver SulfADIAZINE ................ 72, 112, 114
Simethicone..................................... 72, 95
Simvastatin ..................................... 72, 84
Sinemet .......................................... 40, 88
SINEquan .................................. 16, 47, 90
Singulair ....................................... 61, 106
Sodium Bicarbonate .......................... 72, 98
Sodium Chloride . 72, 97, 103, 106, 108, 109,
110, 115
Sodium Chloride Intravenous Solution..... 72,
103
Sodium Citrate-Citric Acid.................. 73, 98
Sodium Polystyrene Sulfonate ............ 73, 81
solifenacin ....................................... 73, 98
SOLU-Medrol ................................... 60, 94
Sorbitol ........................................... 73, 96
Texas HHS Psychiatric Drug Formulary 2020
Index 139
Spiriva .......................................... 75, 105
Spironolactone ................................. 73, 82
Spironolactone-hydroCHLOROthiazide . 73, 82
Spravato .................................... 25, 48, 90
SSKI ............................................. 68, 107
Stelazine .................................... 14, 76, 91
Stimate ........................................... 44, 94
Strattera .................................... 20, 36, 92
Stresscaps .................................... 78, 104
Stromectol .................................... 55, 102
Suboxone ........................................ 23, 38
Subutex .......................................... 23, 38
Sucralfate ....................................... 73, 97
Sudafed ........................................ 69, 106
Sulfacetamide Sodium ...... 73, 107, 110, 112
Sulfamethoxazole-Trimethoprim ...... 73, 101
sulfaSALAzine .................................. 73, 97
Sulindac .......................................... 73, 85
SUMAtriptan .................................... 73, 85
Sunscreen-Block ............................ 74, 114
Surfak ............................................ 46, 96
Symbicort ..................................... 38, 105
Synalar ......................................... 50, 113
Synthroid ........................................ 57, 94
T
Tacrolimus ..................................... 74, 115
Tamiflu ......................................... 65, 102
Tamoxifen ....................................... 74, 81
Tamsulosin ...................................... 74, 98
Tapazole ......................................... 60, 94
Tazarotene ............................. 74, 110, 112
Tazorac .................................. 74, 110, 112
TBC .............................................. 77, 115
Td .................................................. 46, 99
Tdap ............................................... 46, 99
TEGretol ......................... 17, 31, 39, 87, 91
TEGretol XR ............................... 17, 31, 39
Temazepam ............................... 22, 74, 89
Temovate .................................24, 42, 112
Tenex ....................................... 20, 53, 92
Tenormin .................................. 35, 83, 85
Terbinafine ............................. 74, 101, 111
Testosterone .................................... 74, 93
Tetracycline ................................... 74, 100
Tetrahydrozoline ............................ 74, 108
Thiamine ....................................... 74, 103
Thioridazine .................... 14, 15, 30, 74, 91
Thiothixene ............................... 14, 74, 91
Texas HHS Psychiatric Drug Formulary 2020
Index 140
Thorazine ................................... 13, 41, 91
tiaGABine ................................... 31, 74, 87
Tigan .............................................. 76, 87
Timolol ......................................... 75, 107
Timolol-Dorzolamide ....................... 75, 107
Timoptic........................................ 75, 107
Timoptic XE ......................................... 107
Tinactin ................................................ 75
Tioconazole ..................................... 75, 98
Tiotropium .................................... 75, 105
tiZANidine .................................. 30, 75, 88
TobraDex ...................................... 75, 108
Tobramycin ............................ 75, 101, 107
Tobramycin-Dexamethasone ........... 75, 108
Tobrex .......................................... 75, 107
Tofranil ...................................... 16, 54, 90
Tolnaftate ..................................... 75, 111
Tolterodine ...................................... 75, 98
Topamax .............................. 75, 85, 87, 92
Topiramate ......................31, 75, 85, 87, 92
Toprol XL ................................... 60, 83, 85
Toradol ........................................... 56, 85
traMADol ......................................... 75, 86
Tranxene ............................. 21, 43, 86, 89
Tranylcypromine ........................ 16, 76, 89
Travatan Z .................................... 76, 107
Travoprost ..................................... 76, 107
traZODone ..................... 16, 22, 76, 89, 90
Trecator ........................................ 48, 102
Tretinoin ....................................... 76, 110
Triamcinolone ................. 76, 109, 110, 113
Triamterene ..................................... 76, 82
Triamterene-hydroCHLOROthiazide ..... 76, 82
Triazolam .................................. 22, 76, 89
Tricor .............................................. 49, 83
Tridesilon ...................................... 44, 113
Trifluoperazine ........................... 14, 76, 91
Triglide ........................................... 49, 83
Trihexyphenidyl ................................ 76, 88
Trilafon ..................................... 14, 66, 91
Trileptal ............................... 18, 65, 87, 92
Trimethobenzamide .......................... 76, 87
Triple Antibiotic Ointment ................ 63, 111
Triprolidine-Pseudoephedrine ........... 76, 106
Tropicamide ................................... 77, 108
Trospium ......................................... 77, 98
Trypsin-Balsam Peru-Castor Oil ........ 77, 115
Tuberculin, Purified Protein Derivative . 77, 99
Texas HHS Psychiatric Drug Formulary 2020
Index 141
Tums ....................................... 39, 94, 104
Twinrix ........................................... 53, 99
Tylenol ........................................... 32, 86
U
Ultram ............................................ 75, 86
Unicap .......................................... 62, 104
Unifiber ........................................... 40, 96
Urea ............................................. 77, 113
Urecholine ....................................... 37, 98
Urocit K .......................................... 68, 98
V
Vagifem ................................................ 48
valACYclovir .................................. 77, 102
Valisone ........................................ 37, 113
Valium ............................21, 45, 86, 88, 89
Valproic Acid/Valproate ....18, 31, 77, 85, 87,
92
Valsartan ........................................ 77, 84
Valtrex.......................................... 77, 102
Vancocin ....................................... 77, 101
Vancomycin ................................... 77, 101
Vaqta ............................................. 53, 99
Varicella Virus Vaccine, Live .............. 77, 99
Varivax ........................................... 77, 99
Vaseline ........................................ 66, 114
Vaseline Lip Therapy ....................... 65, 114
Vasotec ........................................... 47, 84
V-Cillin K ....................................... 66, 100
Venlafaxine .......................... 16, 77, 85, 90
Ventolin ........................................ 33, 105
Verapamil .................................. 77, 83, 85
Verelan ..................................... 77, 83, 85
Verelan PM ................................ 77, 83, 85
Versacloz .................................. 13, 24, 43
Versed ............................................ 61, 89
Vesicare .......................................... 73, 98
Vibramycin .................................... 47, 100
Vicodin ............................................ 32, 85
Vicodin ES ....................................... 32, 85
Victoza ............................................ 57, 80
Vigamox ...................................27, 62, 107
Vimpat ............................................ 56, 87
Viscous Lidocaine ................................. 109
Visine Allergy Relief ........................ 74, 108
Visine Moisturizing .......................... 74, 108
Vistaril ......................... 22, 54, 87, 89, 106
Vitamin A ...................................... 78, 103
Vitamin A&D Topical .............................. 78
Texas HHS Psychiatric Drug Formulary 2020
Index 142
Vitamin B Complex ......................... 78, 104
Vitamin B Complex-Vitamin C .......... 78, 104
Vitamin B Complex-Vitamin C-Zinc ... 78, 104
Vitamin B1 .................................... 74, 103
Vitamin B12 .................................. 43, 103
Vitamin B6 .................................... 70, 103
Vitamin C ...................................... 35, 103
Vitamin D2 .................................... 78, 103
Vitamin D3 .................................... 78, 103
Vitamin E ...................................... 78, 104
Vitamin K1 ................................. 67, 80, 81
Vivactil ................................................. 16
Vivelle ............................................ 48, 93
Vivitrol ............................20, 28, 29, 62, 92
Voltaren Gel ............................. 24, 45, 110
VoSol ........................................... 32, 108
VoSol HC ...................................... 32, 109
Vraylar ...................................... 13, 40, 91
Vyvanse ............................... 19, 27, 57, 92
W
Warfarin ......................................... 78, 81
Water for Injection ......................... 78, 103
Water for Irrigation ................... 78, 97, 115
Wellbutrin .................................. 15, 38, 90
Wellbutrin SR ........................................ 15
Wellbutrin XL ........................................ 15
Wound Cleanser ............................. 78, 115
Wyanoids ............................................. 70
X
Xalatan ......................................... 56, 107
Xanax ....................................... 21, 33, 89
Xanax XR ........................................ 33, 89
Xarelto ............................................ 71, 81
Xopenex ........................................ 56, 105
Xylocaine ...................................... 57, 110
Z
Zaditor .......................................... 56, 108
Zanaflex .................................... 30, 75, 88
Zanamivir ...................................... 78, 102
Zantac ............................................ 70, 95
Zarontin .................................... 31, 49, 86
Zenzedi ................................................ 19
Zestril ............................................. 57, 84
Zinc Oxide .............................. 78, 113, 114
Zinc Oxide-Petrolatum-Imidazolidinyl Urea 79
Zinc Sulfate ................................... 79, 104
Ziprasidone .................... 10, 12, 14, 79, 91
Zithromax ..................................... 36, 100
Texas HHS Psychiatric Drug Formulary 2020
Index 143
Zocor.............................................. 72, 84
Zofran ............................................ 64, 87
Zofran ODT ..................................... 64, 87
Zoledronic Acid ................................ 79, 93
Zoloft ........................................ 16, 72, 90
Zolpidem ................................... 22, 79, 89
Zonalon ................................................ 47
Zonegran ........................................ 79, 87
Zonisamide ................................ 31, 79, 87
Zoster Vaccine- Recombinant, Adjuvanted 79,
99
Zosyn ........................................... 67, 100
Zovirax .................................. 33, 102, 111
Zyban ............................................. 38, 90
Zyloprim ......................................... 33, 94
ZyPREXA ................................... 13, 64, 91
ZyPREXA Relprevv ...................... 14, 29, 64
ZyPREXA Zydis................................. 13, 64
ZyrTEC .......................................... 41, 106
ZyrTEC D ...................................... 41, 106
Zyvox ......................................27, 57, 101
Texas HHS Psychiatric Drug Formulary 2020
A-1
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)**
Screenshot of New Drug Application Form
Texas HHS Psychiatric Drug Formulary 2020
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Section 415.108 of TDMHMR rules governing the use and maintenance of the THHSC Drug
Formulary (25 TAC, Chapter 415, Subchapter C) describes the procedures for applying to have a
drug added to the formulary, which are:
§415.108. Applying to Have a Drug Added to the Formulary.
(a) Any member of the Executive Forumlary Committee, any service system component*
practitioner, or any contract practictioner may apply to have a drug added to the THHSC
Drug Formulary by completing the New Drug Application Form, referenced as Figure: 25
TAC §415.108(d) § of this title and including:
1) Published articles in biomedical literature that substantiate the efficacy and safety of
the proposed drug.
2) information on the advantages of the proposed drug compared with similar
formulary drugs;
3) a list of formulary drugs that the proposed drug would replace or supplement; and
4) cost effectiveness data
(b) Submitting the application.
1) If the person submitting the application is a facility** practitioner or a facility
contract practitioner, then that practitioner submits the application to the facility’s
pharmacy and therapeutics committee for approval. If the committee approves the
application, then it forwards the application to the HHSC Psychiatric Executive
Formulary Committee.
2) If the person submitting the application is a non-facility service system component
practitioner or a non-facility service system component contract practitioner, then
that practitioner submits the application to the component’s clinical/medical director
or designee who determines if the application is appropriate and complete, and if so,
forwards the application to the HHSC Psychiatric Executive Formulary Committee.
3) If the person completing the application is a member of the HHSC Psychiatric
Executive Formulary Committee, then that person submits the application directly to
HHSC Psychiatric Executive Formulary Committee.
(c) The HHSC Psychiatric Executive Formulary Committee considers the drug application and
recommends:
1) approving the proposed drug’s inclusion and, if appropriate, approving audit criteria
and recommending dosage guidelines;
2) denying the proposed drug’s inclusion;
3) approving the proposed drug on a trial basis for a specified period of time;
4) approving the proposed drug as a reserve drug, with guidelines; or
5) postponing the decision until a later meeting.
* The term “service system component” means a state hospital, state supported living center, state center, or local authority (state-operated community services (SOCS) or
community MHMR center). ** The term “facility” means a state hospital, state supported living center, or state center.
Texas HHS Psychiatric Drug Formulary 2020
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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
Texas HHS Psychiatric Drug Formulary 2020
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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
(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
Texas HHS Psychiatric Drug Formulary 2020
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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
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 2020
C-1
Appendix C. PEFC Disclosure Form
HHSC Psychiatric Executive Formulary Committee (PEFC) Disclosure Form
Texas HHS Psychiatric Drug Formulary 2020
D-1
Appendix D. Non-Formulary Drug Justification Form
Texas HHS
Non-Formulary Drug Justification
Texas HHS Psychiatric Drug Formulary 2020
E-1
Appendix E. Adverse Drug Reaction Reporting (MedWatch) Form
Texas HHS Psychiatric Drug Formulary 2020
E-2
Texas HHS Psychiatric Drug Formulary 2020
F-1
Appendix F. Foods Containing Tyramine
Relative Amount of Tyramine Food
High Amounts of Tyramine May not consume
Smoked, aged or pickled meat or fish Sauerkraut
Aged Cheeses such as Swiss and Cheddar Yeabst extracts
Fava beans
Moderate Amounts of Tyramine
May consume in moderation
Beer
Avacados Meat extracts Red wines such as Chianti
Low Amounts of Tyramine May consume
Caffeine-containing beverages Distilled spirits
Chocolate Soy sauce
Cottage and cream cheeses Yogurt and sour cream
Adapted from Shulman KI, et al. Dietary restriction, tyramine, and the use of monoamine
oxidase inhibitors. J Clin Psychopharmacol. 1989; 9: 397.
Texas HHS Psychiatric Drug Formulary 2020
G-1
Appendix G. Oral Morphine Conversion Table
Opioid Conversion Factor*
Codeine 0.15
Hydrocodone 1
Hydromorphone 4
Morphine 1
Oxycodone 1.5
Oxymorphone 3
Tramadol 0.1
The following cautions should be noted:
1. Opioid conversion charts should NOT be utilized for converting methadone or non-
injectable fentanyl. Thus, they have been excluded from this chart. See product package
insert for prescribing information.
2. Equianalgesic dose conversions are only estimates and cannot account for individual
variability in genetics and pharmacokinetics.
3. When converting patients from one opioid to another opioid, it is recommended to
decrease the dose of the new opioid by 50% due to incomplete cross-tolerance and
individual variability in opioid pharmacokinetics. The patient can then be titrated to a safe,
effective response.
* Multiply the dose for each opioid by the conversion factor to determine the dose in morphine
milligram equivalents (MMEs).
For example:
1. Tablets containing hydrocodone 5 mg and acetaminophen 300 mg taken four times a day
would contain a total of 20 mg of hydrocodone daily, equivalent to 20 MME daily
20 mg hydrocodone/day x 1 (conversion factor) = 20 MME/day
2. Extended release tables containing oxycodone 10 mg taken twice a day would contain a
total of 20 mg oxycodone daily, equivalent to 30 MME daily.
20 mg oxycodone/day x 1.5 (conversion factor) = 30 MME/day
References:
1. Dowell D, Haegerich TM, Chou R. CDC Guidelines for Prescribing Opioids for Chronic Pain.-
United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
2. PL Detail-Document, Equianalgesic Dosing of Opioids for Pain Management. Pharmacist’s
Letter/Prescriber’s Letter. July 2015.
Recommended