TEXAS Health and Human Kidney Services Health Care
Kidney Health Care Reimbursable Drug List by Therapeutic Category*
Disclaimer: This listing is intended to inform patients and providers of the drugs that are reimbursable under Kidney Health Care (KHC). KHC makes no claims on the use, efficacy, or safety of the drugs contained herein.
ANALGESICS/NARCOTIC ANTIARRHYTHMIC/ ANALGESICS ANTIHYPERTENSIVE (see Antihypertensive also)
Acetaminophen w/ Codeine Acetaminophen w/ Hydrocodone Acebutolol Butalbital, Aspirin, Caffeine Amlodipine Ibuprofen Amlodipine, Aliskiren Oxycodone, Acetaminophen Amlodipine, Benazepril Oxycodone, Aspirin Atenolol Pentazocine/Naloxone HCL Benazepril Benazepril, Amlodipine Benazepril, Hydrochlorothiazide ANALGESICS (NSAID) Bisoprolol Bisoprolol, Hydrochlorothiazide Diflunisal Captopril Ibuprofen (Strengths above 200mg) Captopril, Hydrochlorothiazide Indomethacin Carvedilol Meloxicam Diltiazem Naproxen Enalapril Enalapril, Hydrochlorothiazide ANTACID Fosinopril Fosinopril, Hydrochlorothiazide Aluminum Hydroxide Guanfacine Calcium Carbonate Labetalol Magnesium Lactate (Transplants only) Labetalol, Hydrochlorothiazide Magnesium Oxide (Transplants only) Lisinopril Lisinopril, Hydrochlorothiazide Metoprolol Succinate ANTIANGINAL Metoprolol Tartrate Moexipril Nitroglycerin (Oral forms only) Moexipril, HCTZ Nadolol Nifedipine Nisoldipine Penbutolol Pindolol *Products covered are NDC-specific and dependent on a rebate agreement with the manufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website at https://www.txvendordrug.com/formulary/formulary-search Eye and ear drops, injectables (not including insulin), and shampoos are not covered.
Revised 9/1/2021
TEXAS Health and Human Kidney Services Health Care
Propranolol ANTICOAGULANT Propranolol, Hydrochlorothiazide Quinidine Clopidogrel Quinapril Warfarin Sodium Quinapril, Hydrochlorothiazide Ramipril Sotalol ANTICONVULSANT Timolol Maleate Trandolapril Carbamazepine Verapamil Clonazepam Divalproex Sodium ANTIARRHYTHMIC Gabapentin Phenobarbital Phenytoin Digoxin ANTIDEPRESSANT ANTIBIOTIC Amitriptyline Amoxicillin Amoxicillin, Clavulanic Acid ANTIDIARREAL Ampicillin Azithromycin Cefaclor Diphenoxylate, Atropine Cefadroxil Loperamide Cefuroxime Cephalexin ANTIEMETIC (Rx only) Cephradine Ciprofloxacin Chlorpromazine Clindamycin (Oral forms only) Hydroxyzine Cloxacillin Meclizine Dicloxacillin Metoclopramide Doxycycline Prochlorperazine Erythromycin Promethazine Levofloxacin Metronidazole Nitrofurantoin Penicillin G Penicillin V Potassium SMZ-TMP (Sulfamethoxazole, Trimethoprim) TMP (Trimethoprim) Vancomycin
*Products covered are NDC-specific and dependent on a rebate agreement with the manufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website at https://www.txvendordrug.com/formulary/formulary-search Eye and ear drops, injectables (not including insulin), and shampoos are not covered.
Revised 9/1/2021
TEXAS Health and Human Kidney Services Health Care
ANTIFUNGAL Eprosartan (Transplants/peritoneal Eprosartan, Hydrochlorothiazide Felodipine only) Guanfacine Hydralazine Clotrimazole Hydralazine, Hydrochlorothiazide Fluconazole Hydrochlorothiazide (HCTZ) Itraconazole Indapamide Ketoconazole Irbesartan Nystatin Irbesartan, Hydrochlorothiazide Tolnaftate Isradipine Voriconazole (Effective 9/1/2021) Losartan
Losartan, Hydrochlorothiazide ANTIHISTAMINES Methyldopa Methyldopa, Hydrochlorothiazide Diphenhydramine (Oral forms only) Metolazone Hydroxyzine Minoxidil (Oral forms only)
Nicardipine ANTIHYPERLIPIDEMIC Prazosin Telmisartan Atorvastatin Telmisartan, Hydrochlorothiazide Cholestyramine Terazosin Fluvastatin Valsartan Gemfibrozil Valsartan, Amlodipine Pravastatin Valsartan, Amlodipine, HCTZ Rosuvastatin Valsartan, Hydrochlorothiazide Simvastatin
ANTIHYPERLIPIDEMIC ANTIINFECTIVE (TOPICAL) COMBINATIONS Bacitracin Amlodipine, Atorvastatin Bacitracin, Neomycin, Polymyxin Neomycin Sulfate ANTIHYPERTENSIVES Neomycin, Bacitracin Neomycin, Polymyxin Aliskiren Polymyxin, Bacitracin Aliskiren, Amlodipine Triple Antibiotic Ointment
Aliskiren, Valsartan Amlodipine, Valsartan, HCTZ ANTIMALARIAL Candesartan Candesartan, Hydrochlorothiazide Quinine Sulfate Clonidine Doxazosin
*Products covered are NDC-specific and dependent on a rebate agreement with the manufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website at https://www.txvendordrug.com/formulary/formulary-search Eye and ear drops, injectables (not including insulin), and shampoos are not covered.
Revised 9/1/2021
TEXAS Health and Human Kidney Services Health Care
ANTINEOPLASTIC DIURETIC
Cyclophosphamide Bumetanide Furosemide ANTIULCER H2 ANTAGONISTS Hydrochlorothiazide (Also / PROTON PUMP INHIBITORS antihypertensive) Indapamide (Also antihypertensive) Metolazone (Also antihypertensive) Cimetidine Torsemide (Oral forms only) Esomeprazole (Effective 9/1/2021) Famotidine GI STIMULANTS Nizatidine Omeprazole Pantoprazole Metoclopramide Ranitidine
HYPOGLYCEMIC AGENT ANTIVIRAL
Acyclovir (kidney transplants only) Chlorpropamide Valacyclovir (kidney transplants only) Glipizide Valganciclovir (Kidney transplants only, Glyburide Effective 9/1/2021) Insulin (Not all brands/dosage forms covered) CALCIUM SUPPLEMENT Linagliptin Pioglitazone Repaglinide Calcium Carbonate Rosiglitazone Calcium Carbonate Combinations Semaglutide Oystershell Calcium Tolazamide Tolbutamide CORTICOSTEROID/ STEROID IMMUNOSUPPRESSANT Dexamethasone Methylprednisolone Azathioprine Prednisolone Cyclosporine (Kidney transplants only) Prednisone (Oral forms only) Everolimus (Kidney transplants only) Mycophenolic acid (Kidney transplants DIGESTIVE ENZYMES only) Mycophenolate mofetil (Kidney Pancrelipase transplants only) Sirolimus (Kidney transplants only) Tacrolimus (Kidney transplants only)
*Products covered are NDC-specific and dependent on a rebate agreement with the manufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website at https://www.txvendordrug.com/formulary/formulary-search Eye and ear drops, injectables (not including insulin), and shampoos are not covered.
Revised 9/1/2021
TEXAS Health and Human Kidney Services Health Care
ION EXCHANGE RESIN SUPPLIES (limited diabetic supplies) Sodium Polystyrene Sulfonate (SPS)
Glucose Test Strips
Insulin Syringes IRON SUPPLEMENTS Lancets
Ferrous Gluconate Ferrous Sulfate (Iron) Iron (Ferrous Sulfate) URICOSURIC/ANTIGOUT Iron w/ Vitamin B12, Intrinsic Factor Polysaccharide Iron Complex Allopurinol Colchicine Colchicine, Probenecid Probenecid LAXATIVES, BULK FIBER LAXATIVES AND STOOL VASOPRESSORS SOFTENERS Midodrine Bisacodyl Docusate Calcium VITAMIN SUPPLEMENTS Docusate Sodium Polyethylene Glycol Powder Calcitriol Cyanocobalamin (Vitamin B12) PHOSPHATE BINDERS Doxercalciferol Folic Acid Iron-Folic (Vitamins with Iron) Aluminum Hydroxide Multivitamins Calcium Acetate Multivitamins with Iron Sevelamer (Effective 9/1/2021) Pyridoxine (Vitamin B6) Sucroferric Oxyhydroxide (Velphoro) Vitamin B Complex with Vitamin C (Effective 9/1/2021) Vitamin B6 - Pyridoxine Vitamin B12, Cyanocobalamin (Oral forms only) POTASSIUM SUPPLEMENT Vitamin D - Active (Calcitriol, Doxercalciferol) Potassium Chloride Vitamins - Multi Vitamins with Iron Potassium Gluconate
ZINC SUPPLEMENT
Zinc Gluconate Zinc Sulfate
*Products covered are NDC-specific and dependent on a rebate agreement with the manufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website at https://www.txvendordrug.com/formulary/formulary-search Eye and ear drops, injectables (not including insulin), and shampoos are not covered.
Revised 9/1/2021