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Kidney Health Care Reimbursable Drug List by Therapeutic Category*

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Kidney Health Care Reimbursable Drug List by Therapeutic Category* 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 Gabapentin ANTIARRHYTHMIC 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 Eprosartan, Hydrochlorothiazide (Transplants/peritoneal 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 antihypertensive) / PROTON PUMP INHIBITORS 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) Doxercalciferol PHOSPHATE BINDERS 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 .
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