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TEXASHealth and HumanServicesKidneyHealth CareKidney Health CareReimbursable Drug List by Therapeutic Category*Disclaimer: This listing is intended to inform patients and providers of the drugs thatare reimbursable under Kidney Health Care (KHC). KHC makes no claims on the use,efficacy, or safety of the drugs contained herein.ANALGESICS/NARCOTICANALGESICSAcetaminophen w/ CodeineAcetaminophen w/ HydrocodoneButalbital, Aspirin, CaffeineIbuprofenOxycodone, AcetaminophenOxycodone, AspirinPentazocine/Naloxone HCLANALGESICS (NSAID)DiflunisalIbuprofen (Strengths above 200mg)IndomethacinMeloxicamNaproxenANTACIDAluminum HydroxideCalcium CarbonateMagnesium Lactate (Transplants only)Magnesium Oxide (Transplants only)ANTIANGINALNitroglycerin (Oral forms only)ANTIARRHYTHMIC/ANTIHYPERTENSIVE (seeAntihypertensive also)AcebutololAmlodipineAmlodipine, AliskirenAmlodipine, BenazeprilAtenololBenazeprilBenazepril, AmlodipineBenazepril, HydrochlorothiazideBisoprololBisoprolol, HydrochlorothiazideCaptoprilCaptopril, lapril, HydrochlorothiazideFosinoprilFosinopril, HydrochlorothiazideGuanfacineLabetalolLabetalol, HydrochlorothiazideLisinoprilLisinopril, HydrochlorothiazideMetoprolol SuccinateMetoprolol TartrateMoexiprilMoexipril, *Products covered are NDC-specific and dependent on a rebate agreement with themanufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website -searchEye and ear drops, injectables (not including insulin), and shampoos are not covered.Revised 9/1/2021

TEXASHealth and HumanServicesPropranololPropranolol, HydrochlorothiazideQuinidineQuinaprilQuinapril, HydrochlorothiazideRamiprilSotalolTimolol NTIBIOTICAmoxicillinAmoxicillin, Clavulanic ximeCephalexinCephradineCiprofloxacinClindamycin (Oral forms n GPenicillin V PotassiumSMZ-TMP (Sulfamethoxazole,Trimethoprim)TMP (Trimethoprim)VancomycinKidneyHealth CareANTICOAGULANTClopidogrelWarfarin oex NTAmitriptylineANTIDIARREALDiphenoxylate, AtropineLoperamideANTIEMETIC (Rx ideProchlorperazinePromethazine*Products covered are NDC-specific and dependent on a rebate agreement with themanufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website -searchEye and ear drops, injectables (not including insulin), and shampoos are not covered.Revised 9/1/2021

TEXASHealth and HumanServicesKidneyHealth naftateVoriconazole (Effective 9/1/2021)ANTIHISTAMINESDiphenhydramine (Oral forms dipine, AtorvastatinANTIHYPERTENSIVESAliskirenAliskiren, AmlodipineAliskiren, ValsartanAmlodipine, Valsartan, HCTZCandesartanCandesartan, osartan, Hydralazine, HydrochlorothiazideHydrochlorothiazide (HCTZ)IndapamideIrbesartanIrbesartan, HydrochlorothiazideIsradipineLosartanLosartan, HydrochlorothiazideMethyldopaMethyldopa, HydrochlorothiazideMetolazoneMinoxidil (Oral forms only)NicardipinePrazosinTelmisartanTelmisartan, HydrochlorothiazideTerazosinValsartanValsartan, AmlodipineValsartan, Amlodipine, HCTZValsartan, HydrochlorothiazideANTIINFECTIVE (TOPICAL)BacitracinBacitracin, Neomycin, PolymyxinNeomycin SulfateNeomycin, BacitracinNeomycin, PolymyxinPolymyxin, BacitracinTriple Antibiotic OintmentANTIMALARIALQuinine Sulfate*Products covered are NDC-specific and dependent on a rebate agreement with themanufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website -searchEye and ear drops, injectables (not including insulin), and shampoos are not covered.Revised 9/1/2021

TEXASHealth and HumanServicesKidneyHealth deFurosemideHydrochlorothiazide (Alsoantihypertensive)Indapamide (Also antihypertensive)Metolazone (Also antihypertensive)Torsemide (Oral forms only)ANTIULCER H2 ANTAGONISTS/ PROTON PUMP INHIBITORSCimetidineEsomeprazole (Effective eRanitidineANTIVIRALAcyclovir (kidney transplants only)Valacyclovir (kidney transplants only)Valganciclovir (Kidney transplants only,Effective 9/1/2021)CALCIUM SUPPLEMENTCalcium CarbonateCalcium Carbonate CombinationsOystershell CalciumCORTICOSTEROID/ Prednisone (Oral forms only)DIGESTIVE ENZYMESPancrelipaseGI STIMULANTSMetoclopramideHYPOGLYCEMIC AGENTChlorpropamideGlipizideGlyburideInsulin (Not all brands/dosage PPRESSANTAzathioprineCyclosporine (Kidney transplants only)Everolimus (Kidney transplants only)Mycophenolic acid (Kidney transplantsonly)Mycophenolate mofetil (Kidneytransplants only)Sirolimus (Kidney transplants only)Tacrolimus (Kidney transplants only)*Products covered are NDC-specific and dependent on a rebate agreement with themanufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website -searchEye and ear drops, injectables (not including insulin), and shampoos are not covered.Revised 9/1/2021

TEXASHealth and HumanServicesKidneyHealth CareION EXCHANGE RESINSodium Polystyrene Sulfonate (SPS)IRON SUPPLEMENTSFerrous GluconateFerrous Sulfate (Iron)Iron (Ferrous Sulfate)Iron w/ Vitamin B12, Intrinsic FactorPolysaccharide Iron ComplexLAXATIVES, BULK FIBERLAXATIVES AND STOOLSOFTENERSSUPPLIES (limited diabeticsupplies)Glucose Test StripsInsulin icineColchicine, Docusate CalciumDocusate SodiumPolyethylene Glycol PowderPHOSPHATE BINDERSAluminum HydroxideCalcium AcetateSevelamer (Effective 9/1/2021)Sucroferric Oxyhydroxide (Velphoro)(Effective 9/1/2021)POTASSIUM SUPPLEMENTPotassium ChloridePotassium GluconateVITAMIN SUPPLEMENTSCalcitriolCyanocobalamin (Vitamin B12)DoxercalciferolFolic AcidIron-Folic (Vitamins with Iron)MultivitaminsMultivitamins with IronPyridoxine (Vitamin B6)Vitamin B Complex with Vitamin CVitamin B6 - PyridoxineVitamin B12, Cyanocobalamin (Oralforms only)Vitamin D - Active (Calcitriol,Doxercalciferol)Vitamins - Multi Vitamins with IronZINC SUPPLEMENTZinc GluconateZinc Sulfate*Products covered are NDC-specific and dependent on a rebate agreement with themanufacturer. To search by NDC, visit the Texas Vendor Drug Program’s website -searchEye and ear drops, injectables (not including insulin), and shampoos are not covered.Revised 9/1/2021

Moexipril 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