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Maintenance Drug List Below Is Not Comprehensive and Is Subject to Change Without Prior Notification

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Maintenance Drug List Below Is Not Comprehensive and Is Subject to Change Without Prior Notification Maintenance Drugs Maintenance drugs are used on a continuing basis for the treatment of chronic conditions. Select health plans require that pharmacy benefit maintenance drugs are filled at Kaiser Permanente Washington Mail Order or Kaiser Permanente Clinic Pharmacies for ongoing health plan coverage. Please consult your Evidence of Coverage or call Member Services at 1-888-901-4636 if you have questions about your drug coverage. Non-maintenance drugs are generally used for episodic treatment, are considered narrow therapeutic index by Kaiser Permanente Washington, or are schedule 2 controlled substances. Non-maintenance products include: opioids, opioid reversal agents, opioid dependence agents, benzodiazepines, skeletal muscle relaxants, schedule 2 stimulants, vaccines, oral antibiotics, antiemetics, cough/cold/allergy products, emergency contraception, epinephrine pens, bowel preparations, smoking cessation, prednisone, enoxaparin, cyclosporine, digoxin, dofetilide, everolimus, lithium, mycophenolate, sirolimus, sotalol, tacrolimus, theophylline, and warfarin. The maintenance drug list below is not comprehensive and is subject to change without prior notification. Coverage is provided by Kaiser Permanente Health Plan of Washington and Kaiser Permanente Health Plan of Washington Options, Inc. MAINTENANCE DRUG LIST: ADHD/ANTI-NARCOLEPSY AGENTS DICLOFENAC NALFON ARMODAFINIL DICLOFENAC POTASSIUM NAPRELAN ATOMOXETINE DICLOFENAC SODIUM DR NAPROSYN CLONIDINE HCL ER DICLOFENAC SODIUM ER NAPROXEN GUANFACINE ER DICLOFENAC SODIUM/MISOPROSTOL NAPROXEN DR INTUNIV DUEXIS NAPROXEN SODIUM CR KAPVAY EC-NAPROSYN NAPROXEN SODIUM ER MODAFINIL EC-NAPROXEN NAPROXEN/ESOMEPRAZOLE MAGNESIUM NUVIGIL ENBREL OLUMIANT PROVIGIL ENBREL MINI ORENCIA STRATTERA ENBREL SURECLICK ORENCIA CLICKJECT SUNOSI ETODOLAC OTEZLA ETODOLAC ER OTREXUP ALLERGENIC EXTRACTS FELDENE OXAPROZIN ODACTRA FENOPROFEN CALCIUM PIROXICAM FENORTHO PROFENO AMINOGLYCOSIDES FLURBIPROFEN QMIIZ ODT BETHKIS HUMIRA RASUVO KITABIS PAK IBUPROFEN RELAFEN DS TOBI INDOCIN RINVOQ TOBI PODHALER INDOMETHACIN SIMPONI TOBRAMYCIN INDOMETHACIN ER SULINDAC KETOPROFEN TOLMETIN SODIUM ANALGESICS - ANTI-INFLAMMATORY KETOPROFEN ER VIMOVO ACTEMRA KEVZARA VIVLODEX ACTEMRA ACTPEN LEFLUNOMIDE XELJANZ ANAPROX DS LODINE XELJANZ XR ARAVA MECLOFENAMATE SODIUM ZORVOLEX ARTHROTEC MEFENAMIC ACID CELEBREX MELOXICAM ANALGESICS - NONNARCOTIC CELECOXIB MOBIC DIFLUNISAL DAYPRO NABUMETONE SALSALATE page 1 ANDROGENS-ANABOLIC QUINIDINE SULFATE PULMICORT FLEXHALER ANDRODERM RYTHMOL SR QVAR REDIHALER ANDROGEL SEEBRI NEOHALER ANDROGEL PUMP ANTIASTHMATIC AND BRONCHODILATOR SEREVENT DISKUS FORTESTA AGENTS SINGULAIR JATENZO ACCOLATE SPIRIVA HANDIHALER METHITEST ADVAIR DISKUS SPIRIVA RESPIMAT METHYLTESTOSTERONE ADVAIR HFA STIOLTO RESPIMAT NATESTO AIRDUO DIGIHALER STRIVERDI RESPIMAT STRIANT AIRDUO RESPICLICK SYMBICORT TESTIM ALBUTEROL SULFATE TERBUTALINE SULFATE TESTOSTERONE ALBUTEROL SULFATE ER TRELEGY ELLIPTA TESTOSTERONE PUMP ALBUTEROL SULFATE HFA TUDORZA PRESSAIR TESTOSTERONE TOPICAL SOLUTION ALVESCO UTIBRON NEOHALER VOGELXO ANORO ELLIPTA VENTOLIN HFA VOGELXO PUMP ARCAPTA NEOHALER WIXELA INHUB XYOSTED ARMONAIR DIGIHALER XOPENEX ANTIANGINAL AGENTS ARMONAIR RESPICLICK XOPENEX CONCENTRATE DILATRATE SR ARNUITY ELLIPTA XOPENEX HFA GONITRO ASMANEX HFA YUPELRI ISORDIL TITRADOSE ASMANEX TWISTHALER ZAFIRLUKAST ISOSORBIDE DINITRATE ATROVENT HFA ZILEUTON ER ISOSORBIDE DINITRATE ER BEVESPI AEROSPHERE ZYFLO ISOSORBIDE MONONITRATE BREO ELLIPTA ZYFLO CR ISOSORBIDE MONONITRATE ER BREZTRI AEROSPHERE MINITRAN BROVANA ANTICOAGULANTS NITRO-BID BUDESONIDE ELIQUIS NITRO-DUR BUDESONIDE/FORMOTEROL FUMARATE PRADAXA DIHYDRATE NITROGLYCERIN SAVAYSA COMBIVENT RESPIMAT NITROGLYCERIN ER XARELTO CROMOLYN SODIUM NITROGLYCERIN LINGUAL DALIRESP NITROGLYCERIN TRANSDERMAL ANTICONVULSANTS DUAKLIR PRESSAIR NITROLINGUAL PUMPSPRAY APTIOM DULERA NITROMIST BANZEL FASENRA PEN NITROSTAT BRIVIACT FLOVENT DISKUS NITRO-TIME CARBAMAZEPINE FLOVENT HFA RANEXA CARBAMAZEPINE ER FLUTICASONE PROPIONATE/SALMETEROL RANOLAZINE ER CARBATROL INCRUSE ELLIPTA CELONTIN IPRATROPIUM BROMIDE/ALBUTEROL ANTIARRHYTHMICS CLOBAZAM LEVALBUTEROL AMIODARONE HCL DEPAKENE LEVALBUTEROL HCL DISOPYRAMIDE PHOSPHATE DEPAKOTE LEVALBUTEROL TARTRATE HFA FLECAINIDE ACETATE DEPAKOTE ER LONHALA MAGNAIR MEXILETINE HCL DEPAKOTE SPRINKLES METAPROTERENOL SULFATE MULTAQ DILANTIN MONTELUKAST SODIUM NORPACE DILANTIN INFATABS NUCALA NORPACE CR DILANTIN-125 PERFOROMIST PACERONE DIVALPROEX SODIUM PROAIR DIGIHALER PROPAFENONE HCL DIVALPROEX SODIUM DR PROAIR HFA PROPAFENONE HYDROCHLORIDE ER DIVALPROEX SODIUM ER PROAIR RESPICLICK QUINIDINE GLUCONATE CR EPITOL PROVENTIL HFA QUINIDINE GLUCONATE ER ETHOSUXIMIDE PULMICORT page 2 FELBAMATE ANTIDEPRESSANTS SERTRALINE HCL FELBATOL AMITRIPTYLINE HCL SURMONTIL FYCOMPA AMITRIPTYLINE HYDROCHLORIDE TOFRANIL GABAPENTIN AMOXAPINE TRANYLCYPROMINE SULFATE GABITRIL ANAFRANIL TRAZODONE HYDROCHLORIDE KEPPRA APLENZIN TRIMIPRAMINE MALEATE KEPPRA XR BUPROPION HCL TRINTELLIX LAMICTAL BUPROPION HYDROCHLORIDE ER (SR) VENLAFAXINE HCL LAMICTAL CHEWABLE DISPERSIBLE BUPROPION HYDROCHLORIDE ER (XL) VENLAFAXINE HCL ER LAMICTAL ODT CELEXA VIIBRYD LAMICTAL XR CITALOPRAM WELLBUTRIN SR LAMOTRIGINE CITALOPRAM HYDROBROMIDE WELLBUTRIN XL LAMOTRIGINE ER CLOMIPRAMINE HCL ZOLOFT LAMOTRIGINE ODT CYMBALTA LEVETIRACETAM DESIPRAMINE HCL ANTIDIABETICS LEVETIRACETAM ER DESVENLAFAXINE ER ACARBOSE LYRICA DOXEPIN HCL ACTOPLUS MET MYSOLINE DRIZALMA SPRINKLE ACTOPLUS MET XR NEURONTIN DULOXETINE HCL ACTOS ONFI EFFEXOR XR ADLYXIN OXCARBAZEPINE EMSAM ADMELOG OXTELLAR XR ESCITALOPRAM OXALATE ADMELOG SOLOSTAR PEGANONE FETZIMA AFREZZA PHENYTEK FLUOXETINE DR ALOGLIPTIN PHENYTOIN FLUOXETINE HCL ALOGLIPTIN/METFORMIN HCL PHENYTOIN INFATABS FLUVOXAMINE MALEATE ALOGLIPTIN/PIOGLITAZONE PHENYTOIN SODIUM EXTENDED FLUVOXAMINE MALEATE ER AMARYL PREGABALIN FORFIVO XL APIDRA PRIMIDONE IMIPRAMINE HCL APIDRA SOLOSTAR QUDEXY XR IMIPRAMINE PAMOATE AVANDIA ROWEEPRA KHEDEZLA BASAGLAR KWIKPEN ROWEEPRA XR LEXAPRO BYDUREON RUFINAMIDE MAPROTILINE HCL BYDUREON BCISE SPRITAM MARPLAN BYDUREON PEN SUBVENITE MIRTAZAPINE BYETTA SYMPAZAN MIRTAZAPINE ODT CHLORPROPAMIDE TEGRETOL NARDIL CYCLOSET TEGRETOL-XR NEFAZODONE HCL DIAZOXIDE TIAGABINE HYDROCHLORIDE NORPRAMIN DUETACT TOPAMAX NORTRIPTYLINE HCL FARXIGA TOPAMAX SPRINKLE PAMELOR FIASP TOPIRAMATE PARNATE FIASP FLEXTOUCH TOPIRAMATE ER PAROXETINE HCL FORTAMET TRILEPTAL PAROXETINE HCL ER GLIMEPIRIDE TROKENDI XR PAXIL GLIPIZIDE VALPROIC ACID PAXIL CR GLIPIZIDE ER VIMPAT PEXEVA GLIPIZIDE XL XCOPRI PHENELZINE SULFATE GLIPIZIDE/METFORMIN HCL ZARONTIN PRISTIQ GLUCOPHAGE ZONEGRAN PROTRIPTYLINE HCL GLUCOPHAGE XR ZONISAMIDE PROZAC GLUCOTROL REMERON GLUCOTROL XL REMERON SOLTAB GLUMETZA page 3 GLYBURIDE NESINA ANTIDOTES AND SPECIFIC ANTAGONISTS GLYBURIDE MICRONIZED NOVOLIN 70/30 DEFERASIROX GLYBURIDE/METFORMIN HCL NOVOLIN 70/30 RELION DEFERIPRONE GLYNASE NOVOLIN N EXJADE GLYSET NOVOLIN N RELION FERRIPROX GLYXAMBI NOVOLIN R JADENU HUMALOG NOVOLIN R RELION JADENU SPRINKLE HUMALOG JUNIOR KWIKPEN NOVOLOG ANTIFUNGALS HUMALOG KWIKPEN NOVOLOG FLEXPEN NOXAFIL HUMALOG MIX 50/50 NOVOLOG MIX 70/30 POSACONAZOLE DR HUMALOG MIX 50/50 KWIKPEN NOVOLOG MIX 70/30 PREFILLED FLEXPEN HUMALOG MIX 75/25 NOVOLOG PENFILL ANTIHYPERLIPIDEMICS HUMALOG MIX 75/25 KWIKPEN ONGLYZA ALTOPREV HUMULIN 70/30 OSENI ANTARA HUMULIN 70/30 KWIKPEN OZEMPIC ATORVASTATIN CALCIUM HUMULIN N PIOGLITAZONE HCL CHOLESTYRAMINE HUMULIN N KWIKPEN PIOGLITAZONE HCL/METFORMIN HCL CHOLESTYRAMINE LIGHT HUMULIN R PIOGLITAZONE HCL/GLIMEPIRIDE COLESEVELAM HYDROCHLORIDE HUMULIN R U-500 (CONCENTRATED) PRANDIN COLESTID HUMULIN R U-500 KWIKPEN PRECOSE COLESTID FLAVORED INSULIN ASPART PROGLYCEM COLESTIPOL HCL INSULIN ASPART FLEXPEN QTERN CRESTOR INSULIN ASPART PENFILL REPAGLINIDE EZALLOR SPRINKLE INSULIN ASPART PROTAMINE/INSULIN REPAGLINIDE/METFORMIN HCL EZETIMIBE ASPART RIOMET EZETIMIBE/SIMVASTATIN INSULIN ASPART PROTAMINE/INSULIN RIOMET ER FENOFIBRATE ASPART FLEXPEN RYBELSUS FENOFIBRATE MICRONIZED INSULIN LISPRO SEGLUROMET FENOFIBRIC ACID INSULIN LISPRO JUNIOR KWIKPEN SEMGLEE FENOFIBRIC ACID DR INSULIN LISPRO KWIKPEN SOLIQUA 100/33 FENOGLIDE INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN STARLIX FIBRICOR INVOKAMET STEGLATRO FLOLIPID INVOKAMET XR STEGLUJAN FLUVASTATIN INVOKANA SYMLINPEN FLUVASTATIN SODIUM ER JANUMET SYNJARDY GEMFIBROZIL JANUMET XR SYNJARDY XR ICOSAPENT ETHYL JANUVIA TOLAZAMIDE LESCOL XL JARDIANCE TOLBUTAMIDE LIPITOR JENTADUETO TOUJEO MAX SOLOSTAR LIPOFEN JENTADUETO XR TOUJEO SOLOSTAR LIVALO KAZANO TRADJENTA LOPID KOMBIGLYZE XR TRESIBA LOVASTATIN LANTUS TRESIBA FLEXTOUCH LOVAZA LANTUS SOLOSTAR TRIJARDY XR NEXLETOL LEVEMIR TRULICITY NEXLIZET LEVEMIR FLEXTOUCH VICTOZA NIACIN ER LYUMJEV XIGDUO XR NIASPAN LYUMJEV KWIKPEN XULTOPHY 100/3.6 OMEGA-3-ACID ETHYL ESTERS METFORMIN HYDROCHLORIDE PRALUENT METFORMIN HYDROCHLORIDE ER ANTIDIARRHEAL PRAVACHOL MIGLITOL MYTESI PRAVASTATIN SODIUM NATEGLINIDE PREVALITE page 4 QUESTRAN DIOVAN HCT QBRELIS QUESTRAN LIGHT DOXAZOSIN QUINAPRIL HCL REPATHA DOXAZOSIN MESYLATE QUINAPRIL/HYDROCHLOROTHIAZIDE REPATHA PUSHTRONEX SYSTEM DUTOPROL RAMIPRIL REPATHA SURECLICK EDARBI TARKA ROSUVASTATIN CALCIUM EDARBYCLOR TEKTURNA SIMVASTATIN ENALAPRIL MALEATE TEKTURNA HCT TRICOR ENALAPRIL MALEATE/ TELMISARTAN TRIGLIDE HYDROCHLOROTHIAZIDE TELMISARTAN/AMLODIPINE TRILIPIX EPANED TELMISARTAN/HYDROCHLOROTHIAZIDE VASCEPA EPLERENONE TENORETIC VYTORIN EPROSARTAN MESYLATE TERAZOSIN HCL WELCHOL EXFORGE TRANDOLAPRIL ZETIA EXFORGE HCT TRANDOLAPRIL/VERAPAMIL HCL ER ZOCOR FOSINOPRIL SODIUM TRIBENZOR ZYPITAMAG FOSINOPRIL SODIUM/ TWYNSTA HYDROCHLOROTHIAZIDE VALSARTAN GUANFACINE
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