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Maintenance Medication Exclusion List

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Maintenance Medication Exclusion List Maintenance Medication Exclusion List The following is a list of drugs that are excluded as maintenance medications. Medications which are listed here cannot be filled through the mail order pharmacy for the mail order incentive. This list includes both formulary/preferred and non-formulary/non-preferred medications, and does not provide information regarding the specific coverage, limitations, exclusions or quotas an individual member may have. Some dosage forms and strengths of a particular drug may be considered maintenance medications, whereas others may not. This list is sorted alphabetically by generic drug name. Generic drug names are written in lower case letters. Brand drug names (or some generic drugs with a trade name) are written in CAPITAL letters. Some drugs do not have a brand name available, in such cases the generic name is listed in the “Brand Name” column. This list of drugs should not be used to determine pharmacy benefits, such as prescription copay/coinsurance amounts or formulary status. If you have questions about the formulary status of a medication, or your prescription benefits, please call our Member Services Department at 1-888-681-7878 (toll free). For the hearing or speech impaired: 1-800-521-4874 (toll free TTY). The medications on this list are subject to change at any time. Exclusions: Any formulation that is required to be administered by a skilled medical professional or in a medical office, drugs infused in the home or in an infusion center, drugs that may have other quantity restrictions, any state law that may prohibit the mailing of certain dosage formulation of a drug, drugs that have a high potential for waste and diversion, drugs that require temperature control upon mailing and drugs that require refrigeration. Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List Generic Name Product Description abatacept ORENCIA INJ 125MG/ML abatacept ORENCIA INJ 250MG abiraterone acetate ZYTIGA TAB 250MG acetaminophen OFIRMEV INJ 10MG/ML acetaminophen w/ codeine CAPITAL/CODEINE SUS 120-12/5 acetaminophen w/ codeine TYLENOL/CODEINE #3 TAB acetaminophen w/ codeine TYLENOL/CODEINE #4 TAB acetaminophen-caff-dihydrocod acetaminophen-caffeine-dihydrocodeine bitart tab acetaminophen-caff-dihydrocod TREZIX CAP acetaminophen-codeine acetaminophen-codeine #2 tab 300-15mg acetaminophen-codeine acetaminophen-codeine #3 tab 300-30mg acetaminophen-codeine acetaminophen-codeine #4 tab 300-60mg acetaminophen-codeine acetaminophen-codeine sol 120-12/5 acetaminophen-codeine CAPITAL-CODEINE SUS 120-12/5 acetaminophen-codeine COCET PLUS TAB 650-60MG acetaminophen-codeine COCET TAB 650-30MG acetaminophen-codeine & dietary management product THERACODEINE-300 PAK acetaminophen-isometheptene-caffeine MIGRALAM CAP acetaminophen-isometheptene-caffeine PRODRIN TAB acetaminophen-isometheptene-dichloralphenazone MIDRIN CAP acetaminophen-mag salicylate-phenyltolox-caffeine cafgesic forte tab acetaminophen-phenyltoloxamine-caffeine FLEXTRA CAP acetaminophen-salicylamide FRENADOL TAB acetaminophen-salicylamide-phenyltoloxamine ANABAR TAB acetaminophen-salicylamide-phenyltoloxamine dolorex cap acetaminophen-salicylamide-phenyltoloxamine duraxin cap acetaminophen-salicylamide-phenyltoloxamine-caffeine cafgesic cap acrivastine-pseudoephedrine SEMPREX-D CAP 8-60MG acyclovir sodium ACYCLOVIR SODIUM INJ 1000MG acyclovir sodium ACYCLOVIR SODIUM INJ 500MG acyclovir sodium ACYCLOVIR SODIUM INJ 50MG/ML adalimumab HUMIRA KIT 10MG/0.2ML adalimumab HUMIRA KIT 20MG/0.4ML adalimumab HUMIRA KIT 40MG/0.8ML adalimumab HUMIRA PEN KIT 40MG/0.8ML adefovir dipivoxil HEPSERA TAB 10MG alectnib hcl ALECENSA CAPS 150MG afatinib dimaleate GILOTRIF TAB 20MG afatinib dimaleate GILOTRIF TAB 30MG afatinib dimaleate GILOTRIF TAB 40MG alfentanil alfentanil inj 500/ml alirocumab PRALUENT INJ 150MG/ML alirocumab PRALUENT INJ 150MG/ML Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Page 2 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List Generic Name Product Description alirocumab PRALUENT INJ 75MG/ML alirocumab PRALUENT INJ 75MG/ML almotriptan malate AXERT TAB 12.5MG almotriptan malate AXERT TAB 6.25MG alprazolam alprazolam er tab 0.5mg alprazolam alprazolam er tab 1mg alprazolam alprazolam er tab 2mg alprazolam alprazolam er tab 3mg alprazolam ALPRAZOLAM INTENSOL CON 1MG/ML alprazolam alprazolam odt tab 0.25mg alprazolam alprazolam odt tab 0.5mg alprazolam alprazolam odt tab 1mg alprazolam alprazolam odt tab 2mg alprazolam alprazolam tab 0.25mg alprazolam alprazolam tab 0.5mg alprazolam alprazolam tab 1mg alprazolam alprazolam tab 2mg alprazolam NIRAVAM TAB 0.25MG alprazolam XANAX TAB 0.25MG alprazolam XANAX TAB 0.5MG alprazolam XANAX TAB 1MG alprazolam XANAX TAB 2MG alprazolam XANAX XR TAB 0.5MG alprazolam XANAX XR TAB 1MG alprazolam XANAX XR TAB 2MG alprazolam XANAX XR TAB 3MG alprazolam-dietary management product GABAZOLAMINE PAK alprazolam-dietary management product GABAZOLAMINE PAK alprazolam-dietary management product GABAZOLAMINE-0.5 PAK alprazolam-dietary management product SENTRAZOLAM AM 0.25 PAK ambrisentan LETAIRIS TAB 10MG ambrisentan LETAIRIS TAB 5MG amobarbital sodium AMYTAL SODIUM INJ 500MG amoxicillin amoxicillin cap 250mg amoxicillin amoxicillin cap 500mg amoxicillin amoxicillin chw 125mg amoxicillin amoxicillin chw 250mg amoxicillin amoxicillin er tab 775mg amoxicillin amoxicillin sus 125/5ml amoxicillin amoxicillin sus 200/5ml amoxicillin amoxicillin sus 250/5ml amoxicillin amoxicillin sus 400/5ml amoxicillin amoxicillin tab 500mg Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Page 3 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List Generic Name Product Description amoxicillin amoxicillin tab 875mg amoxicillin MOXATAG TAB 775MG amoxicillin & pot clavulanate amoxicillin/clavulanate potassium chw 200mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium chw 400mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium er tab amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 200/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 250/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 400/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 600/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium tab 250mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium tab 500mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium tab 875mg amoxicillin & pot clavulanate AUGMENTIN CHW 125MG amoxicillin & pot clavulanate AUGMENTIN CHW 250MG amoxicillin & pot clavulanate AUGMENTIN ES-600 SUS ES-600 amoxicillin & pot clavulanate AUGMENTIN SUS 125/5ML amoxicillin & pot clavulanate AUGMENTIN SUS 200/5ML amoxicillin & pot clavulanate AUGMENTIN SUS 400/5ML amoxicillin & pot clavulanate AUGMENTIN TAB 250MG amoxicillin & pot clavulanate AUGMENTIN TAB 500MG amoxicillin & pot clavulanate AUGMENTIN TAB 875MG amoxicillin & pot clavulanate AUGMENTIN XR TAB 12HR amphetamine DYANAVEL XR SUER 2.5 MG/ML amphetamine sulfate EVEKEO TAB 10MG amphetamine sulfate EVEKEO TAB 5MG amphetamine-dextroamphetamine ADDERALL TAB 12.5MG amphetamine-dextroamphetamine ADDERALL TAB 15MG amphetamine-dextroamphetamine ADDERALL TAB 7.5MG amphetamine-dextroamphetamine ADDERALL XR CAP 10MG amphetamine-dextroamphetamine ADDERALL XR CAP 15MG amphetamine-dextroamphetamine ADDERALL XR CAP 20MG amphetamine-dextroamphetamine ADDERALL XR CAP 25MG amphetamine-dextroamphetamine ADDERALL XR CAP 30MG amphetamine-dextroamphetamine ADDERALL XR CAP 5MG amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 10mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 15mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 20mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 25mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 30mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 5mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 10mg amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 20mg amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 30mg Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Page 4 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List Generic Name Product Description amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 5mg amphotericin b AMPHOTERICIN B INJ 50MG amphotericin b cholesteryl sulfate complex AMPHOTEC INJ 100MG amphotericin b cholesteryl sulfate complex AMPHOTEC INJ 50MG amphotericin b lipid ABELCET INJ 5MG/ML amphotericin b liposome AMBISOME INJ 50MG ampicillin ampicillin cap 250mg ampicillin ampicillin cap 500mg ampicillin ampicillin sus 125/5ml ampicillin ampicillin sus 250/5ml ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 1.5GM ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 1-0.5GM ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 2-1GM ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 3GM ampicillin & sulbactam sodium UNASYN INJ 1.5GM ampicillin & sulbactam sodium UNASYN INJ 3GM ampicillin sodium AMPICILLIN SODIUM INJ 10GM ampicillin sodium AMPICILLIN SODIUM INJ 125MG
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