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 acetaminophen OFIRMEV INJ 10MG/ML acetaminophen (bulk) ACETAMINOPHEN POW acetaminophen w/ codeine acetaminophen/codeine #2 tab 300-15mg acetaminophen w/ codeine acetaminophen/codeine #3 tab 300-30mg acetaminophen w/ codeine acetaminophen/codeine #4 tab 300-60mg acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine CAPITAL/CODEINE SUS 120-12/5 acetaminophen w/ codeine COCET PLUS TAB 650-60MG acetaminophen w/ codeine COCET TAB 650-30MG acetaminophen-caff-dihydrocod acetaminophen/caffeine/dihydrocodeine bitart tab acetaminophen-caff-dihydrocod TREZIX CAP 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 acetanilide ACETANILIDE POW acrivastine & pseudoephedrine SEMPREX-D CAP 8-60MG adalimumab HUMIRA KIT 20MG/0.4 adalimumab HUMIRA KIT 40MG/0.8 adalimumab HUMIRA PEN KIT 40MG/0.8 alfentanil alfentanil inj 500/ml almotriptan malate AXERT TAB 12.5MG almotriptan malate AXERT TAB 6.25MG alprazolam alprazolam er tab 0.5mg er alprazolam alprazolam er tab 1mg er alprazolam alprazolam er tab 2mg er alprazolam alprazolam er tab 3mg er alprazolam ALPRAZOLAM INTENSOL CON 1 MG/ML alprazolam alprazolam odt tab 0.25mg alprazolam alprazolam odt tab 0.5mg od alprazolam alprazolam odt tab 1mg odt alprazolam alprazolam odt tab 2mg odt alprazolam alprazolam tab 0.25mg alprazolam alprazolam tab 0.5mg alprazolam alprazolam tab 1mg alprazolam alprazolam tab 2mg alprazolam-dietary management product GABAZOLAMINE PAK amobarbital sodium AMYTAL SODIUM INJ 500MG 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 Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 2 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List Generic Name Product Description 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 tab 10mg amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 20mg amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 30mg amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 5mg anakinra KINERET INJ armodafinil NUVIGIL TAB 150MG armodafinil NUVIGIL TAB 250MG armodafinil NUVIGIL TAB 50MG aspirin w/ codeine aspirin/codeine tab 325-30mg aspirin w/ codeine aspirin/codeine tab 325-60mg aspirin-apap-salicyl-caff LEVACET TAB benzonatate benzonatate cap 100mg benzonatate benzonatate cap 200mg benzonatate ZONATUSS CAP 150MG brompheniramine & phenyleph ALACOL DRO 0.4-1MG brompheniramine & phenyleph ALACOL SYP 2-5MG brompheniramine & phenyleph bpm pe liq brompheniramine & phenyleph bromax d tab brompheniramine & phenyleph BROVEX PEB LIQ brompheniramine & phenyleph DECON-A ELX 2-5MG/5M brompheniramine & phenyleph entre-b sus 6-10mg/5 brompheniramine & phenyleph phenylephrine hcl/bromphenir mal cap 15-12mg brompheniramine & phenyleph phenylephrine hcl/bromphenir mal cap 7.5-6mg brompheniramine & phenyleph tanabid sr tab 6-30mg brompheniramine & phenyleph vazotab chw brompheniramine & phenyleph ZOTEX PE TAB brompheniramine & pseudoeph andehist nr syp 4-45mg/m brompheniramine & pseudoeph bpm pseudo tab 6-45mg brompheniramine & pseudoeph bromfenex cap 12-120cr brompheniramine & pseudoeph bromhist pediatric dro ped brompheniramine & pseudoeph bromhist-nr dro brompheniramine & pseudoeph brompheniramine/pse cap 9-90mg brompheniramine & pseudoeph BROVEX PSB LIQ brompheniramine & pseudoeph BROVEX PSE TAB 4-40MG brompheniramine & pseudoeph HISTEX SR TAB 10-120MG brompheniramine & pseudoeph J-TAN D PD DRO 1-7.5MG brompheniramine & pseudoeph LODRANE 24D CAP 12-90MG brompheniramine & pseudoeph pse bpm liq brompheniramine & pseudoeph respahist cap 6-60mgcr brompheniramine maleate BROMPHENIRAMINE MALEATE POW MALEATE brompheniramine maleate bromspiro liq 2mg/5ml brompheniramine maleate J-TAN PD DRO 1MG/ML brompheniramine maleate LODRANE 24 CAP brompheniramine maleate lohist-12 tab 12 hour brompheniramine maleate RESPA-BR TAB 11MG brompheniramine maleate-phenylephrine hcl tannate VAZOTAB CHW brompheniramine tannate BROVEX CT CHW 12MG brompheniramine tannate BROVEX SUS 12MG/5ML brompheniramine tannate J-TAN SUS brompheniramine tannate P-TEX SUS 10MG/5ML brompheniramine tannate TANACOF-XR SUS 8MG/5ML Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 3 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List Generic Name Product Description brompheniramine tannate-phenylephrine tannate brompheniramine tann/phenylephrine tann sus 4-5mg brompheniramine tannate-phenylephrine tannate brompheniramine/phenylephrine tannate sus tann brompheniramine tannate-phenylephrine tannate BROVEX ADT SUS 12-10 brompheniramine tannate-phenylephrine tannate C-TAN D PLUS SUS brompheniramine tannate-phenylephrine tannate J-TAN D SUS brompheniramine tannate-phenylephrine tannate RELHIST CHW brompheniramine tannate-phenylephrine tannate tanabid chw 2.2-1.58 brompheniramine tannate-pseudoephedrine tannate BROVEX PD SUS brompheniramine tannate-pseudoephedrine tannate LODRANE D SUS brompheniramine w/ dm-gg TRISPEC SFX LIQ brompheniramine w/ dm-gg TUSNEL CAP brompheniramine-diphenhydramine ALA-HIST TAB 6-25MG brompheniramine-diphenhydramine-phenylephrine ALA-HIST D TAB 6-25-20 bromphen-pseudoephed-chlorphen-phenyleph-methscopol SYMPAK II MIS buprenorphine BUTRANS DIS 10MCG/HR buprenorphine BUTRANS DIS 15MCG/HR buprenorphine BUTRANS DIS 20MCG/HR buprenorphine BUTRANS DIS 5MCG/HR buprenorphine hcl BUPRENEX INJ 0.3MG/ML buprenorphine hcl buprenorphine hcl inj 0.3mg/ml buprenorphine hcl buprenorphine hcl inj 0.3mg/ml buprenorphine hcl buprenorphine hcl sub 2mg buprenorphine hcl buprenorphine hcl sub 8mg buprenorphine hcl (bulk) BUPRENORPHINE HCL POW HCL buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 12-3MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 2-0.5MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 4-1MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 8-2MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE SUB 2-0.5MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE SUB 8-2MG buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUB 1.4-0.36 buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUB 5.7-1.4 butabarbital sodium BUTISOL SODIUM ELX 30MG/5ML butabarbital sodium BUTISOL SODIUM TAB 30MG butabarbital sodium BUTISOL SODIUM TAB 50MG butalbital-acetaminophen butalbital/acetaminophen tab 50-325 butalbital-acetaminophen