1. No category

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
afatinib dimaleate
GILOTRIF TAB 20MG
afatinib dimaleate
GILOTRIF TAB 30MG
afatinib dimaleate
GILOTRIF TAB 40MG
alfentanil
alfentanil inj 500/ml
almotriptan malate
AXERT TAB 12.5MG
almotriptan malate
AXERT TAB 6.25MG
alprazolam
alprazolam er tab 0.5mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 2 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
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
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
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 3 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
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 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
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
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 4 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
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
ampicillin sodium
AMPICILLIN SODIUM INJ 1GM
ampicillin sodium
AMPICILLIN SODIUM INJ 250MG
ampicillin sodium
AMPICILLIN SODIUM INJ 2GM
ampicillin sodium
AMPICILLIN SODIUM INJ 500MG
anakinra
KINERET INJ
apomorphine hydrochloride
APOKYN INJ
apremilast
OTEZLA TAB 10/20/30
apremilast
OTEZLA TAB 30MG
armodafinil
NUVIGIL TAB 150MG
armodafinil
NUVIGIL TAB 250MG
armodafinil
NUVIGIL TAB 50MG
aspirin-acetaminophen-salicyl-caff
LEVACET TAB
aspirin-codeine
aspirin-codeine tab 325-30mg
aspirin-codeine
aspirin-codeine tab 325-60mg
atovaquone
MEPRON SUS
atovaquone-proguanil hcl
atovaquone/proguanil hcl tab 250-100
atovaquone-proguanil hcl
MALARONE TAB 62.5-25
avanafil
STENDRA TAB 100MG
avanafil
STENDRA TAB 200MG
avanafil
STENDRA TAB 50MG
axitinib
INLYTA TAB 1MG
axitinib
INLYTA TAB 5MG
azithromycin
azithromycin inj 500mg
azithromycin
azithromycin pow 1gm pak
azithromycin
azithromycin sus 100/5ml
azithromycin
azithromycin sus 200/5ml
azithromycin
azithromycin tab 250mg
azithromycin
azithromycin tab 500mg
azithromycin
azithromycin tab 600mg
azithromycin
ZITHROMAX INJ 500MG
azithromycin
ZITHROMAX POW 1GM PAK
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 5 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
azithromycin
ZITHROMAX SUS 100/5ML
azithromycin
ZITHROMAX SUS 200/5ML
azithromycin
ZITHROMAX TAB 250MG
azithromycin
ZITHROMAX TAB 500MG
azithromycin
ZITHROMAX TAB 600MG
azithromycin
ZITHROMAX TRI-PAK TAB
azithromycin
ZITHROMAX Z-PAK TAB
azithromycin
ZMAX SUS 2GM
azithromycin (ophth)
AZASITE SOL 1%
aztreonam
AZACTAM INJ 1GM
aztreonam
AZACTAM INJ 2GM
aztreonam
AZTREONAM INJ 1GM
aztreonam
AZTREONAM INJ 2GM
aztreonam in dextrose
AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM
aztreonam lysine
CAYSTON INH 75MG
bacitracin (ophthalmic)
BACITRACIN OIN OP
bacitracin-polymyxin b
OCUMYCIN
bacitracin-polymyxin b (ophth)
AK-POLY-BAC OIN OP
bacitracin-polymyxin b (ophth)
bacitracin/polymyxin b oin op
bacitracin-polymyxin b (ophth)
POLYCIN B OIN OP
bacitracin-polymyxin b (ophth)
POLYCIN OIN OP
bacitracin-poly-neomycin-hc
neo-polycin hc oin hc 1%op
bedaquiline fumarate
SIRTURO TAB 100MG
benzonatate
benzonatate cap 100mg
benzonatate
benzonatate cap 200mg
benzonatate
TESSALON CAP 200MG
benzonatate
TESSALON PERLES CAP 100MG
benzonatate
ZONATUSS CAP 150MG
besifloxacin hcl
BESIVANCE SUS 0.6%
betaine
CYSTADANE
bexarotene
TARGRETIN CAP 75MG
bexarotene (topical)
TARGRETIN GEL 1%
boceprevir
VICTRELIS CAP 200MG
bosentan
TRACLEER TAB 125MG
bosentan
TRACLEER TAB 62.5MG
bosutinib
BOSULIF TAB 100MG
bosutinib
BOSULIF TAB 500MG
brompheniramine maleate
bromspiro liq 2mg/5ml
brompheniramine maleate
J-TAN PD DROP 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
OIN OP
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 6 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
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
brompheniramine tannate-phenylephrine tannate
brompheniramine tann/phenylephrine tann sus 4-5mg
brompheniramine tannate-phenylephrine tannate
brompheniramine/phenylephrine tannate sus
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-diphenhydramine
ALA-HIST TAB 6-25MG
brompheniramine-diphenhydramine-phenylephrine
ALA-HIST D TAB 6-25-20
brompheniramine-dm-guaifenesin
TRISPEC SFX LIQ
brompheniramine-dm-guaifenesin
TUSNEL CAP
brompheniramine-phenylephrine
ALACOL DROP 0.4-1MG
brompheniramine-phenylephrine
ALACOL SYP 2-5MG
brompheniramine-phenylephrine
andehist nr syp 4-45mg/ml
brompheniramine-phenylephrine
bpm pe liq
brompheniramine-phenylephrine
bpm pseudo tab 6-45mg
brompheniramine-phenylephrine
bromax d tab
brompheniramine-phenylephrine
bromfenex cap 12-120cr
brompheniramine-phenylephrine
bromhist pediatric drop
brompheniramine-phenylephrine
bromhist-nr drop
brompheniramine-phenylephrine
brompheniramine/pse cap 9-90mg
brompheniramine-phenylephrine
BROVEX PEB LIQ
brompheniramine-phenylephrine
BROVEX PSB LIQ
brompheniramine-phenylephrine
BROVEX PSE TAB 4-40MG
brompheniramine-phenylephrine
DECON-A ELX 2-5MG/5ML
brompheniramine-phenylephrine
entre-b sus 6-10mg/5ml
brompheniramine-phenylephrine
HISTEX SR TAB 10-120MG
brompheniramine-phenylephrine
J-TAN D PD DROP 1-7.5MG
brompheniramine-phenylephrine
LODRANE 24D CAP 12-90MG
brompheniramine-phenylephrine
phenylephrine hcl/bromphenir mal cap 15-12mg
brompheniramine-phenylephrine
phenylephrine hcl/bromphenir mal cap 7.5-6mg
brompheniramine-phenylephrine
pse bpm liq
brompheniramine-phenylephrine
respahist cap 6-60mgcr
brompheniramine-phenylephrine
tanabid sr tab 6-30mg
brompheniramine-phenylephrine
vazotab tab
brompheniramine-phenylephrine
ZOTEX PE TAB
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 7 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
bromphen-pseudoephed-chlorphen-phenyleph-methscopol
SYMPAK II MIS
budesonide
UCERIS TAB 9MG
bulk chemicals
BULK CHEMICALS
buprenorphine
BUTRANS DIS 10MCG/HR
buprenorphine
BUTRANS DIS 15MCG/HR
buprenorphine
BUTRANS DIS 20MCG/HR
buprenorphine
BUTRANS DIS 5MCG/HR
buprenorphine
BUTRANS DIS 7.5MCG/HR
buprenorphine hcl
BUPRENEX 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-naloxone hcl dihydrate
BUNAVAIL MIS 2.1-0.3
buprenorphine hcl-naloxone hcl dihydrate
BUNAVAIL MIS 4.2-0.7
buprenorphine hcl-naloxone hcl dihydrate
BUNAVAIL MIS 6.3-1MG
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate sub 2-0.5mg
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate sub 8-2mg
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
ORBIVAN CF TAB 50-300MG
butalbital-acetaminophen
PHRENILIN FORTE CAP FORTE
butalbital-acetaminophen
promacet tab 50-650mg
butalbital-acetaminophen-caffeine
ALAGESIC LQ SOL
butalbital-acetaminophen-caffeine
butalbital/acetaminophen/caffeine cap
butalbital-acetaminophen-caffeine
butalbital/acetaminophen/caffeine tab
butalbital-acetaminophen-caffeine
DOLGIC PLUS TAB
butalbital-acetaminophen-caffeine
ORBIVAN CAP
butalbital-acetaminophen-caffeine
zebutal cap
butalbital-acetaminophen-caffeine-codeine
butalbital-acetaminophen-caffeine-codeine cap
butalbital-acetaminophen-caffeine-codeine
FIORICET-CODEINE CAP
butalbital-aspirin-caffeine
butalbital-aspirin-caffeine cap
butalbital-aspirin-caffeine
butalbital-aspirin-caffeine tab
butalbital-aspirin-caffeine-codeine
ascomp-codeine cap 30mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 8 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
butorphanol tartrate
butorphanol tartrate inj 1mg/ml
butorphanol tartrate
butorphanol tartrate inj 2mg/ml
butorphanol tartrate
butorphanol tartrate sol 10mg/ml
butorphanol tartrate
STADOL INJ 2MG/ML
c1 esterase inhibitor (recombinant)
RUCONEST INJ 2100UNIT
cabozantinib s-malate
COMETRIQ KIT 100MG
cabozantinib s-malate
COMETRIQ KIT 140MG
cabozantinib s-malate
COMETRIQ KIT 60MG
canakinumab
ILARIS INJ 180MG
carbetapentane citrate-carbetapentane tan-pe hcl-pe tan
CARBATUSS-12 SUS
carbetapentane citrate-guaifenesin tannate
RESPI-TANN G SUS
carbetapentane citrate-pseudoephedrine hcl tannate
RESPI-TANN CHW
carbetapentane citrate-pseudoephedrine hcl tannate
RESPI-TANN PD SUS
carbetapentane citrate-pseudoephedrine hcl tannate
RESPI-TANN SUS
carbetapentane tannate
SOLOTUSS SUS 30MG/5ML
carbetapentane tannate-pyrilamine tannate
PYRLEX CB SUS
carbetapentane-guaifenesin
CARBA-XP LIQ
carbetapentane-guaifenesin
DYNEX VR CAP
carbetapentane-guaifenesin
EXALL LIQ 10-100MG
carbetapentane-guaifenesin
EXPECTUSS LIQ 20-75MG/ML
carbetapentane-guaifenesin
TUSSO-ZMR CAP 8-200MG
carbetapentane-guaifenesin
TUSSO-ZR SYP 7.5-150
carbetapentane-pseudoephedrine
CORZALL LIQ 20-30MG
carbinoxamine maleate
carbinoxamine maleate liq 4mg/5ml
carbinoxamine maleate
carbinoxamine maleate tab 4mg
carbinoxamine maleate
KARBINAL ER SUS 4MG/5ML
carbinoxamine maleate
PALGIC SOL 4MG/5ML
carbinoxamine maleate
PALGIC TAB 4MG
cefaclor
cefaclor cap 250mg
cefaclor
cefaclor cap 500mg
cefaclor
CEFACLOR SUS 125/5ML
cefaclor
CEFACLOR SUS 187/5ML
cefaclor
CEFACLOR SUS 250/5ML
cefaclor
CEFACLOR SUS 375/5ML
cefaclor
RANICLOR CHW 250MG
cefaclor
RANICLOR CHW 375MG
cefaclor monohydrate
CEFACLOR ER TAB 500MG
cefadroxil
cefadroxil cap 500mg
cefadroxil
cefadroxil sus 250/5ml
cefadroxil
cefadroxil sus 500/5ml
cefadroxil
cefadroxil tab 1gm
cefazolin in d5w
cefazolin sodium inj 1gm/50ml
cefazolin sodium
ANCEF INJ 1GM
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 9 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
cefazolin sodium
CEFAZOLIN SODIUM INJ 100GM
cefazolin sodium
CEFAZOLIN SODIUM INJ 10GM
cefazolin sodium
CEFAZOLIN SODIUM INJ 1GM
cefazolin sodium
CEFAZOLIN SODIUM INJ 20GM
cefazolin sodium
CEFAZOLIN SODIUM INJ 300gm
cefazolin sodium
CEFAZOLIN SODIUM INJ 500mg
cefazolin sodium and dextrose
CEFAZOLIN SODIUM/DEXTROSE SOL 1GM
cefazolin sodium and dextrose
CEFAZOLIN SODIUM/DEXTROSE SOL 2GM
cefdinir
cefdinir cap 300mg
cefdinir
cefdinir sus 125/5ml
cefdinir
cefdinir sus 250/5ml
cefdinir
OMNICEF CAP 300MG
cefdinir
OMNICEF SUS 125/5ML
cefdinir
OMNICEF SUS 250/5ML
cefdinir
OMNI-PAC CAP 300MG
cefditoren pivoxil
cefditoren pivoxil tab 200mg
cefditoren pivoxil
cefditoren pivoxil tab 400mg
cefditoren pivoxil
SPECTRACEF TAB 200MG
cefditoren pivoxil
SPECTRACEF TAB 400MG
cefepime hcl
CEFEPIME INJ 1GM
cefepime hcl
CEFEPIME INJ 2gm
cefepime hcl
MAXIPIME INJ 1GM
cefepime hcl
MAXIPIME INJ 2GM
cefepime hcl and dextrose
CEFEPIME AND DEXTROSE INJ 1GM
cefepime hcl and dextrose
CEFEPIME AND DEXTROSE INJ 2GM
cefixime
SUPRAX CAP 400MG
cefixime
SUPRAX CHW 100MG
cefixime
SUPRAX SUS 100/5ML
cefixime
SUPRAX SUS 200/5ML
cefixime
SUPRAX SUS 500/5ML
cefixime
SUPRAX TAB 400MG
cefotaxime sodium
CEFOTAXIME SODIUM INJ 1GM
cefotaxime sodium
CEFOTAXIME SODIUM INJ 2GM
cefotaxime sodium
CEFOTAXIME SODIUM INJ 500MG
cefotaxime sodium
CLAFORAN INJ 10GM
cefotaxime sodium
CLAFORAN INJ 1GM
cefotaxime sodium
CLAFORAN INJ 2GM
cefotetan disodium
CEFOTETAN INJ 10G
cefotetan disodium
CEFOTETAN INJ 1GM/10ML
cefotetan disodium
CEFOTETAN INJ 2GM/20ML
cefotetan disodium and dextrose
CEFOTETAN/DEXTROSE INJ 1-3.58%
cefotetan disodium and dextrose
CEFOTETAN/DEXTROSE INJ 2-2.08%
cefoxitin sodium
CEFOXITIN SODIUM INJ 10GM
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 10 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
cefoxitin sodium
CEFOXITIN SODIUM INJ 1GM
cefoxitin sodium and dextrose
CEFOXITIN SODIUM INJ 2GM
cefoxitin sodium in dextrose
MEFOXIN INJ 1GM/50ML
cefoxitin sodium in dextrose
MEFOXIN INJ 2GM/50ML
cefpodoxime proxetil
cefpodoxime proxetil sus 100/5ml
cefpodoxime proxetil
cefpodoxime proxetil sus 50mg/5ml
cefpodoxime proxetil
cefpodoxime proxetil tab 100mg
cefpodoxime proxetil
cefpodoxime proxetil tab 200mg
cefprozil
cefprozil sus 125/5ml
cefprozil
cefprozil sus 250/5ml
cefprozil
cefprozil tab 250mg
cefprozil
cefprozil tab 500mg
ceftaroline fosamil
TEFLARO INJ 400MG
ceftaroline fosamil
TEFLARO INJ 600MG
ceftazidime
FORTAZ INJ 500MG
ceftazidime
TAZICEF INJ 1GM
ceftazidime
TAZICEF INJ 2GM
ceftazidime
TAZICEF INJ 6GM
ceftazidime and dextrose
CEFTAZIDIME/DEXTROSE SOL D5W 1GM
ceftazidime and dextrose
CEFTAZIDIME/DEXTROSE SOL D5W 2GM
ceftazidime sodium in d5w
FORTAZ INJ 1GM
ceftazidime sodium in d5w
FORTAZ INJ 2GM
ceftibuten
CEDAX CAP 400MG
ceftibuten
CEDAX SUS 180/5ML
ceftibuten
CEDAX SUS 90MG/5ML
ceftibuten
ceftibuten sus 180/5ml
ceftriaxone sodium
CEFTRIAXONE SODIUM INJ 10GM
ceftriaxone sodium
CEFTRIAXONE SODIUM INJ 1GM
ceftriaxone sodium
CEFTRIAXONE SODIUM INJ 250MG
ceftriaxone sodium
CEFTRIAXONE SODIUM INJ 2GM
ceftriaxone sodium
CEFTRIAXONE SODIUM INJ 500MG
ceftriaxone sodium
ROCEPHIN INJ 1GM
ceftriaxone sodium
ROCEPHIN INJ 500MG
ceftriaxone sodium and dextrose
CEFTRIAXONE/DEXTROSE INJ 1GM
ceftriaxone sodium and dextrose
CEFTRIAXONE/DEXTROSE INJ 2GM
ceftriaxone sodium in dextrose
CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ 1GM
ceftriaxone sodium in dextrose
CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ 2GM
cefuroxime axetil
CEFTIN SUS 125/5ML
cefuroxime axetil
CEFTIN SUS 250/5ML
cefuroxime axetil
CEFTIN TAB 250MG
cefuroxime axetil
CEFTIN TAB 500MG
cefuroxime axetil
cefuroxime axetil tab 250mg
cefuroxime axetil
cefuroxime axetil tab 500mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 11 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
cefuroxime in sterile water
ZINACEF INJ 1.5GM PB
cefuroxime sodium
CEFUROXIME SODIUM INJ 1.5GM
cefuroxime sodium
CEFUROXIME SODIUM INJ 7.5GM
cefuroxime sodium
CEFUROXIME SODIUM INJ 750MG
cefuroxime sodium
CEFUROXIME SODIUM INJ 75GM
cefuroxime sodium
ZINACEF INJ 1.5GM
cefuroxime sodium
ZINACEF INJ 7.5GM
cefuroxime sodium
ZINACEF INJ 750MG
cefuroxime sodium and dextrose
CEFUROXIME/DEXTROSE INJ 1.5GM
cefuroxime sodium and dextrose
CEFUROXIME/DEXTROSE INJ 750MG
cephalexin
cephalexin cap 250mg
cephalexin
cephalexin cap 500mg
cephalexin
cephalexin cap 750mg
cephalexin
cephalexin sus 125/5ml
cephalexin
cephalexin sus 250/5ml
cephalexin
cephalexin tab 250mg
cephalexin
cephalexin tab 500mg
cephalexin
KEFLEX CAP 250MG
cephalexin
KEFLEX CAP 500MG
cephalexin
KEFLEX CAP 750MG
cephalexin
KEFLEX SUS 125/5ML
cephalexin
KEFLEX SUS 250/5ML
ceretinib
ZYKADIA CAP 150MG
certolizumab pegol
CIMZIA KIT
certolizumab pegol
CIMZIA KIT 200MG/ML
cetirizine hcl
cetirizine hcl syp 1mg/ml
cetirizine hcl
ZYRTEC ALLERGY CAP 10MG
cetirizine hcl
ZYRTEC ALLERGY CHILDRENS TAB 10MG
cetirizine hcl
ZYRTEC ALLERGY TAB 10MG
cetirizine hcl
ZYRTEC CHILDRENS ALLERGY CHW ALG 10MG
cetirizine hcl
ZYRTEC CHILDRENS ALLERGY CHW ALG 5MG
cetirizine hcl
ZYRTEC CHILDRENS ALLERGY SYP 1MG/ML
cetirizine hcl
ZYRTEC CHILDRENS HIVES RELIEF SYP 1MG/ML
cetirizine hcl
ZYRTEC HIVES RELIEF TAB 10MG
cetrorelix acetate
CETROTIDE KIT 0.25MG
cetrorelix acetate
CETROTIDE KIT 3MG
chlophedianol-triprolidine
PROHIST CF LIQ
chloral hydrate
CHLORAL HYDRATE SUP 500MG
chloral hydrate
CHLORAL HYDRATE SYP 500/5ML
chloral hydrate
SOMNOTE CAP 500MG
chlordiazepoxide hcl
chlordiazepoxide hcl cap 10mg
chlordiazepoxide hcl
chlordiazepoxide hcl cap 25mg
chlordiazepoxide hcl
chlordiazepoxide hcl cap 5mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 12 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
chlordiazepoxide hcl
LIBRIUM INJ 100MG
chlordiazepoxide hcl-clidinium bromide
LIBRAX CAP 5-2.5MG
chlorpheniramine maleate
CHLORPHENIRAMINE MALEATE ER CAP 12MG
chlorpheniramine maleate
chlorpheniramine maleate er cap 8mg
chlorpheniramine maleate
CPM CAP 12MG CR
chlorpheniramine maleate
ED CHLORPED LIQ 2MG/ML
chlorpheniramine maleate tannate
PEDIOX-S SUS 4MG/5ML
chlorpheniramine maleate-pseudoephedrine hcl tannate
SUDAL 12 TANNATE CHW 4-30MG
chlorpheniramine mal-phenylephrine hcl-methscop tan
AH-CHEW ULTRA SUS ULTRA
chlorpheniramine tannate
AHIST TAB 12MG
chlorpheniramine tannate
ED CHLORPED SUS 2MG/ML
chlorpheniramine tannate
ED-CHLOR-TAN TAB 8MG
chlorpheniramine tannate
pediaphyl sus 8mg/5ml
chlorpheniramine tannate-carbetapentane tannate
c-tanna 12 sus 4-30mg/5ml
chlorpheniramine tannate-carbetapentane tannate
TUSSI-12 TAB 5-60MG
chlorpheniramine tannate-methscopolamine
DEXODRYL CHW 2-1.5MG
chlorpheniramine tannate-methscopolamine
DEXODRYL SUS
chlorpheniramine tannate-phenylephrine tannate
ALLERX SUS
chlorpheniramine tannate-phenylephrine tannate
DALLERGY-JR SUS
chlorpheniramine tannate-phenylephrine tannate
ED CHLORPED D SUS
chlorpheniramine tannate-phenylephrine tannate
p-tann d sus
chlorpheniramine tannate-phenylephrine tannate
r-tanna pediatric sus
chlorpheniramine tannate-phenylephrine tannate
r-tanna tab 9-25mg
chlorpheniramine tannate-phenylephrine tannate
RYNATAN PEDIATRIC CHW 4.5-5MG
chlorpheniramine tan-phenylephrine tan-methscop
AH-CHEW ULTRA CHW ULTRA
chlorpheniramine tan-phenylephrine tan-methscop
redur-pcm sus
chlorpheniramine tan-phenylephrine tan-methscop
SYMPAK PDX MIS
chlorpheniramine tan-pseudoephrine tan
DICEL SUS
chlorpheniramine tan-pyrilamine tan-phenylephrine tan
conal sus
chlorpheniramine tan-pyrilamine tan-phenylephrine tan
nalex-a 12 sus
chlorpheniramine-codeine
CODAR AR LIQ
chlorpheniramine-codeine
COTAB A TAB 4-10MG
chlorpheniramine-codeine
COTAB AX TAB 4-20MG
chlorpheniramine-codeine
endacof-c liq 2-10mg/5ml
chlorpheniramine-codeine
ZODRYL AC 25 SUS
chlorpheniramine-codeine
ZODRYL AC 30 SUS
chlorpheniramine-codeine
ZODRYL AC 35 SUS
chlorpheniramine-codeine
ZODRYL AC 40 SUS
chlorpheniramine-codeine
ZODRYL AC 50 SUS
chlorpheniramine-codeine
ZODRYL AC 60 SUS
chlorpheniramine-codeine
ZODRYL AC 80 SUS
chlorpheniramine-codeine
Z-TUSS AC LIQ 2-9/5ML
chlorpheniramine-dm-guaifenesin
ALLFEN DMA TAB 4-20-400
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 13 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
chlorpheniramine-methscopolamine
relcof cpm tab 8-2.5mg
chlorpheniramine-methscopolamine
respivent df mis
chlorpheniramine-methscopolamine
RYNEZE LIQ
chlorpheniramine-phenylephrine
ACCUHIST DROP 1-2.5MG
chlorpheniramine-phenylephrine
centergy drop 1-2mg/ml
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
c-phen drop
chlorpheniramine-phenylephrine
DALLERGY JR CAP 4-20MG
chlorpheniramine-phenylephrine
ED A-HIST LIQ 4-10/5ML
chlorpheniramine-phenylephrine
HISTEX SR TAB 6-15MG
chlorpheniramine-phenylephrine
nohist tab 8-20mg
chlorpheniramine-phenylephrine
sildec-pe syp
chlorpheniramine-phenylephrine-acetaminophen
PROTID TAB CR
chlorpheniramine-phenylephrine-methscopolamine
AEROKID SYP
chlorpheniramine-phenylephrine-methscopolamine
AH-CHEW II CHW
chlorpheniramine-phenylephrine-methscopolamine
ALLERX PE MIS
chlorpheniramine-phenylephrine-methscopolamine
chlor-mes d syp liquid
chlorpheniramine-phenylephrine-methscopolamine
cpm 8-pe 20-msc 1.25 tab
chlorpheniramine-phenylephrine-methscopolamine
DALLERGY CHW
chlorpheniramine-phenylephrine-methscopolamine
DALLERGY PE SYP
chlorpheniramine-phenylephrine-methscopolamine
DALLERGY PE TAB
chlorpheniramine-phenylephrine-methscopolamine
DALLERGY SYP
chlorpheniramine-phenylephrine-methscopolamine
DALLERGY TAB
chlorpheniramine-phenylephrine-methscopolamine
DALLERGY TAB ER
chlorpheniramine-phenylephrine-methscopolamine
DEHISTINE SYP
chlorpheniramine-phenylephrine-methscopolamine
OMNIHIST II LA TAB LA
chlorpheniramine-phenylephrine-methscopolamine
phenylephrine cm tab
chlorpheniramine-phenylephrine-methscopolamine
re-drylex jr tab
chlorpheniramine-phenylephrine-methscopolamine
RELCOF DN PE MIS
chlorpheniramine-phenylephrine-methscopolamine
RESCON TAB
chlorpheniramine-pseudoephedrine-methscopolamine
coldamine tab 8-90-2.5
chlorpheniramine-pseudoephedrine-methscopolamine
DALLERGY PSE TAB
chlorpheniramine-pseudoephedrine-methscopolamine
DRYMAX SYP
chlorpheniramine-pseudoephedrine-methscopolamine
pcm la tab
chlorpheniramine-pseudoephedrine-methscopolamine
RELCOF DN PSE MIS PSE
chlorpheniramine-pseudoephedrine-methscopolamine
relcof pse tab
chlorpheniramine-pseudoephedrine-methscopolamine
TIME-HIST QD TAB
chlorpheniramine-pseudoephedrine-methscopolamine
visrx dose pack tab dose pac
chlorpheniramine-pseudoephrine
CHLORPHENIRAMINE/PSEUDOEPHEDRINE SYP
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephedrine cr cap 8-120
chlorpheniramine-pseudoephrine
DECONAMINE TAB 4-60MG
chlorpheniramine-pseudoephrine
duratuss da cap 12-100mg
chlorpheniramine-pseudoephrine
LOHIST-D LIQ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 14 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
chlorpheniramine-pseudoephrine
neutrahist drop 0.8-9mg
chlorpheniramine-pseudoephrine
SUDAHIST TAB 12-120MG
chlorpheniramine-pyrilamine-phenylephrine
myhist-pd liq
chlorpheniramine-pyrilamine-phenylephrine
PHENA-PLUS TAB
chlorpheniramine-pyrilamine-phenylephrine
PHENA-S LIQ
chlorpheniramine-pyrilamine-phenylephrine
RU-HIST FORTE TAB
chlorphenir-phenylephrine-methscopol-homeopathic
ZINX KIDS SNEEZE KIT
chlorphenir-phenyltoloxamine-phenylephrine-acetaminophen
NOREL SR TAB
chlorphenir-pseudoephedrine-belladonna alkaloids
RESPA-A.R. TAB
chlorphenir-pseudoephedrine-homeopathic product
ZINX ALLERGY KIT
chlorphenir-pyrilamine tan-phenyleph hcl-phenyleph tan
PHENA-S 12 SUS
chlorphen-phenyltolox-phenylephrine
chlorpheniramine-phenyltoloxamine-phenylephrine liq
chlorphen-phenyltolox-phenylephrine
rhinacon a tab
chlorphen-pse-atropine-hyoscyamine-scopolamine
ru-tuss tab
choriogonadotropin alfa
OVIDREL INJ
chorionic gonadotropin
chorionic gonadotropin inj 10000unt
cinacalcet hcl
SENSIPAR TAB 30MG
cinacalcet hcl
SENSIPAR TAB 60MG
cinacalcet hcl
SENSIPAR TAB 90MG
ciprofloxacin
CIPRO SUS 250MG/5
ciprofloxacin
CIPRO SUS 500MG/5
ciprofloxacin
CIPROFLOXACIN INJ 200MG
ciprofloxacin
CIPROFLOXACIN INJ 400MG
ciprofloxacin hcl
CIPRO TAB 250MG
ciprofloxacin hcl
CIPRO TAB 500MG
ciprofloxacin hcl
ciprofloxacin hcl tab 100mg
ciprofloxacin hcl
ciprofloxacin hcl tab 250mg
ciprofloxacin hcl
ciprofloxacin hcl tab 500mg
ciprofloxacin hcl
ciprofloxacin hcl tab 750mg
ciprofloxacin hcl (ophth)
CILOXAN OIN 0.3% OP
ciprofloxacin hcl (ophth)
ciprofloxacin hcl sol 0.3% op
ciprofloxacin hcl (otic)
CETRAXAL SOL 0.2%
ciprofloxacin hcl (otic)
ciprofloxacin sol 0.2%
ciprofloxacin in d5w
CIPRO I.V.-IN D5W INJ 200MG
ciprofloxacin in d5w
CIPRO I.V.-IN D5W INJ 400MG
ciprofloxacin in d5w
CIPROFLOXACIN I.V.-IN D5W INJ 200MG
ciprofloxacin in d5w
CIPROFLOXACIN I.V.-IN D5W INJ 400MG
ciprofloxacin-ciprofloxacin hcl
CIPRO XR TAB 1000MG
ciprofloxacin-ciprofloxacin hcl
CIPRO XR TAB 500MG
ciprofloxacin-ciprofloxacin hcl
ciprofloxacin er tab 1000mg
ciprofloxacin-ciprofloxacin hcl
ciprofloxacin er tab 500mg er
ciprofloxacin-dexamethasone
CIPRODEX SUS 0.3-0.1%
ciprofloxacin-hydrocortisone
CIPRO HC SUS OTIC
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 15 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
clemastine fumarate
clemastine fumarate syp 0.5/5ml
clemastine fumarate
clemastine fumarate tab 2.68mg
clemastine fumarate
TAVIST ALLERGY TAB 1.34MG
clomiphene citrate
clomiphene citrate tab 50mg
clonazepam
clonazepam odt tab 0.125mg
clonazepam
clonazepam odt tab 0.25mg
clonazepam
clonazepam odt tab 0.5mg
clonazepam
clonazepam odt tab 1mg
clonazepam
clonazepam odt tab 2mg
clonazepam
clonazepam tab 0.5mg
clonazepam
clonazepam tab 1mg
clonazepam
clonazepam tab 2mg
clonazepam
KLONOPIN TAB 0.5MG
clonazepam
KLONOPIN TAB 1MG
clonazepam
KLONOPIN TAB 2MG
clorazepate dipotassium
clorazepate dipotassium tab 15mg
clorazepate dipotassium
clorazepate dipotassium tab 3.75mg
clorazepate dipotassium
clorazepate dipotassium tab 7.5mg
clorazepate dipotassium
TRANXENE-SD TAB 11.25MG
clorazepate dipotassium
TRANXENE-SD TAB 22.5MG
clotrimazole
clotrimazole tro 10mg
clozapine
clozapine odt tab 100/odt
clozapine
clozapine odt tab 12.5/odt
clozapine
clozapine odt tab 25mg odt
clozapine
CLOZAPINE TAB 200MG
clozapine
CLOZAPINE TAB 50MG
clozapine
CLOZARIL TAB 100MG
clozapine
CLOZARIL TAB 25MG
clozapine
FAZACLO TAB 100/ODT
clozapine
FAZACLO TAB 12.5/ODT
clozapine
FAZACLO TAB 150MG
clozapine
FAZACLO TAB 200MG
clozapine
FAZACLO TAB 25MG ODT
clozapine
VERSACLOZ SUS 50MG/ML
codeine phosphate
CODEINE PHOSPHATE INJ 30MG/2ML
codeine phosphate
CODEINE PHOSPHATE INJ 60MG/2ML
codeine phosphate
CODEINE PHOSPHATE TAB SOL 30MG
codeine sulfate
CODEINE SULFATE SOL 30MG/5ML
codeine sulfate
CODEINE SULFATE TAB 15MG
codeine sulfate
CODEINE SULFATE TAB 30MG
codeine sulfate
CODEINE SULFATE TAB 60MG
codeine-brompheniramine
BROVEX CB TAB 10-4MG
codeine-brompheniramine
BROVEX CBX TAB 20-4MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 16 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
codeine-brompheniramine
NALEX AC SYP
codeine-chlorcyclizine
NOTUSS-NX LIQ
codeine-chlorpheniramine-acetaminophen
COTABFLU TAB 20-4-500
codeine-phenylephrine-chlorcyclizine
NASOTUSS LIQ
codeine-pseudoephedrine-chlorcyclizine
NOTUSS-NXD LIQ
codeine-pyrilamine
PRO-CLEAR AC SYP
corticotropin
ACTHAR HP INJ 80UNIT
crizotinib
XALKORI CAP 200MG
crizotinib
XALKORI CAP 250MG
cycloserine
cycloserine cap 250mg
cyproheptadine hcl
cyproheptadine hcl syp 2mg/5ml
cyproheptadine hcl
cyproheptadine hcl tab 4mg
cysteamine bitartrate
CYSTAGON CAP 150MG
cysteamine bitartrate
CYSTAGON CAP 50MG
cysteamine bitartrate
PROCYSBI CAP 25MG
cysteamine bitartrate
PROCYSBI CAP 75MG
dabrafenib mesylate
TAFINLAR CAP 50MG
dabrafenib mesylate
TAFINLAR CAP 75MG
dalfampridine
AMPYRA TAB 10MG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 100MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 150MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 200MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 25MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 300MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 40MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 500MCG
darbepoetin alfa-polysorbate 80
ARANESP ALBUMIN FREE INJ 60MCG
dasatinib
SPRYCEL TAB 100MG
dasatinib
SPRYCEL TAB 140MG
dasatinib
SPRYCEL TAB 20MG
dasatinib
SPRYCEL TAB 50MG
dasatinib
SPRYCEL TAB 70MG
dasatinib
SPRYCEL TAB 80MG
deferasirox
EXJADE TAB 125MG
deferasirox
EXJADE TAB 250MG
deferasirox
EXJADE TAB 500MG
deferiprone
FERRIPROX TAB 500MG
denosumab
PROLIA SOL 60MG/ML
denosumab
XGEVA INJ
desflurane
SUPRANE INH
desloratadine
CLARINEX REDITABS TAB 2.5MG
desloratadine
CLARINEX REDITABS TAB 5MG
desloratadine
CLARINEX SYP 0.5MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 17 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
desloratadine
CLARINEX TAB 5MG
desloratadine
DESLORATADINE ODT TAB 2.5 ODT
desloratadine
DESLORATADINE ODT TAB 5MG ODT
desloratadine
DESLORATADINE TAB 5MG
desloratadine-pseudoephedrine
CLARINEX-D 12 HOUR TAB 2.5-120
desloratadine-pseudoephedrine
CLARINEX-D 24 HOUR TAB 5-240MG
dexamethasone
BAYCADRON ELX 0.5/5ML
dexamethasone
dexamethasone elx 0.5/5ml
dexamethasone
DEXAMETHASONE INTENSOL CON 1MG/ML
dexamethasone
DEXAMETHASONE SOL 0.5/5ML
dexamethasone
DEXAMETHASONE TAB 0.25MG
dexamethasone
dexamethasone tab 0.5mg
dexamethasone
dexamethasone tab 0.75mg
dexamethasone
dexamethasone tab 1.5mg
dexamethasone
DEXAMETHASONE TAB 1MG
dexamethasone
DEXAMETHASONE TAB 2MG
dexamethasone
dexamethasone tab 4mg
dexamethasone
dexamethasone tab 6mg
dexamethasone
DEXPAK 10 DAY PAK 10 DAY
dexamethasone
DEXPAK 13 DAY PAK 13 DAY
dexamethasone
DEXPAK 6 DAY PAK 6 DAY
dexamethasone
zema-pak 10 day pak 10 day
dexamethasone
zema-pak 13 day pak 13 day
dexamethasone
zema-pak 6 day pak 6 day
dexamethasone (ophth)
MAXIDEX SUS 0.1% OP
dexamethasone (ophth)
OZURDEX IMP 0.7MG
dexamethasone sodium phosphate (ophth)
dexamethasone sodium phosphate sol 0.1% op
dexbrompheniramine tannate-pyrilamine maleate
POLY TAN SUS
dexbrompheniramine tan-pyrilamine mal-phenylephrine tan
POLY TAN D SUS
dexchlorpheniramine maleate
DEXCHLORPHENIRAMINE MALEATE SYP 2MG/5ML
dexchlorpheniramine maleate
dexchlorpheniramine maleate tab 6mg cr
dexchlorpheniramine tannate-pseudoephedrine tannate
SUTAN SUS
dexchlorpheniramine-phenylephrine
NALDEX TAB
dexchlorpheniramine-phenylephrine
RESCON-JR TAB
dexchlorpheniramine-phenylephrine
RESCON-MX TAB
dexchlorpheniramine-phenylephrine-methscopolamine
dexphen m sol
dexchlorpheniramine-pseudoephedrine-methscopolamine
DURAHIST D TAB
dexmedetomidine hcl
dexmethylphenidate hcl
PRECEDEX INJ 100MCG
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL CAP 5MG
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL ER CAP 15MG ER
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL ER CAP 30MG ER
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL ER CAP 40MG ER
DEXMETHYLPHENIDATE HCL CAP 10MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 18 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
dexmethylphenidate hcl
Product Description
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL TAB 10MG
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL TAB 2.5MG
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL TAB 5MG
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL CAP 10MG
dexmethylphenidate hcl
DEXMETHYLPHENIDATE HCL CAP 5MG
dexmethylphenidate hcl
FOCALIN TAB 10MG
dexmethylphenidate hcl
FOCALIN TAB 2.5MG
dexmethylphenidate hcl
FOCALIN TAB 5MG
dexmethylphenidate hcl
FOCALIN XR CAP 10MG
dexmethylphenidate hcl
FOCALIN XR CAP 15MG
dexmethylphenidate hcl
FOCALIN XR CAP 20MG
dexmethylphenidate hcl
FOCALIN XR CAP 25MG
dexmethylphenidate hcl
FOCALIN XR CAP 30MG
dexmethylphenidate hcl
FOCALIN XR CAP 35MG
dexmethylphenidate hcl
FOCALIN XR CAP 40MG
dexmethylphenidate hcl
FOCALIN XR CAP 5MG
dextroamphetamine sulfate
DEXEDRINE CAP 10MG CR
dextroamphetamine sulfate
DEXEDRINE CAP 15MG CR
dextroamphetamine sulfate
DEXEDRINE CAP 5MG CR
dextroamphetamine sulfate
dextroamphetamine sulfate er cap 10mg
dextroamphetamine sulfate
dextroamphetamine sulfate er cap 15mg
dextroamphetamine sulfate
dextroamphetamine sulfate er cap 5mg
dextroamphetamine sulfate
dextroamphetamine sulfate tab 10mg
dextroamphetamine sulfate
PROCENTRA SOL 5MG/5ML
dextroamphetamine sulfate
ZENZEDI TAB 15MG
dextroamphetamine sulfate
ZENZEDI TAB 2.5MG
dextroamphetamine sulfate
ZENZEDI TAB 20MG
dextroamphetamine sulfate
ZENZEDI TAB 30MG
dextroamphetamine sulfate
ZENZEDI TAB 5mg
dextroamphetamine sulfate
ZENZEDI TAB 7.5MG
dextromethorphan hbr-guaifenesin tannate
DURATUSS DM 12 SUS DM
dextromethorphan-chlorpheniramine-methscopolamine
EXTENDRYL DM TAB
dextromethorphan-guaifenesin
allfen dm tab 400-20mg
dextromethorphan-guaifenesin
dm/guai liq 10-300mg
dextromethorphan-guaifenesin
DURATUSS DM ELX
dextromethorphan-guaifenesin
gani-tuss dm nr liq 100-10/5
dextromethorphan-guaifenesin
NORTUSS-EX LIQ 200-20/5
dextromethorphan-guaifenesin
su-tuss dm elx 200-20/5
dextromethorphan-guaifenesin
TRISPEC DMX LIQ
dextromethorphan-potassium guaiacolsulfonate
guiadex dm liq
dextromethorphan-potassium guaiacolsulfonate
PROLEX DMX LIQ
diazepam
DIAZEPAM INJ 10MG/2ML
DEXMETHYLPHENIDATE HCL ER CAP 5MG ER
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 19 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
diazepam
DIAZEPAM INJ 5MG/ML
diazepam
DIAZEPAM INTENSOL CON 5MG/ML
diazepam
DIAZEPAM SOL 1MG/ML
diazepam
DIAZEPAM SOL 1MG/ML
diazepam
diazepam tab 10mg
diazepam
diazepam tab 2mg
diazepam
diazepam tab 5mg
diazepam
VALIUM TAB 10MG
diazepam
VALIUM TAB 2MG
diazepam
VALIUM TAB 5MG
diazepam (anticonvulsant)
DIASTAT ACUDIAL GEL 12.5-20
diazepam (anticonvulsant)
DIASTAT ACUDIAL GEL 5-10MG
diazepam (anticonvulsant)
DIASTAT PEDIATRIC GEL 2.5MG
diazepam (anticonvulsant)
DIAZEPAM GEL 10MG
diazepam (anticonvulsant)
DIAZEPAM GEL 2.5MG
diazepam (anticonvulsant)
DIAZEPAM GEL 20MG
diazepam-dietary management product
GABAVALE-5 PAK
dicloxacillin sodium
dicloxacillin sodium cap 250mg
dicloxacillin sodium
dicloxacillin sodium cap 500mg
dihydrocodeine compound
SYNALGOS-DC CAP
dihydrocodeine-guaifenesin
J-MAX DHC LIQ
dihydroergotamine mesylate
dihydroergotamine mesylate inj 1mg/ml
dihydroergotamine mesylate
MIGRANAL SPR 4MG/ML
dimethyl fumarate
TECFIDERA CAP 120MG
dimethyl fumarate
TECFIDERA CAP 240MG
dimethyl fumarate
TECFIDERA STARTER PACK
dimethyl sulfoxide
RIMSO-50 SOL 50%
diphenhydramine hcl
DICOPANOL FUSEPAQ SUS 5MG/ML
diphenhydramine hcl
diphenhydramine hcl cap 25mg
diphenhydramine hcl
diphenhydramine hcl cap 50mg
diphenhydramine hcl
diphenhydramine hcl elx 12.5/5ml
diphenhydramine hcl
diphenhydramine hcl inj 50mg/ml
diphenhydramine hcl
dytuss syp 12.5/5ml
diphenhydramine hcl-phenylephrine hcl tannate
ALDEX-CT CHW 12.5-5MG
diphenhydramine tannate
ben-tann sus 25mg/5ml
diphenhydramine tannate
DYTAN CHW 25MG
diphenhydramine tannate-carbetapentane tannate
D-TANN AT SUS
diphenhydramine tannate-phenylephrine tannate
d-tann chw 25-10mg
diphenhydramine tannate-phenylephrine tannate
d-tann sus 25-7.5mg
diphenhydramine-hydrocortisone-nystatin
FIRST-DUKES MOUTHWASH SUS
diphenhydramine-hydrocortisone-nystatin-tetracycline
FIRST-MARYS MOUTHWASH SUS
diphenhydramine-lidocaine-nystatin
FIRST-BXN MOUTHWASH SUS
diphenhydramine-phenylephrine
zoden pd liq 25-7.5
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 20 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
diphenhydramine-pseudoephrineed
TEKRAL TAB
dornase alfa
PULMOZYME SOL 1MG/ML
doxycycline calcium
VIBRAMYCIN SYP 50MG/5ML
doxycycline hyclate w/ eyelid cleanser & spray
OCUDOX KIT
doxycycline hyclate w/ eyelid cleansers
ALODOX CONVENIENCE KIT KIT 20MG
doxylamine succinate
DOXYTEX LIQ
doxylamine succinate tannate
ALDEX AN SUS
droperidol
droperidol inj 2.5mg/ml
droxidopa
NORTHERA CAP 100MG
droxidopa
NORTHERA CAP 200MG
droxidopa
NORTHERA CAP 300MG
eletriptan hydrobromide
RELPAX TAB 20MG
eletriptan hydrobromide
RELPAX TAB 40MG
eliglustat
CERDELGA 84MG
eltrombopag olamine
PROMACTA TAB 12.5MG
eltrombopag olamine
PROMACTA TAB 25MG
eltrombopag olamine
PROMACTA TAB 50MG
eltrombopag olamine
PROMACTA TAB 75MG
enflurane
ETHRANE INH
enfuvirtide
FUZEON INJ 90MG
enfuvirtide
FUZEON KIT
enoxaparin sodium
enoxaparin sodium inj 100mg/ml
enoxaparin sodium
enoxaparin sodium inj 120/0.7
enoxaparin sodium
enoxaparin sodium inj 150mg/ml
enoxaparin sodium
enoxaparin sodium inj 30/0.3ml
enoxaparin sodium
enoxaparin sodium inj 300/3ml
enoxaparin sodium
enoxaparin sodium inj 40/0.4ml
enoxaparin sodium
ENOXAPARIN SODIUM INJ 60/0.6ML
enoxaparin sodium
enoxaparin sodium inj 80/0.8ml
enoxaparin sodium
LOVENOX INJ 100MG/ML
enoxaparin sodium
LOVENOX INJ 120/0.8
enoxaparin sodium
LOVENOX INJ 150MG/ML
enoxaparin sodium
LOVENOX INJ 30/0.3ML
enoxaparin sodium
LOVENOX INJ 300/3ML
enoxaparin sodium
LOVENOX INJ 40/0.4ML
enoxaparin sodium
LOVENOX INJ 80/0.8ML
enzalutamide
XTANDI CAP 40MG
ephedrine-guaifenesin
BRONCHOLATE SYP 6.25-100
epinephrine
epinephrine inj 0.15mg
epinephrine
EPIPEN 2-PAK INJ 0.3MG
epinephrine
EPIPEN-JR 2-PAK INJ 2-PAK
epoetin alfa
EPOGEN INJ 2000/ML
epoetin alfa
EPOGEN INJ 20000/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 21 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
epoetin alfa
PROCRIT INJ 10000/ML
epoetin alfa
PROCRIT INJ 3000/ML
epoetin alfa
PROCRIT INJ 4000/ML
epoetin alfa
PROCRIT INJ 40000/ML
ergoloid mesylates
ergoloid mesylates tab 1mg
ergotamine tartrate
ERGOMAR SUB 2MG
ergotamine-caffeine
ergotamine tartrate-caffeine tab 1/100
ergotamine-caffeine
MIGERGOT SUP 2/100
erlotinib
TARCEVA TAB 100MG
erlotinib
TARCEVA TAB 150MG
erlotinib
TARCEVA TAB 25MG
ertapenem sodium
INVANZ INJ 1GM
erythromycin (ophth)
erythromycin oin op
erythromycin (ophth)
ILOTYCIN OIN OP
erythromycin (ophth)
ROMYCIN OIN OP
estazolam
estazolam tab 1mg
estazolam
estazolam tab 2mg
estramustine phosphate sodium
EMCYT CAP 140MG
eszopiclone
LUNESTA TAB 1MG
eszopiclone
LUNESTA TAB 2MG
eszopiclone
LUNESTA TAB 3MG
etanercept
ENBREL INJ 25/0.5ML
etanercept
ENBREL INJ 25MG
etanercept
ENBREL INJ 50MG/ML
etanercept
ENBREL SURECLICK INJ 50MG/ML
ethambutol hcl
ETHAMBUTOL HCL TAB 100MG
ethambutol hcl
ETHAMBUTOL HCL TAB 400MG
ethambutol hcl
MYAMBUTOL TAB 100MG
ethambutol hcl
MYAMBUTOL TAB 400MG
etomidate
AMIDATE INJ 2MG/ML
etomidate
etomidate inj 2mg/ml
everolimus
AFINITOR DISPERZ TAB 2MG
everolimus
AFINITOR DISPERZ TAB 3MG
everolimus
AFINITOR DISPERZ TAB 5MG
everolimus
AFINITOR TAB 10MG
everolimus
AFINITOR TAB 2.5MG
everolimus
AFINITOR TAB 5MG
everolimus
AFINITOR TAB 7.5MG
factor ix complex
PROFILNINE SD INJ
factor ix complex
PROFILNINE SD INJ 1000UNIT
factor ix complex
PROFILNINE SD INJ 1500UNIT
factor ix complex
PROFILNINE SD INJ 500UNIT
fentanyl
fentanyl dis 100mcg/hr
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 22 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
fentanyl
fentanyl dis 12mcg/hr
fentanyl
fentanyl dis 25mcg/hr
fentanyl
fentanyl dis 50mcg/hr
fentanyl
fentanyl dis 75mcg/hr
fentanyl
SUBSYS SPR 100MCG
fentanyl
SUBSYS SPR 1200MCG
fentanyl
SUBSYS SPR 1600MCG
fentanyl
SUBSYS SPR 200MCG
fentanyl
SUBSYS SPR 400MCG
fentanyl
SUBSYS SPR 600MCG
fentanyl
SUBSYS SPR 800MCG
fentanyl citrate
ABSTRAL SUB 100MCG
fentanyl citrate
ABSTRAL SUB 200MCG
fentanyl citrate
ABSTRAL SUB 300MCG
fentanyl citrate
ABSTRAL SUB 400MCG
fentanyl citrate
ABSTRAL SUB 600MCG
fentanyl citrate
ABSTRAL SUB 800MCG
fentanyl citrate
fentanyl citrate inj 0.05mg/1ml
fentanyl citrate
fentanyl citrate oral transmucosal loz 1200mcg
fentanyl citrate
fentanyl citrate oral transmucosal loz 1600mcg
fentanyl citrate
fentanyl citrate oral transmucosal loz 200mcg
fentanyl citrate
fentanyl citrate oral transmucosal loz 400mcg
fentanyl citrate
fentanyl citrate oral transmucosal loz 600mcg
fentanyl citrate
fentanyl citrate oral transmucosal loz 800mcg
fentanyl citrate
FENTANYL CITRATE POWDER
fentanyl citrate
FENTORA TAB 100MCG
fentanyl citrate
FENTORA TAB 200MCG
fentanyl citrate
FENTORA TAB 300MCG
fentanyl citrate
FENTORA TAB 400MCG
fentanyl citrate
FENTORA TAB 600MCG
fentanyl citrate
FENTORA TAB 800MCG
fentanyl citrate
LAZANDA SPR 100MCG
fentanyl citrate
LAZANDA SPR 400MCG
fentanyl citrate
ONSOLIS MIS 1200MCG
fentanyl citrate
ONSOLIS MIS 200MCG
fentanyl citrate
ONSOLIS MIS 400MCG
fentanyl citrate
ONSOLIS MIS 600MCG
fentanyl citrate
ONSOLIS MIS 800MCG
fexofenadine hcl
ALLEGRA ALLERGY CHILDRENS SUS 30MG/5ML
fexofenadine hcl
ALLEGRA ALLERGY CHILDRENS TAB 30MG
fexofenadine hcl
ALLEGRA ALLERGY TAB 180MG
fexofenadine hcl
ALLEGRA ALLERGY TAB 60MG
fexofenadine hcl
ALLEGRA ODT TAB 30MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 23 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
fexofenadine hcl
ALLEGRA SUS 30MG/5ML
fexofenadine hcl
fexofenadine hcl tab 180mg
fexofenadine hcl
fexofenadine hcl tab 30mg
fexofenadine hcl
fexofenadine hcl tab 60mg
fexofenadine-pseudoephedrine
ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TAB
fexofenadine-pseudoephedrine
ALLEGRA-D 24 HOUR ALLERGY & CONGESTION TAB
fexofenadine-pseudoephedrine
FEXOFENADINE/PSEUDOEPHEDRINE TAB 24 HOUR
fexofenadine-pseudoephedrine
FEXOFENADINE/PSEUDOEPHEDRINE TAB 60-120MG
fidaxomicin
DIFICID TAB 200MG
fingolimod hcl
GILENYA CAP 0.5MG
flavocoxid
LIMBREL CAP 250MG
flavocoxid
LIMBREL CAP 500MG
flavocoxid-citrated zinc bisglycinate
LIMBREL250 CAP 250-50MG
flavocoxid-citrated zinc bisglycinate
LIMBREL500 CAP 500-50MG
fluconazole
DIFLUCAN SUS 10MG/ML
fluconazole
DIFLUCAN SUS 40MG/ML
fluconazole
DIFLUCAN TAB 100MG
fluconazole
DIFLUCAN TAB 150MG
fluconazole
DIFLUCAN TAB 200MG
fluconazole
DIFLUCAN TAB 50MG
fluconazole
fluconazole sus 10mg/ml
fluconazole
fluconazole sus 40mg/ml
fluconazole
fluconazole tab 100mg
fluconazole
fluconazole tab 150mg
fluconazole
fluconazole tab 200mg
fluconazole
fluconazole tab 50mg
fluconazole in dextrose
FLUCONAZOLE IN DEXTROSE INJ 200
fluconazole in dextrose
FLUCONAZOLE IN DEXTROSE INJ 400
fluconazole in nacl
FLUCONAZOLE IN NACL INJ 100
fluconazole in nacl
FLUCONAZOLE IN NACL INJ 200
fluconazole in nacl
FLUCONAZOLE IN NACL INJ 400
flucytosine
ANCOBON CAP 250MG
flucytosine
ANCOBON CAP 500MG
fluorouracil (topical)
CARAC CRE 0.5%
fluorouracil (topical)
EFUDEX CRE 5%
fluorouracil (topical)
EFUDEX OCCLUSION PACK KIT
fluorouracil (topical)
fluoroplex cre 1%
fluorouracil (topical)
fluorouracil cre 0.5%
fluorouracil (topical)
fluorouracil cre 5%
fluorouracil (topical)
fluorouracil sol 2%
fluorouracil (topical)
fluorouracil sol 5%
flurazepam hcl
flurazepam hcl cap 15mg
flurazepam hcl
flurazepam hcl cap 30mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 24 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
follitropin alfa
GONAL-F INJ 1050UNIT
follitropin alfa
GONAL-F INJ 450UNIT
follitropin alfa
GONAL-F RFF INJ 75UNIT
follitropin alfa
GONAL-F RFF PEN INJ 300
follitropin alfa
GONAL-F RFF PEN INJ 450
follitropin alfa
GONAL-F RFF PEN INJ 900
follitropin beta
FOLLISTIM AQ INJ 150UNIT
follitropin beta
FOLLISTIM AQ INJ 300UNIT
follitropin beta
FOLLISTIM AQ INJ 600UNIT
follitropin beta
FOLLISTIM AQ INJ 75UNIT
follitropin beta
FOLLISTIM AQ INJ 900UNIT
fondaparinux sodium
ARIXTRA SOL 10/0.8
fondaparinux sodium
ARIXTRA SOL 2.5/0.5
fondaparinux sodium
ARIXTRA SOL 5.0/0.4
fondaparinux sodium
ARIXTRA SOL 7.5/0.6
fondaparinux sodium
FONDAPARINUX SODIUM SOL 10/0.8
fondaparinux sodium
FONDAPARINUX SODIUM SOL 2.5/0.5
fondaparinux sodium
fondaparinux sodium sol 5.0/0.3
fondaparinux sodium
fondaparinux sodium sol 7.5/0.5
foscarnet sodium
FOSCARNET SODIUM INJ 24MG/ML
fosfomycin tromethamine
MONUROL PAK GRANULES
frovatriptan succinate
FROVA TAB 2.5MG
fulvestrant
FASLODEX INJ 250MG
gabapentin (phn)
GRALISE STARTER MIS 300/600
gabapentin (phn)
GRALISE TAB 300MG
gabapentin (phn)
GRALISE TAB 600MG
ganciclovir ophthalmic
ZIRGAN GEL 0.15%
ganciclovir sodium
CYTOVENE INJ 500MG
ganirelix acetate
GANIRELIX ACETATE INJ
gatifloxacin (ophth)
ZYMAXID SOL 0.5%
gefitinib
IRESSA TAB 250MG
gemifloxacin mesylate
FACTIVE TAB 320MG
gentamicin in saline
gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml
gentamicin sulfate (ophth)
garamycin oin 0.3% op
gentamicin sulfate (ophth)
GARAMYCIN SOL 0.3% OP
gentamicin sulfate (ophth)
genoptic sol 0.3% op
gentamicin sulfate (ophth)
gentak oin 0.3% op
gentamicin sulfate (ophth)
gentamicin sulfate oin 0.3% op
gentamicin sulfate (ophth)
gentamicin sulfate sol 0.3% op
gentamicin-prednisolone acetate
PRED-G S.O.P. OIN OP
gentamicin-prednisolone acetate
PRED-G SUS OP
glatiramer acetate
COPAXONE INJ 40MG/ML
glatiramer acetate
COPAXONE KIT 20MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 25 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
glycerol phenylbutyrate
RAVICTI LIQ 1.1GM/ML
golimumab
SIMPONI ARIA 50MG/4ML
golimumab
SIMPONI INJ 100MG
golimumab
SIMPONI INJ 50MG
griseofulvin microsize
GRIFULVIN V TAB 500MG
griseofulvin microsize
griseofulvin microsize sus 125/5ml
griseofulvin microsize
griseofulvin microsize tab micr 500
griseofulvin ultramicrosize
griseofulvin ultramicrosi ze tab ultr 125
griseofulvin ultramicrosize
griseofulvin ultramicrosi ze tab ultr 250
griseofulvin ultramicrosize
GRIS-PEG TAB 125MG
griseofulvin ultramicrosize
GRIS-PEG TAB 250MG
guaifenesin-chlorpheniramine maleate
ALLFEN A TAB 400-4MG
guaifenesin-codeine
ALLFEN CD TAB 400-10MG
guaifenesin-codeine
ALLFEN CDX LIQ
guaifenesin-codeine
ALLFEN CDX TAB 400-20MG
guaifenesin-codeine
BRONTEX LIQ
guaifenesin-codeine
BRONTEX TAB
guaifenesin-codeine
dex-tuss liq
guaifenesin-codeine
guaifenesin ac syp ac
guaifenesin-codeine
MAR-COF CG EXPECTORANT LIQ
guaifenesin-codeine
m-clear wc liq
guaifenesin-codeine
PRO-CLEAR CAP 200-9MG
guaifenesin-codeine
TUSSO-C LIQ 200-10MG
hydrocodone bitartrate
HYSINGLA ER TAB 100 MG
hydrocodone bitartrate
HYSINGLA ER TAB 120 MG
hydrocodone bitartrate
HYSINGLA ER TAB 20 MG
hydrocodone bitartrate
HYSINGLA ER TAB 30 MG
hydrocodone bitartrate
HYSINGLA ER TAB 40 MG
hydrocodone bitartrate
HYSINGLA ER TAB 60 MG
hydrocodone bitartrate
HYSINGLA ER TAB 80 MG
hydrocodone bitartrate
ZOHYDRO ER CAP 10MG
hydrocodone bitartrate
ZOHYDRO ER CAP 15MG
hydrocodone bitartrate
ZOHYDRO ER CAP 20MG
hydrocodone bitartrate
ZOHYDRO ER CAP 30MG
hydrocodone bitartrate
ZOHYDRO ER CAP 40MG
hydrocodone bitartrate
ZOHYDRO ER CAP 50MG
hydrocodone polistirex-chlorpheniramine polistirex
hydrocodone polistirex and chlorpheniramine polistir liq
hydrocodone polistirex-chlorpheniramine polistirex
TUSSICAPS CAP 10-8MG
hydrocodone polistirex-chlorpheniramine polistirex
TUSSICAPS CAP 5-4MG
hydrocodone polistirex-chlorpheniramine polistirex
TUSSIONEX PENNKINETIC EXTENDED RELEASE SUS
hydrocodone w/ homatropine
hydrocodone bit/homatropine methylbrom syp 5-1.5/5
hydrocodone w/ homatropine
HYDROMET SYP 5-1.5/5
hydrocodone w/ homatropine
TUSSIGON TAB 5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 26 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
hydrocodone-acetaminophen
HYCET SOL 7.5-325
hydrocodone-acetaminophen
HYDROCODONE BITART-ACETAMINOPHEN TAB 2.5-325
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen sol
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen sol 5-217/10mg
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen sol 7.5-325mg
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen tab 10-300mg
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen tab 10-750mg
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen tab 5-300mg
hydrocodone-acetaminophen
hydrocodone bitartrate-acetaminophen tab 7.5-300mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen sol
hydrocodone-acetaminophen
HYDROCODONE-ACETAMINOPHEN SOL 10-325MG
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 10-325mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 10-500mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 10-650mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 10-660mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 2.5-500mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 5-325mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 5-500mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 7.5-325mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 7.5-500mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 7.5-650mg
hydrocodone-acetaminophen
hydrocodone-acetaminophen tab 7.5-750mg
hydrocodone-acetaminophen
stagesic cap 500-5mg
hydrocodone-acetaminophen
ZAMICET SOL 10-325MG
hydrocodone-acetaminophen
ZOLVIT SOL 10-300MG
hydrocodone-acetaminophen
ZYDONE TAB 10-400MG
hydrocodone-acetaminophen
ZYDONE TAB 5-400MG
hydrocodone-acetaminophen
ZYDONE TAB 7.5-400MG
hydrocodone-acetaminophen-dietary management product
THERACODOPHEN-325 PAK
hydrocodone-acetaminophen-dietary management product
THERACODOPHEN-650 PAK
hydrocodone-acetaminophen-dietary management product
THERACODOPHEN-LOW-90 PAK
hydrocodone-chlorpheniramine
VITUZ SOL 5-4MG
hydrocodone-guaifenesin
OBREDON SOL
hydrocodone-homatropine
hydromet syp 5-1.5/5
hydrocodone-homatropine
tussigon tab 5mg
hydrocodone-ibuprofen
hydrocodone-ibuprofen tab 7.5-200
hydrocodone-ibuprofen
IBUDONE TAB 10-200MG
hydrocodone-ibuprofen
REPREXAIN TAB 2.5-200
hydrocodone-ibuprofen
REPREXAIN TAB 5-200MG
hydrocodone-ibuprofen
VICOPROFEN TAB
hydrocortisone w/acetic acid
ACETASOL HC SOL OTIC
hydrocortisone w/acetic acid
HYDROCORTISONE/ACETIC ACID SOL OTIC
hydrocortisone w/acetic acid
VOSOL HC SOL OTIC
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 27 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
hydromorphone hcl
DILAUDID INJ 1MG/ML
hydromorphone hcl
DILAUDID INJ 2MG/ML
hydromorphone hcl
DILAUDID INJ 4MG/ML
hydromorphone hcl
DILAUDID LIQ 1MG/ML
hydromorphone hcl
DILAUDID TAB 2MG
hydromorphone hcl
DILAUDID TAB 4MG
hydromorphone hcl
DILAUDID TAB 8MG
hydromorphone hcl
DILAUDID-5 LIQ 1MG/ML
hydromorphone hcl
DILAUDID-HP INJ 10MG/ML
hydromorphone hcl
DILAUDID-HP INJ 10MG/ML
hydromorphone hcl
DILAUDID-HP INJ 250MG
hydromorphone hcl
DILAUDID-HP INJ 250MG
hydromorphone hcl
EXALGO TAB 12MG
hydromorphone hcl
EXALGO TAB 16MG
hydromorphone hcl
EXALGO TAB 32MG
hydromorphone hcl
EXALGO TAB 8MG
hydromorphone hcl
HYDROMORPHONE HCL DOSETTE INJ 2MG/ML
hydromorphone hcl
HYDROMORPHONE HCL ER TAB 32MG ER
hydromorphone hcl
HYDROMORPHONE HCL INJ 1MG/ML
hydromorphone hcl
hydromorphone hcl inj 2mg/ml
hydromorphone hcl
HYDROMORPHONE HCL INJ 2MG/ML
hydromorphone hcl
hydromorphone hcl inj 4mg/ml
hydromorphone hcl
HYDROMORPHONE HCL INJ 4MG/ML
hydromorphone hcl
hydromorphone hcl inj 500/50ml
hydromorphone hcl
HYDROMORPHONE HCL SUP 3MG
hydromorphone hcl
hydromorphone hcl tab 2mg
hydromorphone hcl
hydromorphone hcl tab 4mg
hydromorphone hcl
hydromorphone hcl tab 8mg
hydromorphone hcl-sodium chloride
HYDROMORPHONE-SODIUM CHLORIDE INJ /NACL
hydroxyprogesterone caproate
MAKENA INJ 250MG/ML
ibrutinib
IMBRUVICA CAP 140MG
icatibant acetate
FIRAZYR INJ 30MG/3ML
idelalisib
ZYDELIG TAB 100MG
idelalisib
ZYDELIG TAB 150MG
iloprost
VENTAVIS SOL 10MCG/ML
iloprost
VENTAVIS SOL 20MCG/ML
imatinib mesylate
GLEEVEC TAB 100MG
imatinib mesylate
GLEEVEC TAB 400MG
imiglucerase
CEREZYME INJ 200UNIT
imiglucerase
CEREZYME INJ 400UNIT
imiquimod
ALDARA CRE 5%
imiquimod
imiquimod cre 5%
imiquimod
ZYCLARA CRE 3.75%
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 28 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
imiquimod
ZYCLARA PUMP CRE 2.5%
infliximab
REMICADE INJ 100MG
interferon alfa-2b
INTRON-A INJ 10MU PEN
interferon alfa-2b
INTRON-A INJ 18MU
interferon alfa-2b
INTRON-A INJ 25MU
interferon alfa-2b
INTRON-A INJ 3MU PEN
interferon alfa-2b
INTRON-A INJ 5MU PEN
interferon alfa-2b
INTRON-A W/DILUENT INJ 10MU
interferon alfa-2b
INTRON-A W/DILUENT INJ 18MU
interferon alfa-2b
INTRON-A W/DILUENT INJ 50MU
interferon alfacon-1
INFERGEN INJ 15MCG
interferon alfacon-1
INFERGEN INJ 9MCG
interferon beta-1a
AVONEX KIT 30MCG
interferon beta-1a
AVONEX PEN KIT 30MCG
interferon beta-1a
REBIF INJ 22/0.5
interferon beta-1a
REBIF INJ 44/0.5
interferon beta-1a
REBIF REBIDOSE INJ 22/0.5
interferon beta-1a
REBIF REBIDOSE INJ 44/0.5
interferon beta-1a
REBIF REBIDOSE TITRATION PACK SOL
interferon beta-1a
REBIF TITRATION PACK SOL PACK
interferon beta-1b
BETASERON INJ 0.3MG
interferon beta-1b
EXTAVIA INJ 0.3MG
interferon gamma-1b
ACTIMMUNE INJ 2MU/0.5
iodine strong (lugol's)
IODINE STRONG SOL STRONG
isoflurane
FORANE SOL
isoniazid
ISONIAZID INJ 100MG/ML
isoniazid
ISONIAZID SYR 50MG/5ML
isoniazid
isoniazid tab 100mg
isoniazid
isoniazid tab 300mg
isoniazid & rifampin
RIFAMATE CAP
isoniazid-rifampin w/ pyrazinamide
RIFATER TAB
itraconazole
ONMEL TAB 200MG
itraconazole
SPORANOX SOL 10MG/ML
ivacaftor
KALYDECO TAB 150MG
ivermectin
STROMECTOL TAB 3MG
ketamine hcl
KETALAR INJ 100MG/ML
ketamine hcl
KETALAR INJ 10MG/ML
ketamine hcl
KETALAR INJ 50MG/ML
ketamine hcl
ketamine hcl inj 100mg/ml
ketamine hcl
ketamine hcl inj 10mg/ml
ketamine hcl
ketamine hcl inj 50mg/ml
ketoconazole
KETOCONAZOLE TAB 200MG
lanreotide acetate
SOMATULINE DEPOT INJ 120/.5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 29 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
lanreotide acetate
SOMATULINE DEPOT INJ 60/0.2ML
lanreotide acetate
SOMATULINE DEPOT INJ 90/0.3ML
lapatinib ditosylate
TYKERB TAB 250MG
ledipasvir/sofosbuvir
HARVONI TAB 90-400MG
lenalidomide
REVLIMID CAP 10MG
lenalidomide
REVLIMID CAP 15MG
lenalidomide
REVLIMID CAP 2.5MG
lenalidomide
REVLIMID CAP 20MG
lenalidomide
REVLIMID CAP 25MG
lenalidomide
REVLIMID CAP 5MG
lenvatinib mesylate
LENVIMA 10MG DAILY DOSE CAP 10MG
lenvatinib mesylate
LENVIMA 14MG DAILY DOSE CAP 14MG
lenvatinib mesylate
LENVIMA 20MG DAILY DOSE CAP 20MG
lenvatinib mesylate
LENVIMA 24MG DAILY DOSE CAP 24MG
levocetirizine dihydrochloride
levocetirizine dihydrochloride tab 5mg
levocetirizine dihydrochloride
XYZAL SOL
levocetirizine dihydrochloride
XYZAL 5MG TAB
levofloxacin
LEVAQUIN SOL 25MG/ML
levofloxacin
LEVAQUIN TAB 250MG
levofloxacin
LEVAQUIN TAB 500MG
levofloxacin
LEVAQUIN TAB 750MG
levofloxacin
LEVOFLOXACIN INJ 25MG/ML
levofloxacin
LEVOFLOXACIN SOL 25MG/ML
levofloxacin
levofloxacin tab 250mg
levofloxacin
levofloxacin tab 500mg
levofloxacin
levofloxacin tab 750mg
levofloxacin (ophth)
levofloxacin sol 0.5%
levofloxacin (ophth)
QUIXIN SOL 0.5%
levofloxacin in d5w
LEVAQUIN INJ 500/100ML
levofloxacin in d5w
LEVAQUIN INJ 750/150ML
levofloxacin in d5w
LEVOFLOXACIN IN D5W INJ 250/50ML
levofloxacin in d5w
LEVOFLOXACIN IN D5W INJ 500/100ML
levofloxacin in d5w
LEVOFLOXACIN IN D5W INJ 750/150ML
levorphanol tartrate
LEVO DROMORAN INJ 2MG/ML
levorphanol tartrate
LEVORPHANOL TARTRATE TAB 2MG
linezolid
ZYVOX SOL 2MG/ML
linezolid
ZYVOX SUS 100MG/5M
linezolid
ZYVOX TAB 600MG
lisdexamfetamine dimesylate
VYVANSE CAP 20MG
lisdexamfetamine dimesylate
VYVANSE CAP 30MG
lisdexamfetamine dimesylate
VYVANSE CAP 40MG
lisdexamfetamine dimesylate
VYVANSE CAP 50MG
lisdexamfetamine dimesylate
VYVANSE CAP 60MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 30 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
lisdexamfetamine dimesylate
VYVANSE CAP 70MG
l-methylfolate-algae
DEPLIN 15 CAP
l-methylfolate-algae
L-METHYLFOLATE FORTE CAP FORTE
lomitapide mesylate
JUXTAPID CAP 10MG
lomitapide mesylate
JUXTAPID CAP 20MG
lomitapide mesylate
JUXTAPID CAP 5MG
lorazepam
ATIVAN INJ 2MG/ML
lorazepam
ATIVAN INJ 4MG/ML
lorazepam
ATIVAN TAB 0.5MG
lorazepam
ATIVAN TAB 1MG
lorazepam
ATIVAN TAB 2MG
lorazepam
lorazepam inj 2mg/ml
lorazepam
lorazepam inj 4mg/ml
lorazepam
LORAZEPAM INTENSOL CON 2MG/ML
lorazepam
lorazepam tab 0.5mg
lorazepam
lorazepam tab 1mg
lorazepam
lorazepam tab 2mg
lutropin alfa
LUVERIS INJ 75UNIT
macitentan
OPSUMIT TAB 10MG
mecamylamine hcl
VECAMYL TAB 2.5MG
mecasermin
INCRELEX INJ 40MG/4ML
mecasermin rinfabate (rdna)
IPLEX INJ 36/0.6ML
Mechlorethamine hcl (topical)
VALCHLOR GEL 0.016%
mefloquine hcl
mefloquine hcl tab 250mg
menotropins
MENOPUR INJ 75UNIT
menotropins
REPRONEX INJ 75UNIT
meperidine hcl
DEMEROL INJ 100/2ML
meperidine hcl
DEMEROL INJ 100MG/ML
meperidine hcl
DEMEROL INJ 25MG/0.5ML
meperidine hcl
DEMEROL INJ 25MG/ML
meperidine hcl
DEMEROL INJ 50MG/ML
meperidine hcl
DEMEROL INJ 75MG/1.5ML
meperidine hcl
DEMEROL INJ 75MG/ML
meperidine hcl
meperidine hcl inj 100mg/ml
meperidine hcl
meperidine hcl inj 10mg/ml
meperidine hcl
meperidine hcl inj 25mg/ml
meperidine hcl
meperidine hcl inj 50mg/ml
meperidine hcl
meperidine hcl inj 75mg/ml
meperidine hcl
MEPERIDINE HCL SOL 50MG/5ML
meperidine hcl
meperidine hcl tab 50mg
meperidine hcl
meperitab tab 100mg
meperidine-promethazine
meperidine/promethazine cap
mephobarbital
MEBARAL TAB 100MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 31 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
mephobarbital
MEBARAL TAB 32MG
mephobarbital
MEBARAL TAB 50MG
meprobamate
meprobamate tab 200mg
meprobamate
meprobamate tab 400mg
meprobamate-aspirin
EQUAGESIC TAB 200-325
methadone hcl
DOLOPHINE HCL TAB 5MG
methadone hcl
DOLOPHINE TAB 10MG
methadone hcl
METHADONE HCL INJ 10MG/ML
methadone hcl
METHADONE HCL SOL 10MG/5ML
methadone hcl
METHADONE HCL SOL 5MG/5ML
methadone hcl
methadone hcl tab 10mg
methadone hcl
methadone hcl tab 5mg
methadone hcl
METHADOSE CON 10MG/ML
methadone hcl
METHADOSE SUGAR-FREE CON 10MG/ML
methadone hcl
METHADOSE TAB 40MG
methamphetamine hcl
DESOXYN TAB 5MG
methohexital sodium
BREVITAL SODIUM INJ 2.5GM
methohexital sodium
BREVITAL SODIUM INJ 200MG
methohexital sodium
BREVITAL SODIUM INJ 500MG
methylphenidate
DAYTRANA DIS 10MG/9HR
methylphenidate
DAYTRANA DIS 15MG/9HR
methylphenidate
DAYTRANA DIS 20MG/9HR
methylphenidate
DAYTRANA DIS 30MG/9HR
methylphenidate hcl
CONCERTA TAB 18MG
methylphenidate hcl
CONCERTA TAB 27MG
methylphenidate hcl
CONCERTA TAB 36MG
methylphenidate hcl
CONCERTA TAB 54MG
methylphenidate hcl
METADATE CD CAP 10MG
methylphenidate hcl
METADATE CD CAP 20MG
methylphenidate hcl
METADATE CD CAP 30MG
methylphenidate hcl
METADATE CD CAP 40MG
methylphenidate hcl
METADATE CD CAP 50MG
methylphenidate hcl
METADATE CD CAP 60MG
methylphenidate hcl
METHYLIN CHW 10MG
methylphenidate hcl
METHYLIN CHW 2.5MG
methylphenidate hcl
METHYLIN CHW 5MG
methylphenidate hcl
METHYLIN SOL 10MG/5ML
methylphenidate hcl
METHYLIN SOL 5MG/5ML
methylphenidate hcl
methylphenidate hcl cd cap 10mg
methylphenidate hcl
methylphenidate hcl cd cap 20mg
methylphenidate hcl
methylphenidate hcl cd cap 30mg
methylphenidate hcl
methylphenidate hcl cd cap 40mg
methylphenidate hcl
methylphenidate hcl cd cap 50mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 32 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
methylphenidate hcl
methylphenidate hcl cd cap 60mg
methylphenidate hcl
METHYLPHENIDATE HCL ER TAB 10MG
methylphenidate hcl
methylphenidate hcl er tab 18mg
methylphenidate hcl
methylphenidate hcl er tab 20mg
methylphenidate hcl
methylphenidate hcl er tab 27mg
methylphenidate hcl
methylphenidate hcl er tab 36mg
methylphenidate hcl
methylphenidate hcl er tab 54mg
methylphenidate hcl
methylphenidate hcl tab 10mg
methylphenidate hcl
methylphenidate hcl tab 20mg
methylphenidate hcl
methylphenidate hcl tab 5mg
methylphenidate hcl
methylphenidate hydrochloride sol 10mg/5ml
methylphenidate hcl
methylphenidate hydrochloride sol 5mg/5ml
methylphenidate hcl
QUILLIVANT XR SUS XR
methylphenidate hcl
RITALIN LA CAP 10MG
methylphenidate hcl
RITALIN LA CAP 20MG
methylphenidate hcl
RITALIN LA CAP 30MG
methylphenidate hcl
RITALIN LA CAP 40MG
methylphenidate hcl
RITALIN TAB 10MG
methylphenidate hcl
RITALIN TAB 20MG
methylphenidate hcl
RITALIN TAB 5MG
methylprednisolone
MEDROL DOSEPAK PAK 4MG
methylprednisolone
MEDROL TAB 16MG
methylprednisolone
MEDROL TAB 2MG
methylprednisolone
MEDROL TAB 32MG
methylprednisolone
MEDROL TAB 4MG
methylprednisolone
MEDROL TAB 8MG
methylprednisolone
methylprednisolone dose pack pak 4mg
methylprednisolone
methylprednisolone tab 16mg
methylprednisolone
methylprednisolone tab 32mg
methylprednisolone
methylprednisolone tab 4mg
methylprednisolone
methylprednisolone tab 8mg
methylprednisolone acetate & bupivacaine hcl
PHYSICIANS EZ USE M-PRED KIT
metreleptin
MYALEPT INJ 11.3MG
metyrosine
DEMSER CAP 250MG
micafungin sodium
MYCAMINE INJ 100MG
micafungin sodium
MYCAMINE INJ 50MG
miconazole (mouth-throat)
ORAVIG TAB 50MG
midazolam hcl
midazolam hcl inj 10mg/2ml
midazolam hcl
midazolam hcl inj 1mg/ml
midazolam hcl
midazolam hcl inj 2mg/2ml
midazolam hcl
midazolam hcl inj 5mg/5ml
midazolam hcl
midazolam hcl inj 5mg/ml
midazolam hcl
midazolam hcl syp 2mg/ml
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 33 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
mifepristone (hyperglycemia)
KORLYM TAB 300MG
miglustat
ZAVESCA CAP 100MG
mipomersen sodium
KYNAMRO INJ 200MG/ML
mitomycin (ophthalmic)
MITOSOL KIT 0.2MG
mitotane
LYSODREN TAB 500MG
modafanil
MODAFINIL TAB 100MG
modafanil
MODAFINIL TAB 200MG
modafinil
PROVIGIL TAB 100MG
modafinil
PROVIGIL TAB 200MG
morphine sulfate
duramorph inj 0.5mg/ml
morphine sulfate
duramorph inj 1mg/ml
morphine sulfate
KADIAN CAP 100MG CR
morphine sulfate
KADIAN CAP 10MG CR
morphine sulfate
KADIAN CAP 130MG CR
morphine sulfate
KADIAN CAP 150MG CR
morphine sulfate
KADIAN CAP 200MG CR
morphine sulfate
KADIAN CAP 20MG CR
morphine sulfate
KADIAN CAP 30MG CR
morphine sulfate
KADIAN CAP 40MG CR
morphine sulfate
KADIAN CAP 50MG CR
morphine sulfate
KADIAN CAP 60MG CR
morphine sulfate
KADIAN CAP 70MG CR
morphine sulfate
KADIAN CAP 80MG CR
morphine sulfate
morphine sulfate dilute-a-jet inj 25mg/ml
morphine sulfate
morphine sulfate er cap 100mg
morphine sulfate
morphine sulfate er cap 20mg
morphine sulfate
morphine sulfate er cap 30mg
morphine sulfate
morphine sulfate er cap 50mg
morphine sulfate
morphine sulfate er cap 60mg
morphine sulfate
morphine sulfate er cap 80mg
morphine sulfate
morphine sulfate er tab 100mg
morphine sulfate
morphine sulfate er tab 15mg
morphine sulfate
morphine sulfate er tab 200mg
morphine sulfate
morphine sulfate er tab 30mg
morphine sulfate
morphine sulfate er tab 60mg
morphine sulfate
morphine sulfate inj 0.5mg/ml
morphine sulfate
MORPHINE SULFATE INJ 10/0.7ML
morphine sulfate
morphine sulfate inj 10mg/ml
morphine sulfate
MORPHINE SULFATE INJ 10MG/ML
morphine sulfate
MORPHINE SULFATE INJ 150/30ML
morphine sulfate
morphine sulfate inj 15mg/ml
morphine sulfate
morphine sulfate inj 1mg/ml
morphine sulfate
morphine sulfate inj 25mg/ml
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 34 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
morphine sulfate
MORPHINE SULFATE INJ 25MG/ML
morphine sulfate
MORPHINE SULFATE INJ 2MG/ML
morphine sulfate
MORPHINE SULFATE INJ 2MG/ML
morphine sulfate
MORPHINE SULFATE INJ 4MG/ML
morphine sulfate
MORPHINE SULFATE INJ 4MG/ML
morphine sulfate
morphine sulfate inj 50mg/ml
morphine sulfate
MORPHINE SULFATE INJ 50MG/ML
morphine sulfate
MORPHINE SULFATE INJ 5MG/ML
morphine sulfate
MORPHINE SULFATE INJ 5MG/ML
morphine sulfate
morphine sulfate inj 8mg/ml
morphine sulfate
MORPHINE SULFATE INJ 8MG/ML
morphine sulfate
morphine sulfate sol 10/0.5ml
morphine sulfate
MORPHINE SULFATE SOL 10MG/5ML
morphine sulfate
MORPHINE SULFATE SOL 20MG/5ML
morphine sulfate
morphine sulfate sol 20mg/ml
morphine sulfate
morphine sulfate sol 5/0.25ml
morphine sulfate
MORPHINE SULFATE SUP 10MG
morphine sulfate
MORPHINE SULFATE SUP 20MG
morphine sulfate
MORPHINE SULFATE SUP 30MG
morphine sulfate
MORPHINE SULFATE SUP 5MG
morphine sulfate
MORPHINE SULFATE TAB 10MG
morphine sulfate
morphine sulfate tab 15mg
morphine sulfate
MORPHINE SULFATE TAB 30MG
morphine sulfate beads
AVINZA CAP 120MG
morphine sulfate beads
AVINZA CAP 30MG
morphine sulfate beads
AVINZA CAP 45MG
morphine sulfate beads
AVINZA CAP 60MG
morphine sulfate beads
AVINZA CAP 75MG
morphine sulfate beads
AVINZA CAP 90MG
morphine sulfate for continuous microinfusion
INFUMORPH 200 INJ 10MG/ML
morphine sulfate for continuous microinfusion
INFUMORPH 500 INJ 25MG/ML
morphine sulfate in dextrose
MORPHINE SULF IN DEXTROSE 5% INJ 1MG/ML
morphine sulfate liposome
DEPODUR INJ 10MG/ML
morphine sulfate liposome
DEPODUR INJ 15/1.5ML
morphine-naltrexone
EMBEDA CAP 100-4MG
morphine-naltrexone
EMBEDA CAP 20-0.8MG
morphine-naltrexone
EMBEDA CAP 30-1.2MG
morphine-naltrexone
EMBEDA CAP 50-2MG
morphine-naltrexone
EMBEDA CAP 60-2.4MG
morphine-naltrexone
EMBEDA CAP 80-3.2MG
moxifloxacin hcl
AVELOX ABC PACK TAB 400MG
moxifloxacin hcl
AVELOX TAB 400MG
moxifloxacin hcl
moxifloxacin hcl tab 400mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 35 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
moxifloxacin hcl (ophth)
MOXEZA SOL 0.5%
moxifloxacin hcl (ophth)
VIGAMOX DRO 0.5%
moxifloxacin hcl in sodium chloride
AVELOX INJ
nafarelin acetate
SYNAREL SOL 2MG/ML
nafcillin sodium
NAFCILLIN SODIUM INJ 1GM
nafcillin sodium
NAFCILLIN SODIUM INJ 2GM
nafcillin sodium in dextrose
NALLPEN ISO-OSMOTIC IN DEXTROSE INJ 2GM/100
nafcillin sodium in dextrose
NALLPEN/DEXTROSE INJ 1GM/50ML
nalbuphine hcl
nalbuphine hcl inj 10mg/ml
nalbuphine hcl
nalbuphine hcl inj 20mg/ml
nalmefene hcl
REVEX INJ 100MCG
nalmefene hcl
REVEX INJ 1MG/ML
naloxone hcl
DEPADE TAB 50MG
naloxone hcl
EVZIO INJ
naloxone hcl
NALOXONE HCL INJ 0.4MG/ML
naloxone hcl
naloxone hcl inj 1mg/ml
naloxone hcl
REVIA TAB 50MG
naloxone hcl-bupropion hcl
CONTRAVE TAB 8-90MG
naltrexone
VIVITROL INJ 380MG
naltrexone hcl
naltrexone hcl tab 50mg
naproxen-esomeprazole magnesium
VIMOVO TAB 375-20MG
naproxen-esomeprazole magnesium
VIMOVO TAB 500-20MG
naratriptan hcl
naratriptan hcl tab 1mg
naratriptan hcl
naratriptan hcl tab 2.5mg
natamycin
NATACYN SUS 5% OP
neomycin-bacitracin zn-polymyxin
neomycin/polymyxin/bacitracin zinc oin op
neomycin-bacitracin zn-polymyxin
NEO-POLYCIN OIN OP
neomycin-colistin-hc-thonzonium
COLY-MYCIN S SUS OTIC
neomycin-colistin-hc-thonzonium
CORTISPORIN-TC SUS -TC OTIC
neomycin-polymy-dexameth
DEXASPORIN SUS 0.1% OP
neomycin-polymy-dexameth
MAXITROL OIN 0.1% OP
neomycin-polymy-dexameth
MAXITROL SUS 0.1% OP
neomycin-polymy-dexameth
neomycin/polymyxin/dexamethasone oin 0.1% op
neomycin-polymy-dexameth
neomycin/polymyxin/dexamethasone sus 0.1% op
neomycin-polymy-dexameth
POLY-DEX OIN 0.1% OP
neomycin-polymy-dexameth
POLY-DEX SUS 0.1% OP
neomycin-polymy-gramicid
OCUTRICIN SOL OP
neomycin-polymyxin-gramicidin
NEOSPORIN SOL OP
neomycin-polymyxin-hc
OTIMAR SOL 1% OTIC
neomycin-polymyxin-hc
OTIMAR SUS 1% OTIC
neomycin-polymyxin-hc (ophth)
CORTISPORIN SUS 1% OP
neomycin-polymyxin-hc (ophth)
neomycin/polymyxin/hydrocortisone sus op
neomycin-polymyxin-hc (otic)
CORTISPORIN SOL 1% OTIC
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 36 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
neomycin-polymyxin-hc (otic)
CORTISPORIN SUS 1% OTIC
neomycin-polymyxin-hc (otic)
CORTOMYCIN SOL 1% OTIC
neomycin-polymyxin-hc (otic)
CORTOMYCIN SUS 1% OTIC
neomycin-polymyxin-hc (otic)
neomycin/polymyxin/hc sol 1% otic
neomycin-polymyxin-hc (otic)
neomycin/polymyxin/hydrocortisone sus 1% otic
neomycin-polymyxin-hc (otic)
OTICIN HC SUS 1% OTIC
neomycin-polymyxin-hc (otic)
PEDIOTIC SUS 1% OTIC
neomycin-polymyx-pred acetate
POLY-PRED SUS OP
netupitant-palonosetron
AKYNZEO CAP
nicotine
nicotine transdermal system dis 14mg/24h
nicotine
nicotine transdermal system dis 21mg/24h
nicotine
nicotine transdermal system dis 7mg/24hr
nicotine
NICOTINE TRANSDERMAL SYSTEM KIT
nicotine
NICOTROL INHALER INH
nicotine
NICOTROL NS SPR 10MG/ML
nicotine polacrilex
COMMIT LOZ 4MG
nicotine polacrilex
NICORETTE LOZ 2MG
nicotine polacrilex
nicotine polacrilex gum 2mg orig
nicotine polacrilex
nicotine polacrilex gum 4mg
nilotinib
TASIGNA CAP 150MG
nilotinib
TASIGNA CAP 200MG
nintedanib esylate
OFEV CAP 100MG
nintedanib esylate
OFEV CAP 150MG
nitisinone
ORFADIN CAP 10MG
nitisinone
ORFADIN CAP 2MG
nitisinone
ORFADIN CAP 5MG
nystatin
BIO-STATIN CAP 1000000
nystatin
BIO-STATIN CAP 500000
nystatin
nystatin tab 500000
nystatin (mouth-throat)
nystatin sus 100000
obinutuzumab
GAZYVA INJ 25MG/ML
octreotide acetate
SANDOSTATIN LAR DEPOT KIT 10MG
octreotide acetate
SANDOSTATIN LAR DEPOT KIT 20MG
octreotide acetate
SANDOSTATIN LAR DEPOT KIT 30MG
ofloxacin
ofloxacin tab 400mg
ofloxacin (ophth)
OCUFLOX DRO 0.3% OP
ofloxacin (ophth)
ofloxacin dro 0.3% op
ofloxacin (otic)
FLOXIN OTIC DRO 0.3%
ofloxacin (otic)
FLOXIN OTIC SINGLES DRO SINGLES
ofloxacin (otic)
ofloxacin dro 0.3% otic
olaparib
LYNPARZA CAP 50MG
omacetaxine mepesuccinate
SYNRIBO INJ 3.5MG
omalizumab
XOLAIR SOL 150MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 37 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
ombitasvir-paritaprevir-ritonavir & dasabuvir
VIEKIRA PAK TAB
ondansetron
ondansetron odt tab 4mg odt
ondansetron
ondansetron
ondansetron odt tab 8mg odt
ZOFRAN ODT TAB 4MG ODT
ondansetron
ZOFRAN ODT TAB 8MG ODT
ondansetron
ZUPLENZ MIS 4MG
ondansetron
ZUPLENZ MIS 8MG
ondansetron
ondansetron hcl sol 4mg/5ml
ondansetron
ondansetron hcl tab 24mg
ondansetron
ondansetron hcl tab 4mg
ondansetron
ondansetron hcl tab 8mg
ondansetron hcl
ZOFRAN INJ 40/20ML
ondansetron hcl
ZOFRAN SOL 4MG/5ML
ondansetron hcl
ZOFRAN TAB 4MG
ondansetron hcl
ZOFRAN TAB 8MG
orphenadrine-aspirin-caffeine
ORPHENADRINE COMPOUND DS TAB
orphenadrine-aspirin-caffeine
orphenadrine/aspirin/caffeine tab
oseltamivir phosphate
TAMIFLU CAP 30MG
oseltamivir phosphate
TAMIFLU CAP 45MG
oseltamivir phosphate
TAMIFLU CAP 75MG
oseltamivir phosphate
TAMIFLU SUS 6MG/ML
oxacillin sodium
OXACILLIN SODIUM INJ 10GM
oxacillin sodium
OXACILLIN SODIUM INJ 1GM
oxacillin sodium
OXACILLIN SODIUM INJ 2GM
oxacillin sodium in dextrose
BACTOCILL IN DEXTROSE INJ 1GM
oxacillin sodium in dextrose
BACTOCILL IN DEXTROSE INJ 2GM
oxazepam
oxazepam cap 10mg
oxazepam
oxazepam cap 15mg
oxazepam
oxazepam cap 30mg
oxazepam
SERAX TAB 15MG
oxycodone hcl
DAZIDOX TAB 10MG
oxycodone hcl
eth-oxydose con 20mg/ml
oxycodone hcl
OXECTA TAB 5MG
oxycodone hcl
OXECTA TAB 7.5MG
oxycodone hcl
OXYCODONE HCL CAP 5MG
oxycodone hcl
oxycodone hcl con 20mg/ml
oxycodone hcl
oxycodone hcl sol 5mg/5ml
oxycodone hcl
oxycodone hcl tab 10mg
oxycodone hcl
oxycodone hcl tab 15mg
oxycodone hcl
OXYCODONE HCL TAB 20MG
oxycodone hcl
oxycodone hcl tab 30mg
oxycodone hcl
oxycodone hcl tab 5mg
oxycodone hcl
OXYCONTIN TAB 10MG CR
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 38 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
oxycodone hcl
OXYCONTIN TAB 15MG CR
oxycodone hcl
OXYCONTIN TAB 20MG CR
oxycodone hcl
OXYCONTIN TAB 30MG CR
oxycodone hcl
OXYCONTIN TAB 40MG CR
oxycodone hcl
OXYCONTIN TAB 60MG CR
oxycodone hcl
OXYCONTIN TAB 80MG CR
oxycodone-acetaminophen
MAGNACET TAB 10-400MG
oxycodone-acetaminophen
MAGNACET TAB 2.5-400MG
oxycodone-acetaminophen
MAGNACET TAB 5-400MG
oxycodone-acetaminophen
MAGNACET TAB 7.5-400MG
oxycodone-acetaminophen
oxycodone-acetaminophen cap 5-500mg
oxycodone-acetaminophen
oxycodone-acetaminophen tab 10-325mg
oxycodone-acetaminophen
oxycodone-acetaminophen tab 10-650mg
oxycodone-acetaminophen
oxycodone-acetaminophen tab 2.5-325mg
oxycodone-acetaminophen
oxycodone-acetaminophen tab 5-325mg
oxycodone-acetaminophen
oxycodone-acetaminophen tab 7.5-325mg
oxycodone-acetaminophen
oxycodone-acetaminophen tab 7.5-500mg
oxycodone-acetaminophen
PRIMALEV TAB 2.5-300
oxycodone-acetaminophen
PRIMLEV TAB 10-300MG
oxycodone-acetaminophen
PRIMLEV TAB 5-300MG
oxycodone-acetaminophen
PRIMLEV TAB 7.5-300
oxycodone-acetaminophen
ROXICET SOL 5-325/5
oxycodone-acetaminophen
ROXICET TAB 5-500MG
oxycodone-acetaminophen
XOLOX TAB 10-500MG
oxycodone-aspirin
endodan tab
oxycodone-aspirin
oxycodone-aspirin tab
oxycodone-ibuprofen
oxycodone-ibuprofen tab 5-400mg
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 10MG
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 15MG
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 20MG
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 30MG
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 40MG
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 5MG
oxymorphone hcl
OPANA ER (CRUSH RESISTANT) TAB 7.5MG
oxymorphone hcl
OPANA ER TAB 10MG
oxymorphone hcl
OPANA ER TAB 15MG
oxymorphone hcl
OPANA ER TAB 20MG
oxymorphone hcl
OPANA ER TAB 30MG
oxymorphone hcl
OPANA ER TAB 40MG
oxymorphone hcl
OPANA ER TAB 5MG
oxymorphone hcl
OPANA ER TAB 7.5MG
oxymorphone hcl
OPANA INJ 1MG/ML
oxymorphone hcl
oxymorphone hydrochloride ER tab 10mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 39 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
oxymorphone hcl
oxymorphone hydrochloride ER tab 15mg
oxymorphone hcl
oxymorphone hydrochloride ER tab 20mg
oxymorphone hcl
oxymorphone hydrochloride ER tab 30mg
oxymorphone hcl
oxymorphone hydrochloride ER tab 40mg
oxymorphone hcl
oxymorphone hydrochloride ER tab 5mg
oxymorphone hcl
oxymorphone hydrochloride ER tab 7.5mg
oxymorphone hcl
oxymorphone hydrochloride tab 10mg
oxymorphone hcl
oxymorphone hydrochloride tab 5mg
palbociclib
IBRANCE CAP 100MG
palbociclib
IBRANCE CAP 125MG
palbociclib
IBRANCE CAP 75MG
palifermin
KEPIVANCE INJ 6.25MG
paliperidone palmitate
INVEGA SUSTENNA INJ 117/0.75
paliperidone palmitate
INVEGA SUSTENNA INJ 156MG/ML
paliperidone palmitate
INVEGA SUSTENNA INJ 234/1.5
paliperidone palmitate
INVEGA SUSTENNA INJ 39/0.25
paliperidone palmitate
INVEGA SUSTENNA INJ 78/0.5ML
panobinostat
FARYDAK CAP 10MG
panobinostat
FARYDAK CAP 15MG
panobinostat
FARYDAK CAP 20MG
pasireotide diaspartate
SIGNIFOR INJ 0.3MG/ML
pasireotide diaspartate
SIGNIFOR INJ 0.6MG/ML
pasireotide diaspartate
SIGNIFOR INJ 0.9MG/ML
pasireotide diaspartate
SIGNIFOR LAR INJ 20MG
pasireotide diaspartate
SIGNIFOR LAR INJ 40MG
pasireotide diaspartate
SIGNIFOR LAR INJ 60MG
pazopanib hcl
VOTRIENT TAB 200MG
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
COLYTE SOL
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
COLYTE-FLAVOR PACKS SOL PACKS
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
GAVILYTE-C SOL
peg 3350-kcl-sod bicarb-sod chloride-sod sulfate
peg 3350/electrolytes sol electrol
peginterferon alfa-2a
PEGASYS INJ
peginterferon alfa-2a
PEGASYS INJ 180MCG/M
peginterferon alfa-2a
PEGASYS KIT
peginterferon alfa-2a
PEGASYS PROCLICK INJ
peginterferon alfa-2b
PEG-INTRON KIT 120MCG
peginterferon alfa-2b
PEG-INTRON KIT 150MCG
peginterferon alfa-2b
PEG-INTRON KIT 50MCG
peginterferon alfa-2b
PEG-INTRON KIT 80MCG
peginterferon alfa-2b (antineoplastic)
SYLATRON KIT 296MCG
peginterferon alfa-2b (antineoplastic)
SYLATRON KIT 444MCG
peginterferon alfa-2b (antineoplastic)
SYLATRON KIT 888MCG
peginterferon beta-1a
PLEGRIDY INJ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 40 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
peginterferon beta-1a
PLEGRIDY INJ PEN
peginterferon beta-1a
PLEGRIDY STARTER PACK INJ
pegvisomant
SOMAVERT INJ 10MG
pegvisomant
SOMAVERT INJ 15MG
pegvisomant
SOMAVERT INJ 20MG
pegvisomant
SOMAVERT INJ 25MG
pegvisomant
SOMAVERT INJ 30MG
penicillamine
CUPRIMINE CAP 250MG
penicillamine
DEPEN TITRATABS TAB 250MG
penicillin g benzathine
BICILLIN L-A INJ 1200000
penicillin g benzathine
BICILLIN L-A INJ 2400000
penicillin g benzathine
BICILLIN L-A INJ 600000
penicillin g benzathine & procaine
BICILLIN C-R INJ 1200000
penicillin g benzathine & procaine
BICILLIN C-R INJ 900/300
penicillin g pot in dextrose
PENICILLIN G POT IN ISO-OSMOTIC DEXT INJ 1MU
penicillin g pot in dextrose
PENICILLIN G POT IN ISO-OSMOTIC DEXT INJ 2MU
penicillin g pot in dextrose
PENICILLIN G POT IN ISO-OSMOTIC DEXT INJ 3MU
penicillin g potassium
PENICILLIN G POTASSIUM INJ 20MU
penicillin g potassium
PENICILLIN G POTASSIUM INJ 5MU
penicillin g potassium
PFIZERPEN-G INJ 20MU
penicillin g potassium
PFIZERPEN-G INJ 5MU
penicillin g procaine
PENICILLIN G PROCAINE INJ 600000
penicillin g sodium
PENICILLIN G SODIUM INJ 5000000
penicillin v potassium
penicillin v potassium sol 125/5ml
penicillin v potassium
penicillin v potassium sol 250/5ml
penicillin v potassium
penicillin v potassium tab 250mg
penicillin v potassium
penicillin v potassium tab 500mg
pentamidine isethionate
NEBUPENT INH 300MG
pentamidine isethionate
PENTAM 300 INJ 300MG
pentazocine lactate
TALWIN INJ 30MG/ML
pentazocine-acetaminophen
PENTAZOCINE-ACETAMINOPHEN TAB 25-650MG
pentazocine-naloxone
pentazocine-naloxone hcl tab
pentobarbital sodium
NEMBUTAL INJ 50MG/ML
pentosan polysulfate sodium
ELMIRON CAP 100MG
phenylephrine hcl-dextrometh hbr-guaifenesin tannate
TUSSO-XR SUS
phenylephrine hcl-diphenhyd hcl-dextrometh hbr tannate
DURATUSS AC 12 SUS AC
phenylephrine hcl-pyrilamine mal-dm hbr tannate
DECONSAL DM CHW
phenylephrine tan-carbetapentane tan-homeopathic prod
ZINX COLD KIT
phenylephrine tan-dm tan-pyrilamine maleate-dm tan
POLY TAN DM SUS
phenylephrine tan-dexchlorphenir tan-dextromethorphan tan
DONATUSSIN DM SUS DM
phenylephrine tannate-bromphen tan-dextromethorphan tan
bromatan-dm sus
phenylephrine tannate-bromphen tan-dextromethorphan tan
NEO DM SUS
phenylephrine tannate-carbetapentane tannate
carb/phenyl-12 sus
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 41 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
phenylephrine tannate-carbetapentane tannate
DYNEX 12 SUS
phenylephrine tannate-carbetapentane tannate
l-all 12 nf sus 25-30mg
phenylephrine tannate-chlorphen tan-carbetapentane tan
CARBAPHEN 12 PED SUS PED
phenylephrine tannate-chlorphen tan-carbetapentane tan
CARBAPHEN 12 SUS
phenylephrine tannate-chlorphen tan-dextromethorphan tan
MAXIPHEN ADT TAB
phenylephrine tannate-diphenhyd tan-carbetapentane tan
d-tann ct sus
phenylephrine tannate-diphenhyd tan-carbetapentane tan
d-tann ct tab
phenylephrine tannate-diphenhyd tan-carbetapentane tan
DYTAN-CD SUS
phenylephrine tannate-diphenhyd tan-dextromethorphan tan
livetan dm sus
phenylephrine tannate-guaifenesin
SINA-12X SUS
phenylephrine tannate-guaifenesin
SINA-12X TAB 25-200MG
phenylephrine tannate-pyrilamine tan-carbetapentane tan
TUSSI-12D S SUS
phenylephrine tannate-pyrilamine tan-carbetapentane tan
TUSSI-12D TAB 10-40-60
phenylephrine tannate-pyrilamine tan-dextromethorphan tan
SINADEX 12 SUS
phenylephrine tannate-pyrilamine tan-dextromethorphan tan
VIRATAN-DM CHW 25-30-25
phenylephrine tannate-pyrilamine tannate-guaifenesin
RYNA-12X SUS 5-30-100
phenylephrine tannate-pyrilamine tannate-guaifenesin
RYNA-12X TAB
phenylephrine tannate-pyrilamine tann-dextromethorphan tan
allanvan-dm sus
phenylephrine-brompheniramine-carbetapentane
trexbrom liq
phenylephrine-brompheniramine-carbetapentane
VAZOTAN SUS
phenylephrine-brompheniramine-carbetapentane
v-cof sus
phenylephrine-brompheniramine-codeine
BROVEX PB C TAB 10-4-10
phenylephrine-brompheniramine-codeine
BROVEX PB CX TAB 10-4-20
phenylephrine-brompheniramine-codeine
M-END PE LIQ
phenylephrine-brompheniramine-codeine
POLY-TUSSIN AC LIQ AC
phenylephrine-brompheniramine-dihydrocodeine
POLY-TUSSIN DHC LIQ DHC
phenylephrine-brompheniramine-dm
ALACOL DM DROP
phenylephrine-brompheniramine-dm
ALAHIST DM LIQ 7.5-4-15
phenylephrine-brompheniramine-dm
bpm pe dm syp 5-2-10mg
phenylephrine-brompheniramine-dm
brompheniramine-phenylephrine-dm liq 4-10-20
phenylephrine-brompheniramine-dm-guaifenesin
BROMHIST-PDX SYP
phenylephrine-brompheniramine-guaifenesin
DECON-G DRO 2-1-40MG
phenylephrine-carbetapentane-guaifenesin
albatussin nn liq
phenylephrine-carbetapentane-guaifenesin
AQUATAB C TAB
phenylephrine-carbetapentane-guaifenesin
carbetaplex syp
phenylephrine-carbetapentane-guaifenesin
extendryl gcp sol
phenylephrine-carbetapentane-guaifenesin
phencarb guaifenesin syp
phenylephrine-carbetapentane-guaifen-homeopathic prod
ZINX COUGH KIT
phenylephrine-carbetapentane-potassium guaiacolsulfonate
CARBATUSS-CL LIQ
phenylephrine-chlorphen-dm
ACCUHIST PDX DROP PDX
phenylephrine-chlorphen-dm
centergy dm drop
phenylephrine-chlorphen-dm
c-phen dm drop
phenylephrine-chlorphen-dm
de-chlor dm syp liquid
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 42 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
phenylephrine-chlorphen-dm
de-chlor dr syp liquid
phenylephrine-chlorphen-dm
ed-a-hist dm liq
phenylephrine-chlorphen-dm
NEO DM DROP
phenylephrine-chlorphen-dm
NEOTUSS PLUS LIQ
phenylephrine-chlorphen-dm
pe-hist dm syp 5-2-15mg
phenylephrine-chlorphen-dm
sildec pe-dm syp
phenylephrine-chlorphen-dm
zoden dm drop
phenylephrine-chlorphen-dm
zotex-12d tab
phenylephrine-chlorphen-guaifenesin
p chlor gg sol drop
phenylephrine-chlorpheniramine-carbetapentane
CARBAPHEN 12 LIQ
phenylephrine-chlorpheniramine-codeine
CAPCOF SYP
phenylephrine-chlorpheniramine-codeine
ENDAL CD SYP
phenylephrine-chlorpheniramine-dihydrocodeine
BALTUSSIN SYP 20-5-3
phenylephrine-chlorpheniramine-dihydrocodeine
DESPEC-PDC LIQ
phenylephrine-chlorpheniramine-dihydrocodeine
DIHYDRO-PE SYP
phenylephrine-chlorpheniramine-dihydrocodeine
DUOHIST DH LIQ 5-2-7.25
phenylephrine-chlorpheniramine-dihydrocodeine
NOVAHISTINE DH LIQ
phenylephrine-chlorpheniramine-dm-gg-methscopolamine
SYMPAK DM MIS
phenylephrine-chlorpheniramine-dm-guaifenesin
chlordex gp syp
phenylephrine-chlorpheniramine-dm-guaifenesin
DONATUSSIN SYP
phenylephrine-chlorpheniramine-dm-guaifenesin
ZOTEX-DM SYP
phenylephrine-codeine
ALAHIST AC LIQ 7.5-10
phenylephrine-codeine
NOTUSS-PE LIQ
phenylephrine-codeine-guaifenesin
GILTUSS PED-C LIQ PED-C
phenylephrine-codeine-guaifenesin
MAXIPHEN CD TAB
phenylephrine-codeine-guaifenesin
MAXIPHEN CDX TAB
phenylephrine-codeine-guaifenesin-acetaminophen
PHENFLU CD TAB
phenylephrine-codeine-guaifenesin-acetaminophen
PHENFLU CDX TAB
phenylephrine-dexbrompheniramine-dextromethorphan
DEXALL SYP 10-2-20
phenylephrine-dexbrompheniramine-dextromethorphan
TUSSALL-ER TAB 20-6-30
phenylephrine-dexbrompheniramine-dm-guaifenesin
PANATUSS DXP PEDIATRIC LIQ
phenylephrine-dexchlorpheniramine-carbetapentane
CORZALL-PE LIQ
phenylephrine-dexchlorpheniramine-codeine
VANACOF CD LIQ
phenylephrine-dexchlorpheniramine-pyrilamine-dm
coryza-dm syp
phenylephrine-dihydrocodeine
ALAHIST DHC LIQ 7.5-3
phenylephrine-dihydrocodeine-guaifenesin
DONATUSS DC SYP
phenylephrine-dihydrocodeine-guaifenesin
POLY-TUSSIN EX SYP EX
phenylephrine-diphenhydramine-codeine
AIRACOF SYP
phenylephrine-diphenhydramine-dm-acetaminophen
RESPA C&C IR TAB
phenylephrine-diphenhydramine-dm-acetaminophen
RESPA C&C TAB
phenylephrine-dm-guaifenesin
biotuss liq
phenylephrine-dm-guaifenesin
biotuss pediatric liq
phenylephrine-dm-guaifenesin
BRONCOTRON-D SUS
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 43 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
phenylephrine-dm-guaifenesin
DESPEC DM SYP
phenylephrine-dm-guaifenesin
GILTUSS LIQ
phenylephrine-dm-guaifenesin
GILTUSS PEDIATRIC LIQ
phenylephrine-dm-guaifenesin
GILTUSS TR CAP 7-14-288
phenylephrine-dm-guaifenesin
GILTUSS TR TAB
phenylephrine-dm-guaifenesin
MAXIPHEN DM TAB
phenylephrine-dm-guaifenesin
nortuss-de drop
phenylephrine-dm-guaifenesin
PDM GG SYP 10-30-20
phenylephrine-dm-guaifenesin
SINUTUSS DM TAB
phenylephrine-dm-guaifenesin
TRITUSS SYP
phenylephrine-dm-guaifenesin
TUSSAFED EX LIQ
phenylephrine-dm-guaifenesin
TUSSI-PRES PEDIATRIC LIQ
phenylephrine-dm-guaifenesin
z-dex syp
phenylephrine-dm-guaifenesin
ZOTEX PEDIATRIC DROP
phenylephrine-dm-guaifenesin
ZOTEX-EX TAB
phenylephrine-dm-guaifenesin
ZOTEX-G SYP
phenylephrine-dm-guaifenesin-acetaminophen
PHENFLU DM TAB
phenylephrine-dm-guaifenesin-acetaminophen
PHENFLU G TAB
phenylephrine-dm-pyril-pot guai-sod cit-citric acid
GENTEX 30 LIQ
phenylephrine-ephedrine-chlorphenir-carbetapentane
RYNATUSS TAB
phenylephrine-ephedrine-chlorphenirw-carbetapentane
quad-tuss tannate pediatric sus
phenylephrine-guaifenesin
GILPHEX TR TAB 10-388MG
phenylephrine-guaifenesin
guaifenesin-phenylephrine hcl syp
phenylephrine-guaifenesin
maxiphen tab 10-400mg
phenylephrine-guaifenesin
nazarin liq
phenylephrine-guaifenesin
phenavent ped cap 7.5-200
phenylephrine-guaifenesin
phenylephrine-guaifenesin drop 1.5-20mg
phenylephrine-guaifenesin
quintex syp 7.5-100
phenylephrine-guaifenesin
SINUVENT PE TAB 15-600MG
phenylephrine-guaifenesin
SITREX PD LIQ 7.5-75MG
phenylephrine-guaifenesin
ZOTEX-GP TAB
phenylephrine-guaifenesin-chlorphenir-methscopolamine
SYMPAK MIS
phenylephrine-hydrocodone-guaifenesin
GILTUSS HC LIQ
phenylephrine-methscopolamine
EXTENDRYL PEM TAB PEM
phenylephrine-promethazine-cod
promethazine vc-codeine syp
phenylephrine-pyrilamine-codeine
PRO-RED AC SYP
phenylephrine-pyrilamine-codeine
ZOTEX-C SYP
phenylephrine-pyrilamine-dihydrocodeine
POLY HIST DHC LIQ DHC
phenylephrine-pyrilamine-dm
POLY HIST DM LIQ
phenylephrine-pyrilamine-dm
pyril dm sus
phenylephrine-triprolidine-chlophedianol
PROHIST CD LIQ
phenyltoloxamine-acetaminophen
ACUFLEX TAB
phenyltoloxamine-acetaminophen
biogesic tab 30-500mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 44 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
phenyltoloxamine-acetaminophen
bp poly-650 tab
phenyltoloxamine-acetaminophen
DOLOGESIC LIQ 30-500MG
phenyltoloxamine-acetaminophen
RELAGESIC LIQ 5-160MG
phenyltoloxamine-acetaminophen
RELAGESIC TAB 50-650MG
phenyltoloxamine-acetaminophen
rhinoflex tab 50-500mg
phenyltoloxamine-acetaminophen
STAFLEX TAB 55-500MG
phenyltoloxamine-acetaminophen
zgesic tab 66-600mg
piperacillin sodium-tazobactam sodium
PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM INJ 36-4.5GM
piperacillin sodium-tazobactam sodium
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INJ 2-0.25GM
piperacillin sodium-tazobactam sodium
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INJ 3-0.375G
piperacillin sodium-tazobactam sodium
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INJ 4-0.5GM
piperacillin sodium-tazobactam sodium
ZOSYN INJ 2-0.25GM
piperacillin sodium-tazobactam sodium
ZOSYN INJ 3-0.375G
piperacillin sodium-tazobactam sodium
ZOSYN INJ 36-4.5GM
piperacillin sodium-tazobactam sodium
ZOSYN INJ 4-0.5GM
piperacillin sodium-tazobactam sodium in dextrose
ZOSYN SOL 2-0.25GM
piperacillin sodium-tazobactam sodium in dextrose
ZOSYN SOL 3-0.375G
piperacillin sodium-tazobactam sodium in dextrose
ZOSYN SOL 4-0.50GM
pirfenidone
ESBRIET CAP 267MG
piroxicam
FELDENE CAP 10MG
piroxicam
piroxicam cap 20mg
polymyxin b-trimethoprim
polymyxin b sulfate/trimethoprim sulfate sol
polymyxin b-trimethoprim
POLYTRIM SOL OP
polymyxin b-trimethoprim
trimethoprim sulfate/polymyxin b sulfate sol
pomalidomide
POMALYST CAP 1MG
pomalidomide
POMALYST CAP 2MG
pomalidomide
POMALYST CAP 3MG
pomalidomide
POMALYST CAP 4MG
ponatinib hcl
ICLUSIG TAB 15MG
ponatinib hcl
ICLUSIG TAB 45MG
posaconazole
NOXAFIL INJ 300/16.7
posaconazole
NOXAFIL SUS 40MG/ML
posaconazole
NOXAFIL TAB 100MG
potassium guaiacolsulfonate
YODEFAN-NF LIQ 300MG/5ML
povidone-iodine (ophth)
BETADINE OPHTHALMIC PREP SOL 5% OP
praziquantel
BILTRICIDE TAB 600MG
prednisolone
MILLIPRED DP PAK 5MG
prednisolone
MILLIPRED TAB 5MG
prednisolone
PREDNISOLONE SOL 15MG/5ML
prednisolone
prednisolone syp 5mg/5ml
prednisolone
PRELONE SYP 15MG/5ML
prednisolone sodium phosphate
ASMALPRED PLUS SOL
prednisolone sodium phosphate
ASMALPRED SOL 15MG/5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 45 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
prednisolone sodium phosphate
MILLIPRED SOL 10MG/5ML
prednisolone sodium phosphate
ORAPRED ODT TAB 10MG
prednisolone sodium phosphate
ORAPRED ODT TAB 15MG
prednisolone sodium phosphate
ORAPRED ODT TAB 30MG
prednisolone sodium phosphate
ORAPRED SOL 15MG/5ML
prednisolone sodium phosphate
PEDIAPRED SOL 6.7/5ML
prednisolone sodium phosphate
prednisolone sodium phosphate odt tab 10mg
prednisolone sodium phosphate
prednisolone sodium phosphate odt tab 15mg
prednisolone sodium phosphate
prednisolone sodium phosphate odt tab 30mg
prednisolone sodium phosphate
prednisolone sodium phosphate sol 15mg/5ml
prednisolone sodium phosphate
prednisolone sodium phosphate sol 25mg/5ml
prednisolone sodium phosphate
prednisolone sodium phosphate sol 5mg/5ml
prednisolone sodium phosphate
VERIPRED 20 SOL 20MG/5ML
prednisone
DELTASONE
prednisone
PREDNISONE INTENSOL CON 5MG/ML
prednisone
PREDNISONE PAK 10MG
prednisone
PREDNISONE PAK 5MG
prednisone
PREDNISONE SOL 5MG/5ML
prednisone
prednisone tab 10mg
prednisone
prednisone tab 1mg
prednisone
prednisone tab 2.5mg
prednisone
prednisone tab 20mg
prednisone
prednisone tab 50mg
prednisone
prednisone tab 5mg
prednisone
RAYOS TAB 1MG
prednisone
RAYOS TAB 2MG
prednisone
RAYOS TAB 5MG
prednisone
STERAPRED DS PAK 10MG
prednisone
STERAPRED PAK 5MG
primaquine phosphate
primaquine phosphate tab 26.3mg
procarbazine hcl
MATULANE CAP 50MG
progesterone (vaginal)
ENDOMETRIN SUP 100MG
progesterone (vaginal)
FIRST-PROGESTERONE VGS 100 COMPD KIT SUP
progesterone (vaginal)
FIRST-PROGESTERONE VGS 200 COMPD KIT SUP
progesterone (vaginal)
FIRST-PROGESTERONE VGS 25 COMPD KIT SUP
progesterone (vaginal)
FIRST-PROGESTERONE VGS 400 COMPD KIT SUP
progesterone (vaginal)
FIRST-PROGESTERONE VGS 50 CCOMPD KIT SUP
promethazine & phenylephrine
promethazine vc plain syp plain
promethazine hcl
PHENERGAN INJ 25MG/ML
promethazine hcl
PHENERGAN INJ 50MG/ML
promethazine hcl
promethazine hcl inj 25mg/ml
promethazine hcl
promethazine hcl inj 50mg/ml
promethazine hcl
promethazine hcl syp 6.25/5ml
TAB 10MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 46 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
promethazine hcl
promethazine hcl tab 12.5mg
promethazine hcl
promethazine hcl tab 25mg
promethazine hcl
promethazine hcl tab 50mg
promethazine hcl
promethegan sup 12.5mg
promethazine hcl
promethegan sup 25mg
promethazine hcl
promethegan sup 50mg
promethazine w/codeine
promethazine-codeine syp 6.25-10
promethazine-dm
promethazine-dextromethorphan syp
propofol
fresenius propoven inj 10mg/ml
propofol
propofol inj 10mg/ml
propoxyphene compound
DARVON CAP CPD 65
propoxyphene hcl
DARVON CAP 65MG
propoxyphene hcl
propoxyphene hcl cap 65mg
propoxyphene hcl-acetaminophen
DARVOCET A500 TAB
propoxyphene hcl-acetaminophen
DARVOCET-N 100 TAB
propoxyphene hcl-acetaminophen
DARVOCET-N 50 TAB
propoxyphene hcl-acetaminophen
propoxyphene/acetaminophen tab 65-650mg
propoxyphene napsylate
DARVON-N TAB 100MG
propoxyphene-n-acetaminophen
propoxyphene napsylate-acetaminophen tab 100-325
propoxyphene-n-acetaminophen
propoxyphene-n-acetaminophen tab 100-500
propoxyphene-n-acetaminophen
propoxyphene-n-acetaminophen tab 100-650
propoxyphene-n-acetaminophen
propoxyphene-n-acetaminophen tab 50/325
pseudoephedrine hcl-chlorphen mal-dm hbr tannate
chlorpheniramine-pseudoephedrine-dm tannate sus
pseudoephedrine hcl-dm hbr-guaifenesin tannate
Z-COF 12DM SUS
pseudoephedrine tan-bromphen tan-dm tan
ANAPLEX DMX SUS
pseudoephedrine tan-chlorphen tan-dm tan
DICEL DM SUS
pseudoephedrine tan-dexchlorphen tan-dm tan
dur-tann forte sus forte
pseudoephedrine tan-dexchlorphen tan-dm tan
sutan-dm sus
pseudoephedrine tan-dexchlorphen tan-dm tan
TANAFED DMX SUS
pseudoephedrine tannate-carbetapentane tannate
PSEUDACARB CHW 75-25MG
pseudoephedrine-bromphen-dm
allanhist pdx drop pdx
pseudoephedrine-bromphen-dm
andehist dm nr syp nr
pseudoephedrine-bromphen-dm
bromfed dm syp
pseudoephedrine-bromphen-dm
BROVEX PSB DM LIQ DM
pseudoephedrine-bromphen-dm
BROVEX PSE DM TAB DM
pseudoephedrine-bromphen-dm
DELTUSS DMX LIQ
pseudoephedrine-bromphen-dm
pbm allergy syp
pseudoephedrine-bromphen-dm
PEDIAHIST DM DROP 15-1-4MG
pseudoephedrine-bromphen-dm
pse brom dm syp
pseudoephedrine-bromphen-dm
RESPERAL-DM DROP 12-1-5MG
pseudoephedrine-bromphen-dm
tgq 50pse-3brm-30dm syp brm-30dm
pseudoephedrine-brompheniramine-codeine
CPB WC LIQ
pseudoephedrine-brompheniramine-codeine
MAR-COF BP LIQ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 47 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
pseudoephedrine-brompheniramine-codeine
mesehist wc liq
pseudoephedrine-brompheniramine-dihydrocodeine
J-COF DHC LIQ
pseudoephedrine-brompheniramine-dm-guaifenesin
bromhist-dm pediatric syp ped
pseudoephedrine-carbetapentane-guaifenesin
EXALL-D LIQ
pseudoephedrine-chlorphen-dm
ACCUHIST PDX DROP
pseudoephedrine-chlorphen-dm
HDC DM SYP
pseudoephedrine-chlorphen-dm
mesehist dm liq
pseudoephedrine-chlorphen-dm
TUSSAFED LIQ
pseudoephedrine-chlorpheniramine-dihydrocodeine
DIHYDRO-CP SYP
pseudoephedrine-chlorpheniramine-dm-guaifenesin
NEOTUSS-D LIQ
pseudoephedrine-codeine
endacof-dc liq
pseudoephedrine-codeine
NUCOFED CAP
pseudoephedrine-codeine-guaifenesin
AMBIFED CD TAB
pseudoephedrine-codeine-guaifenesin
AMBIFED CDX TAB
pseudoephedrine-codeine-guaifenesin
AMBIFED-G CD TAB
pseudoephedrine-codeine-guaifenesin
AMBIFED-G CDX TAB CDX
pseudoephedrine-codeine-guaifenesin
cheratussin dac sol dac
pseudoephedrine-codeine-guaifenesin
LORTUSS EX LIQ
pseudoephedrine-codeine-guaifenesin
MAXIFED CD TAB
pseudoephedrine-codeine-guaifenesin
MAXIFED CDX TAB
pseudoephedrine-codeine-guaifenesin
MAXIFED-G CD TAB
pseudoephedrine-codeine-guaifenesin
MAXIFED-G CDX TAB CDX
pseudoephedrine-codeine-guaifenesin
TUSNEL C SYP
pseudoephedrine-codeine-guaifenesin
TUSNEL PED-C SYP
pseudoephedrine-codeine-guaifenesin
ZODRYL DEC 50 SUS
pseudoephedrine-codeine-guaifenesin
ZODRYL DEC 60 SUS
pseudoephedrine-codeine-guaifenesin
ZODRYL DEC 80 SUS
pseudoephedrine-codeine-guaifenesin
Z-TUSS E LIQ
pseudoephedrine-codeine-guaifenesin-acetaminophen
MAXIFLU CD TAB
pseudoephedrine-codeine-guaifenesin-acetaminophen
MAXIFLU CDX TAB
pseudoephedrine-cpm-hydrocod
ZUTRIPRO LIQ
pseudoephedrine-dexbrompheniramine-dm-guaifenesin
DEKA LIQ
pseudoephedrine-dihydrocodeine-guaifenesin
DESPEC-EXP SYP
pseudoephedrine-dm-guaifenesin
ALDEX GS DM TAB
pseudoephedrine-dm-guaifenesin
ambi 60pse-400gfn-20dm tab
pseudoephedrine-dm-guaifenesin
DONATUSS XP SUS
pseudoephedrine-dm-guaifenesin
DONATUSSIN DM SYP DM
pseudoephedrine-dm-guaifenesin
pseudo cough liq
pseudoephedrine-dm-guaifenesin
PSEUDOEPHEDRINE-DM-GUAIFENESIN SYP 40-15-10
pseudoephedrine-dm-guaifenesin
RU-TUSS DM SYP
pseudoephedrine-dm-guaifenesin
sudatex-dm tab
pseudoephedrine-dm-guaifenesin
tl-dex dm liq
pseudoephedrine-dm-guaifenesin
TRISPEC PSE LIQ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 48 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
pseudoephedrine-dm-guaifenesin
TUSNEL LIQ
pseudoephedrine-dm-guaifenesin
TUSNEL PEDIATRIC LIQ
pseudoephedrine-dm-guaifenesin
TUSNEL-DM PEDIATRIC LIQ PEDI DROP
pseudoephedrine-dm-guaifenesin
Z-COF 8DM SUS
pseudoephedrine-dm-guaifenesin
Z-COF I SUS
pseudoephedrine-dm-guaifenesin-acetaminophen
DURAFLU TAB
pseudoephedrine-dm-guaifenesin-acetaminophen
MAXIFLU DM TAB
pseudoephedrine-dm-guaifenesin-acetaminophen
MAXIFLU-G TAB
pseudoephedrine-guaifenesin
ALDEX GS TAB 30-190MG
pseudoephedrine-guaifenesin
ambi 40pse-400gfn tab 400gfn
pseudoephedrine-guaifenesin
ambi 60-580 tab
pseudoephedrine-guaifenesin
maxifed tab 60-400mg
pseudoephedrine-guaifenesin
PSEUDOEPHEDRINE-GUAIFENESIN SYP 40-200MG
pseudoephedrine-guaifenesin
PSEUDOVENT 400 CAP 400
pseudoephedrine-guaifenesin
PSEUDOVENT CAP CR
pseudoephedrine-guaifenesin
pseudovent ped cap ped cr
pseudoephedrine-guaifenesin
RESPAIRE-30 CAP
pseudoephedrine-guaifenesin
TENAR PSE LIQ
pseudoephedrine-guaifenesin
TUSNEL PEDIATRIC DROP 5-10MG/ML
pseudoephedrine-hydrocodone
REZIRA SOL 60-5/5ML
pseudoephedrine-methscop-chlorphen-phenyleph-methscop
ALLERX DOSE PACK MIS
pseudoephedrine-methscopolamine
respivent-d tab
pseudoephedrine-pyrilamine-carbetapentane
CORZALL PLUS LIQ
pseudoephedrine-pyrilamine-carbetapentane
ZOTEX-D SYP
pseudoephedrine-pyrilamine-codeine
NEO AC SYP
pseudoephedrine-pyrilamine-dextromethorphan
VIRAVAN-PDM LIQ
pseudoephrine hcl-pyrilamine mal-dextromethorphan hbr tan
VIRAVAN-PDM SUS 15-15-15
pseudoephrine-chlorphen-codeine
PHENYLHISTINE DH LIQ DH
pseudoephrine-chlorphen-codeine
ZODRYL DAC 50 SUS
pseudoephrine-chlorphen-codeine
ZODRYL DAC 60 SUS
pseudoephrine-chlorphen-codeine
ZODRYL DAC 80 SUS
pseudoephrine-triprolidine-codeine
POLY HIST NC LIQ
pseudoephrine-triprolidine-dm
PEDIATEX TDM SUS
pyrazinamide
pyrazinamide tab 500mg
pyrilamine maleate-phenylephrine hcl tannate
DECONSAL CT CHW 16-10MG
pyrilamine maleate-phenylephrine hcl tannate
pyril d sus 16-5mg/5ml
pyrilamine maleate-pseudoephedrine hcl tannate
VIRAVAN-P SUS 15-15MG
pyrilamine tannate
PYRLEX SUS 12MG/5ML
pyrilamine tannate-phenylephrine tannate
allanvan-s sus 30-12.5
pyrilamine tannate-phenylephrine tannate
PYRLEX PD SUS 12-9MG
pyrilamine tannate-phenylephrine tannate
RYNA-12 TAB 60-25MG
pyrilamine tannate-phenylephrine tannate
rynesa 12s sus
pyrilamine-pseudoephedrine
VIRAVAN-P LIQ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 49 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
pyrimethamine
DARAPRIM TAB 25MG
quazepam
DORAL TAB 15MG
quinine sulfate
QUININE SULFATE CAP 324MG
quinupristin-dalfopristin
SYNERCID INJ 500MG
ramelteon
ROZEREM TAB 8MG
regorafenib
STIVARGA TAB 40MG
remifentanil hcl
ULTIVA INJ 1MG
remifentanil hcl
ULTIVA INJ 2MG
remifentanil hcl
ULTIVA INJ 5MG
rifabutin
MYCOBUTIN CAP 150MG
rifampin
RIFADIN CAP 150MG
rifampin
RIFADIN CAP 300MG
rifampin
RIFADIN INJ 600 MG
rifampin
rifampin cap 150mg
rifampin
rifampin cap 300mg
rifampin
RIFAMPIN INJ 600 MG
rifapentine
PRIFTIN TAB 150MG
rifaximin
XIFAXAN TAB 200MG
rifaximin
XIFAXAN TAB 550MG
rilonacept
ARCALYST INJ 220MG
rimantadine hydrochloride
rimantadine hcl tab 100mg
riociguat
ADEMPAS TAB 0.5MG
riociguat
ADEMPAS TAB 1.5MG
riociguat
ADEMPAS TAB 1MG
riociguat
ADEMPAS TAB 2.5MG
riociguat
ADEMPAS TAB 2MG
risperidone microspheres
RISPERDAL CONSTA INJ 12.5MG
risperidone microspheres
RISPERDAL CONSTA INJ 25MG
risperidone microspheres
RISPERDAL CONSTA INJ 37.5MG
risperidone microspheres
RISPERDAL CONSTA INJ 50MG
rizatriptan benzoate
MAXALT TAB 10MG
rizatriptan benzoate
MAXALT TAB 5MG
rizatriptan benzoate
MAXALT-MLT TAB 10MG
rizatriptan benzoate
MAXALT-MLT TAB 5MG
ruxolitinib phosphate
JAKAFI TAB 10MG
ruxolitinib phosphate
JAKAFI TAB 15MG
ruxolitinib phosphate
JAKAFI TAB 20MG
ruxolitinib phosphate
JAKAFI TAB 25MG
ruxolitinib phosphate
JAKAFI TAB 5MG
sapropterin dihydrochloride
KUVAN TAB 100MG
sargramostim
LEUKINE INJ 250MCG
sargramostim
LEUKINE INJ 500 MCG
secobarbital sodium
SECONAL CAP 100MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 50 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
secukinumab
COSENTYX INJ
sevoflurane
ULTANE SOL
sildenafil citrate
VIAGRA TAB 100MG
sildenafil citrate
VIAGRA TAB 25MG
sildenafil citrate
VIAGRA TAB 50MG
simeprevir sodium
OLYSIO CAP 150MG
sodium oxybate
XYREM SOL 500MG/ML
sofosbuvir
SOVALDI TAB 400MG
somatropin
GENOTROPIN INJ 12MG
somatropin
GENOTROPIN INJ 5MG
somatropin
GENOTROPIN MINIQUICK INJ 0.2MG
somatropin
GENOTROPIN MINIQUICK INJ 0.4MG
somatropin
GENOTROPIN MINIQUICK INJ 0.6MG
somatropin
GENOTROPIN MINIQUICK INJ 0.8MG
somatropin
GENOTROPIN MINIQUICK INJ 1.2MG
somatropin
GENOTROPIN MINIQUICK INJ 1.4MG
somatropin
GENOTROPIN MINIQUICK INJ 1.6MG
somatropin
GENOTROPIN MINIQUICK INJ 1.8MG
somatropin
GENOTROPIN MINIQUICK INJ 1MG
somatropin
GENOTROPIN MINIQUICK INJ 2MG
somatropin
HUMATROPE COMBO PACK INJ 5MG
somatropin
HUMATROPE INJ 12MG
somatropin
HUMATROPE INJ 24MG
somatropin
HUMATROPE INJ 6MG
somatropin
NORDITROPIN CARTRIDGE INJ 15/1.5ML
somatropin
NORDITROPIN FLEXPRO INJ 10/1.5ML
somatropin
NORDITROPIN FLEXPRO INJ 5/1.5ML
somatropin
NORDITROPIN NORDIFLEX PEN INJ 15/1.5ML
somatropin
NORDITROPIN NORDIFLEX PEN INJ 30/3ML
somatropin
NUTROPIN AQ INJ 10MG/2ML
somatropin
NUTROPIN AQ NUSPIN 5 INJ
somatropin
NUTROPIN AQ PEN INJ 10MG/2ML
somatropin
NUTROPIN AQ PEN INJ 20MG/2ML
somatropin
NUTROPIN INJ 10MG
somatropin
NUTROPIN INJ 5MG
somatropin
OMNITROPE INJ 10/1.5ML
somatropin
OMNITROPE INJ 5.8MG
somatropin
OMNITROPE INJ 5/1.5ML
somatropin
ZORBTIVE INJ
somatropin (non-refrigerated)
SAIZEN CLICK.EASY INJ 8.8MG
somatropin (non-refrigerated)
SAIZEN INJ 5MG
somatropin (non-refrigerated)
SAIZEN INJ 8.8MG
somatropin (non-refrigerated)
SEROSTIM INJ 4MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 51 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
somatropin (non-refrigerated)
SEROSTIM INJ 5MG
somatropin (non-refrigerated)
SEROSTIM INJ 6MG
somatropin (non-refrigerated)
ZORBTIVE INJ 8.8MG
sorafenib tosylate
NEXAVAR TAB 200MG
sufentanil citrate
sufentanil citrate inj 50mcg/ml
sulfacetamide sodium (ophth)
BLEPH-10 SOL 10% OP
sulfacetamide sodium (ophth)
sodium sulfacetamide sol 10% op
sulfacetamide sodium (ophth)
SULFACET SOD OIN 10% OP
sulfacetamide sodium (ophth)
sulfacetamide sodium oin 10% op
sulfacetamide sod-prednisolone
BLEPHAMIDE S.O.P. OIN S.O.P.
sulfacetamide sod-prednisolone
BLEPHAMIDE SUS OP
sulfacetamide sod-prednisolone
sulfacetamide sod/prednisolone sodium phosphate sol op
sumatriptan
SUMATRIPTAN SPR 20MG/ACT
sumatriptan
SUMATRIPTAN SPR 5MG/ACT
sumatriptan succinate
ALSUMA KIT 6MG/0.5ml
sumatriptan succinate
IMITREX INJ 6MG/0.5ML
sumatriptan succinate
IMITREX STATDOSE REFILL INJ 4MG/0.5ML
sumatriptan succinate
IMITREX STATDOSE REFILL INJ 6MG/0.5ML
sumatriptan succinate
IMITREX STATDOSE SYSTEM KIT 4MG/0.5ML
sumatriptan succinate
IMITREX TAB 100MG
sumatriptan succinate
IMITREX TAB 25MG
sumatriptan succinate
IMITREX TAB 50MG
sumatriptan succinate
sumatriptan succinate inj 4mg/0.5ml
sumatriptan succinate
sumatriptan succinate inj 6mg/0.5ml
sumatriptan succinate
sumatriptan succinate inj kit 6mg/0.5ml
sumatriptan succinate
sumatriptan succinate inj refill kit 4mg/0.5ml
sumatriptan succinate
sumatriptan succinate inj refill kit 6mg/0.5ml
sumatriptan succinate
sumatriptan succinate tab 100mg
sumatriptan succinate
sumatriptan succinate tab 25mg
sumatriptan succinate
sumatriptan succinate tab 50mg
sumatriptan succinate
SUMAVEL DOSEPRO INJ 4MG/0.5ML
sumatriptan succinate
SUMAVEL DOSEPRO INJ 6MG/0.5ML
sumatriptan-naproxen sodium
TREXIMET TAB 85-500MG
sunitinib malate
SUTENT CAP 12.5MG
sunitinib malate
SUTENT CAP 25MG
sunitinib malate
SUTENT CAP 50MG
tadalafil
CIALIS TAB 10MG
tadalafil
CIALIS TAB 2.5MG
tadalafil
CIALIS TAB 20MG
tadalafil
CIALIS TAB 5MG
taliglucerase alfa
ELELYSO INJ 200UNIT
tapentadol hcl
NUCYNTA ER TAB 100MG
tapentadol hcl
NUCYNTA ER TAB 150MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 52 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
tapentadol hcl
NUCYNTA ER TAB 200MG
tapentadol hcl
NUCYNTA ER TAB 250MG
tapentadol hcl
NUCYNTA ER TAB 50MG
tapentadol hcl
NUCYNTA TAB 100MG
tapentadol hcl
NUCYNTA TAB 50MG
tapentadol hcl
NUCYNTA TAB 75MG
tasimelteon
HETLIOZ CAP 20MG
tedizolid phosphate
SIVEXTRO INJ 200MG
tedizolid phosphate
SIVEXTRO TAB 200MG
teduglutide (rdna)
GATTEX KIT 5MG
telaprevir
INCIVEK TAB 375MG
telbivudine
TYZEKA TAB 600MG
temazepam
RESTORIL CAP 15MG
temazepam
RESTORIL CAP 22.5MG
temazepam
RESTORIL CAP 30MG
temazepam
RESTORIL CAP 7.5MG
temazepam
temazepam cap 15mg
temazepam
temazepam cap 22.5mg
temazepam
temazepam cap 30mg
temazepam
temazepam cap 7.5mg
temazepam-dietary management product
STRAZEPAM PAK
temozolomide
TEMODAR CAP 100MG
temozolomide
TEMODAR CAP 140MG
temozolomide
TEMODAR CAP 180MG
temozolomide
TEMODAR CAP 20MG
temozolomide
TEMODAR CAP 250MG
temozolomide
TEMODAR CAP 5MG
temozolomide
TEMODAR INJ 100MG
temozolomide
temozolomide cap 180mg
temozolomide
temozolomide cap 20mg
temozolomide
temozolomide cap 250mg
temozolomide
temozolomide cap 5mg
terbinafine hcl
LAMISIL GRA 125MG
terbinafine hcl
LAMISIL GRA 187.5MG
terbinafine hcl
LAMISIL TAB 250MG
terbinafine hcl
terbinafine hcl tab 250mg
terbinafine-hydroxypropyl chitosan
TERBINEX KIT
teriflunomide
AUBAGIO TAB 14MG
teriflunomide
AUBAGIO TAB 7MG
teriparatide (recombinant)
FORTEO SOL 600/2.4
tesamorelin acetate
EGRIFTA INJ 1MG
tesamorelin acetate
EGRIFTA SOL 2MG
tetrabenazine
XENAZINE TAB 12.5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 53 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
tetrabenazine
XENAZINE TAB 25MG
thalidomide
THALOMID CAP 100MG
thalidomide
THALOMID CAP 150MG
thalidomide
THALOMID CAP 200MG
thalidomide
THALOMID CAP 50MG
tiopronin
THIOLA TAB 100MG
tobramycin
BETHKIS NEB 300/4ML
tobramycin
KITABIS PAK NEB 300/5ML
tobramycin
TOBI PODHALER CAP 28MG
tobramycin
tobramycin neb 300/5ml
tobramycin (ophth)
TOBRAMYCIN SULFATE SOL 0.3% OP
tobramycin (ophth)
TOBREX OIN 0.3% OP
tobramycin (ophth)
TOBREX SOL 0.3% OP
tocilizumab
ACTEMRA INJ 162/0.9
tocilizumab
ACTEMRA INJ 200/10ML
tocilizumab
ACTEMRA INJ 400/20ML
tocilizumab
ACTEMRA INJ 80MG/4ML
tofacitinib citrate
XELJANZ TAB 5MG
tramadol hcl
CONZIP CAP 100MG
tramadol hcl
CONZIP CAP 200MG
tramadol hcl
CONZIP CAP 300MG
tramadol hcl
RYBIX ODT TAB 50MG
tramadol hcl
RYZOLT TAB 100MG
tramadol hcl
RYZOLT TAB 200MG
tramadol hcl
RYZOLT TAB 300MG
tramadol hcl
SYNAPRYN FUSEPAQ SUS 10MG/ML
tramadol hcl
TRAMADOL HCL ER CAP 150MG
tramadol hcl
tramadol hcl er tab 100mg
tramadol hcl
tramadol hcl er tab 200mg
tramadol hcl
tramadol hcl er tab 300mg
tramadol hcl
tramadol hcl tab 50mg
tramadol hcl
ULTRAM ER TAB 100MG
tramadol hcl
ULTRAM ER TAB 200MG
tramadol hcl
ULTRAM ER TAB 300MG
tramadol hcl
ULTRAM TAB 50MG
tramadol hcl-dietary management product
THERATRAMADOL-60 PAK -60
tramadol-acetaminophen
tramadol hydrochloride-acetaminophen tab 37.5-325
tramadol-acetaminophen
ULTRACET TAB 37.5-325MG
trametinib dimethyl sulfoxide
MEKINIST TAB 0.5MG
trametinib dimethyl sulfoxide
MEKINIST TAB 2MG
treprostinil diolamine
ORENITRAM TAB 0.125MG
treprostinil diolamine
ORENITRAM TAB 0.25MG
treprostinil diolamine
ORENITRAM TAB 1MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 54 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
treprostinil diolamine
ORENITRAM TAB 2.5MG
tretinoin (chemotherapy)
VESANOID CAP 10MG
triazolam
HALCION TAB 0.25MG
triazolam
triazolam tab 0.125mg
triazolam
triazolam tab 0.25mg
trientine hcl
SYPRINE CAP 250MG
trifluridine
trifluridine sol 1% op
trifluridine
VIROPTIC SOL 1% OP
triprolidine hcl
tripohist liq 1.25/5ml
triprolidine tannate
ZYMINE XR SUS 2.5MG
triprolidine tannate-pseudoephedrine tannate
ZYMINE DXR SUS 2.5-45MG
triprolidine-phenylephrine
PROHIST LQ LIQ
triprolidine-pseudoephedrine
PEDIATEX TD LIQ
triprolidine-pseudoephedrine
ZYMINE-D LIQ 1.25-45
urofollitropin purified
BRAVELLE INJ 75UNIT
ustekinumab
STELARA INJ 45MG/0.5
ustekinumab
STELARA INJ 90MG/ML
valganciclovir hcl*
VALCYTE SOL 50MG/ML
valganciclovir hcl*
VALCYTE TAB 450MG
vancomycin hcl
FIRST-VANCOMYCIN 25 SOL 25MG/ML
vancomycin hcl
FIRST-VANCOMYCIN 50 SOL 50MG/ML
vancomycin hcl
VANCOCIN HCL CAP 125MG
vancomycin hcl
VANCOCIN HCL CAP 250MG
vancomycin hcl
vancomycin hcl cap 125mg
vancomycin hcl
vancomycin hcl cap 250mg
vancomycin hcl
VANCOMYCIN HCL INJ 1000MG
vancomycin hcl
VANCOMYCIN HCL INJ 10GM
vancomycin hcl
VANCOMYCIN HCL INJ 500MG
vancomycin hcl
VANCOMYCIN HCL INJ 5GM
vancomycin hcl
VANCOMYCIN HCL INJ 750MG
vancomycin hcl in dextrose
VANCOMYCIN HCL IN DEXTROS E INJ 1GM
vancomycin hcl in dextrose
VANCOMYCIN HCL IN DEXTROS E INJ 500MG
vandetanib
CAPRELSA TAB 100MG
vandetanib
VANDETANIB TAB 300MG
vardenafil hcl
LEVITRA TAB 10MG
vardenafil hcl
LEVITRA TAB 2.5MG
vardenafil hcl
LEVITRA TAB 20MG
vardenafil hcl
LEVITRA TAB 5MG
vardenafil hcl
STAXYN TAB 10MG
varenicline tartrate
CHANTIX PAK 0.5& 1MG
varenicline tartrate
CHANTIX PAK 1MG
varenicline tartrate
CHANTIX TAB 0.5MG
velaglucerase alfa
VPRIV INJ 400UNIT
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 55 of 56
Revision date: March 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
vemurafenib
ZELBORAF TAB 240MG
vigabatrin
SABRIL POW 500MG
vigabatrin
SABRIL TAB 500MG
vismodegib
ERIVEDGE CAP 150MG
voriconazole
VFEND IV INJ 200MG
voriconazole
VFEND SUS 40MG/ML
voriconazole
VFEND TAB 200MG
voriconazole
VFEND TAB 50MG
voriconazole
voriconazole sus 40mg/ml
voriconazole
voriconazole tab 200mg
voriconazole
voriconazole tab 50mg
vorinostat
ZOLINZA CAP 100MG
zaleplon
SONATA CAP 10MG
zaleplon
SONATA CAP 5MG
zaleplon
zaleplon cap 10mg
zaleplon
zaleplon cap 5mg
zanamivir
RELENZA DISKHALER MIS DISKHALE
ziconotide acetate
PRIALT INJ 100MCG
ziconotide acetate
PRIALT INJ 25MCG/ML
zileuton
ZYFLO CR TAB 600MG
zileuton
ZYFLO TAB 600MG
zolmitriptan
ZOMIG SPR 5MG
zolmitriptan
ZOMIG TAB 2.5MG
zolmitriptan
ZOMIG TAB 5MG
zolmitriptan
ZOMIG ZMT TAB 2.5 MG
zolmitriptan
ZOMIG ZMT TAB 5MG
zolpidem tartrate
AMBIEN CR TAB 12.5MG
zolpidem tartrate
AMBIEN CR TAB 6.25MG
zolpidem tartrate
AMBIEN TAB 10MG
zolpidem tartrate
AMBIEN TAB 5MG
zolpidem tartrate
EDLUAR SUB 10MG
zolpidem tartrate
EDLUAR SUB 5MG
zolpidem tartrate
EDLUAR SUB 5MG
zolpidem tartrate
INTERMEZZO SUB 1.75MG
zolpidem tartrate
INTERMEZZO SUB 3.5MG
zolpidem tartrate
zolpidem tartrate er tab 12.5mg
zolpidem tartrate
zolpidem tartrate er tab 6.25mg
zolpidem tartrate
zolpidem tartrate tab 10mg
zolpidem tartrate
zolpidem tartrate tab 5mg
zolpidem tartrate
ZOLPIMIST SPR 5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 56 of 56
Revision date: March 2015