Maintenance Medication Exclusion List

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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
abatacept
abiraterone acetate
acetaminophen
acetaminophen-caff-dihydrocod
acetaminophen-caff-dihydrocod
acetaminophen-codeine
acetaminophen-codeine
acetaminophen-codeine
acetaminophen-codeine
acetaminophen-codeine
acetaminophen-codeine
acetaminophen-codeine
acetaminophen-isometheptene-caffeine
acetaminophen-isometheptene-caffeine
acetaminophen-isometheptene-dichloralphenazone
acetaminophen-mag salicylate-phenyltolox-caffeine
acetaminophen-phenyltoloxamine-caffeine
acetaminophen-salicylamide
acetaminophen-salicylamide-phenyltoloxamine
acetaminophen-salicylamide-phenyltoloxamine
acetaminophen-salicylamide-phenyltoloxamine
acetaminophen-salicylamide-phenyltoloxamine-caffeine
acrivastine-pseudoephedrine
acyclovir sodium
acyclovir sodium
acyclovir sodium
adalimumab
adalimumab
adalimumab
adalimumab
adefovir dipivoxil
afatinib dimaleate
afatinib dimaleate
afatinib dimaleate
alfentanil
almotriptan malate
almotriptan malate
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
alprazolam
ORENCIA INJ 125MG/ML
ORENCIA INJ 250MG
ZYTIGA TAB 250MG
OFIRMEV INJ 10MG/ML
acetaminophen-caffeine-dihydrocodeine bitart tab
TREZIX CAP
acetaminophen-codeine #2 tab 300-15mg
acetaminophen-codeine #3 tab 300-30mg
acetaminophen-codeine #4 tab 300-60mg
acetaminophen-codeine sol 120-12/5
CAPITAL-CODEINE SUS 120-12/5
COCET PLUS TAB 650-60MG
COCET TAB 650-30MG
MIGRALAM CAP
PRODRIN TAB
MIDRIN CAP
cafgesic forte tab
FLEXTRA CAP
FRENADOL TAB
ANABAR TAB
dolorex cap
duraxin cap
cafgesic cap
SEMPREX-D CAP 8-60MG
ACYCLOVIR SODIUM INJ 500MG
ACYCLOVIR SODIUM INJ 1000MG
ACYCLOVIR SODIUM INJ 50MG/ML
HUMIRA KIT 10MG/0.2ML
HUMIRA KIT 20MG/0.4ML
HUMIRA KIT 40MG/0.8ML
HUMIRA PEN KIT 40MG/0.8
HEPSERA TAB 10MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
alfentanil inj 500/ml
AXERT TAB 12.5MG
AXERT TAB 6.25MG
alprazolam er tab 0.5mg er
alprazolam er tab 1mg er
alprazolam er tab 2mg er
alprazolam er tab 3mg er
ALPRAZOLAM INTENSOL CON 1MG/ML
alprazolam odt tab 0.25mg
alprazolam odt tab 0.5mg od
alprazolam odt tab 1mg odt
alprazolam odt tab 2mg odt
alprazolam tab 0.25mg
alprazolam tab 0.5mg
alprazolam tab 1mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 2 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
alprazolam
alprazolam-dietary management product
ambrisentan
ambrisentan
amobarbital sodium
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amoxicillin & pot clavulanate
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphetamine-dextroamphetamine
amphotericin b
amphotericin b lipid
amphotericin b liposome
ampicillin
ampicillin
ampicillin
ampicillin
ampicillin & sulbactam sodium
ampicillin & sulbactam sodium
ampicillin & sulbactam sodium
alprazolam tab 2mg
GABAZOLAMINE PAK
LETAIRIS TAB 5MG
LETAIRIS TAB 10MG
AMYTAL SODIUM INJ 500MG
amoxicillin cap 250mg
amoxicillin cap 500mg
amoxicillin sus 125/5ml
amoxicillin sus 250/5ml
amoxicillin chw 125mg
amoxicillin chw 250mg
amoxicillin tab 500mg
amoxicillin tab 875mg
amoxicillin sus 400/5ml
amoxicillin sus 200/5ml
amoxicillin er tab 775mg
AUGMENTIN SUS 125/5ML
amoxicillin/clavulanate p otassium sus 250/5ml
amoxicillin/clavulanate p otassium tab 250mg
amoxicillin/clavulanate p otassium tab 500mg
amoxicillin/clavulanate p otassium tab 875mg
amoxicillin/clavulanate p otassium sus 400/5ml
amoxicillin/clavulanate p otassium chw 400mg
amoxicillin/clavulanate p otassium chw 200mg
amoxicillin/clavulanate p otassium sus 200/5ml
amoxicillin/clavulanate p otassium sus 600/5ml
amoxicillin/clavulanate p otassium er tab er
ADDERALL TAB 12.5MG
ADDERALL TAB 15MG
ADDERALL TAB 7.5MG
ADDERALL XR CAP 10MG
ADDERALL XR CAP 15MG
ADDERALL XR CAP 20MG
ADDERALL XR CAP 25MG
ADDERALL XR CAP 30MG
ADDERALL XR CAP 5MG
amphetamine-dextroamphetamine tab 10mg
amphetamine-dextroamphetamine tab 20mg
amphetamine-dextroamphetamine tab 30mg
amphetamine-dextroamphetamine tab 5mg
AMPHOTERICIN B INJ 50MG
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
ampicillin cap 250mg
ampicillin cap 500mg
ampicillin sus 125/5ml
ampicillin sus 250/5ml
AMPICILLIN-SULBACTAM INJ 1-0.5GM
AMPICILLIN-SULBACTAM INJ 2-1GM
AMPICILLIN-SULBACTAM INJ 1.5GM
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 3 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
ampicillin & sulbactam sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
ampicillin sodium
anakinra
apomorphine hydrochloride
apremilast
apremilast
armodafinil
armodafinil
armodafinil
aspirin-acetaminophen-salicyl-caff
aspirin-codeine
aspirin-codeine
atovaquone
atovaquone-proguanil hcl
atovaquone-proguanil hcl
avanafil
avanafil
avanafil
axitinib
axitinib
aztreonam
aztreonam
aztreonam lysine
bedaquiline fumarate
benzonatate
benzonatate
benzonatate
benzonatate
benzonatate
betaine
bexarotene
bexarotene (topical)
boceprevir
bosentan
bosentan
bosutinib
bosutinib
brompheniramine maleate
brompheniramine maleate
brompheniramine maleate
brompheniramine maleate
brompheniramine maleate
AMPICILLIN-SULBACTAM INJ 3GM
AMPICILLIN SODIUM INJ 1GM
AMPICILLIN SODIUM INJ 10GM
AMPICILLIN SODIUM INJ 10GM
AMPICILLIN SODIUM INJ 125MG
AMPICILLIN SODIUM INJ 2GM
AMPICILLIN SODIUM INJ 250MG
AMPICILLIN SODIUM INJ 500MG
AMPICILLIN SODIUM INJ 1GM
AMPICILLIN SODIUM INJ 2GM
KINERET INJ
APOKYN INJ
OTEZLA TAB 10/20/30
OTEZLA TAB 30MG
NUVIGIL TAB 150MG
NUVIGIL TAB 250MG
NUVIGIL TAB 50MG
LEVACET TAB
aspirin-codeine tab 325-30mg
aspirin-codeine tab 325-60mg
MEPRON SUS
MALARONE TAB 62.5-25
atovaquone/proguanil hcl tab 250-100
STENDRA TAB 100MG
STENDRA TAB 200MG
STENDRA TAB 50MG
INLYTA TAB 1MG
INLYTA TAB 5MG
AZTREONAM INJ 1GM
AZTREONAM INJ 2GM
CAYSTON INH 75MG
SIRTURO TAB 100MG
benzonatate cap 100mg
benzonatate cap 200mg
TESSALON CAP 200MG
TESSALON PERLES CAP 100MG
ZONATUSS CAP 150MG
CYSTADANE
TARGRETIN CAP 75MG
TARGRETIN GEL 1%
VICTRELIS CAP 200MG
TRACLEER TAB 125MG
TRACLEER TAB 62.5MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
bromspiro liq 2mg/5ml
J-TAN PD DROP 1MG/ML
LODRANE 24 CAP
lohist-12 tab 12 hour
RESPA-BR TAB 11MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 4 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
brompheniramine maleate-phenylephrine hcl tannate
brompheniramine tannate
brompheniramine tannate
brompheniramine tannate
brompheniramine tannate
brompheniramine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-phenylephrine tannate
brompheniramine tannate-pseudoephedrine tannate
brompheniramine tannate-pseudoephedrine tannate
brompheniramine-diphenhydramine
brompheniramine-diphenhydramine-phenylephrine
brompheniramine-dm-guaifenesin
brompheniramine-dm-guaifenesin
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
brompheniramine-phenylephrine
bromphen-pseudoephed-chlorphen-phenyleph-methscopol
budesonide
bulk chemicals
buprenorphine
buprenorphine
buprenorphine
VAZOTAB CHW
BROVEX CT CHW 12MG
BROVEX SUS 12MG/5ML
J-TAN SUS
P-TEX SUS 10MG/5ML
TANACOF-XR SUS 8MG/5ML
brompheniramine tann/phenylephrine tann sus 4-5mg
brompheniramine/phenylephrine tannate sus
BROVEX ADT SUS 12-10
C-TAN D PLUS SUS
J-TAN D SUS
RELHIST CHW
tanabid chw 2.2-1.58
BROVEX PD SUS
LODRANE D SUS
ALA-HIST TAB 6-25MG
ALA-HIST D TAB 6-25-20
TRISPEC SFX LIQ
TUSNEL CAP
ALACOL DROP 0.4-1MG
ALACOL SYP 2-5MG
andehist nr syp 4-45mg/ml
bpm pe liq
bpm pseudo tab 6-45mg
bromax d tab
bromfenex cap 12-120cr
bromhist pediatric drop
bromhist-nr drop
brompheniramine/pse cap 9-90mg
BROVEX PEB LIQ
BROVEX PSB LIQ
BROVEX PSE TAB 4-40MG
DECON-A ELX 2-5MG/5ML
entre-b sus 6-10mg/5ml
HISTEX SR TAB 10-120MG
J-TAN D PD DROP 1-7.5MG
LODRANE 24D CAP 12-90MG
phenylephrine hcl/bromphenir mal cap 15-12mg
phenylephrine hcl/bromphenir mal cap 7.5-6mg
pse bpm liq
respahist cap 6-60mgcr
tanabid sr tab 6-30mg
vazotab tab
ZOTEX PE TAB
SYMPAK II MIS
UCERIS TAB 9MG
BULK CHEMICALS
BUTRANS DIS 10MCG/HR
BUTRANS DIS 15MCG/HR
BUTRANS DIS 20MCG/HR
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 5 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
buprenorphine
buprenorphine
buprenorphine hcl
buprenorphine hcl
buprenorphine hcl
buprenorphine hcl
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
buprenorphine hcl-naloxone hcl dihydrate
butabarbital sodium
butabarbital sodium
butabarbital sodium
butalbital-acetaminophen
butalbital-acetaminophen
butalbital-acetaminophen
butalbital-acetaminophen
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine
butalbital-acetaminophen-caffeine-codeine
butalbital-acetaminophen-caffeine-codeine
butalbital-aspirin-caffeine
butalbital-aspirin-caffeine
butalbital-aspirin-caffeine-codeine
butorphanol tartrate
butorphanol tartrate
butorphanol tartrate
c1 esterase inhibitor (recombinant)
cabozantinib s-malate
cabozantinib s-malate
cabozantinib s-malate
canakinumab
carbetapentane citrate-carbetapentane tannate-pe hcl-pe tan
carbetapentane citrate-guaifenesin tannate
carbetapentane citrate-pseudoephedrine hcl tannate
carbetapentane citrate-pseudoephedrine hcl tannate
carbetapentane citrate-pseudoephedrine hcl tannate
BUTRANS DIS 5MCG/HR
BUTRANS DIS 7.5MCG/HR
BUPRENEX INJ 0.3MG/ML
buprenorphine hcl inj 0.3mg/ml
buprenorphine hcl sub 2mg
buprenorphine hcl sub 8mg
BUNAVAIL MIS 2.1-0.3
BUNAVAIL MIS 4.2-0.7
BUNAVAIL MIS 6.3-1MG
buprenorphine hcl-naloxone hcl dihydrate sub 2-0.5mg
buprenorphine hcl-naloxone hcl dihydrate sub 8-2mg
SUBOXONE MIS 12-3MG
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
SUBOXONE SUB 2-0.5MG
SUBOXONE SUB 8-2MG
ZUBSOLV SUB 1.4-0.36
ZUBSOLV SUB 5.7-1.4
BUTISOL SODIUM ELX 30MG/5ML
BUTISOL SODIUM TAB 30MG
BUTISOL SODIUM TAB 50MG
butalbital/acetaminophen tab 50-325
ORBIVAN CF TAB 50-300MG
PHRENILIN FORTE CAP FORTE
promacet tab 50-650mg
ALAGESIC LQ SOL
butalbital/acetaminophen/caffeine cap
butalbital/acetaminophen/caffeine tab
DOLGIC PLUS TAB
ORBIVAN CAP
zebutal cap
butalbital-acetaminophen-caffeine-codeine cap
FIORICET-CODEINE CAP
butalbital-aspirin-caffeine cap
butalbital-aspirin-caffeine tab
ascomp-codeine cap 30mg
butorphanol tartrate inj 1mg/ml
butorphanol tartrate inj 2mg/ml
butorphanol tartrate sol 10mg/ml
RUCONEST INJ 2100UNIT
COMETRIQ KIT 140MG
COMETRIQ KIT 100MG
COMETRIQ KIT 60MG
ILARIS INJ 180MG
CARBATUSS-12 SUS
RESPI-TANN G SUS
RESPI-TANN CHW
RESPI-TANN PD SUS
RESPI-TANN SUS
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 6 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
carbetapentane tannate
carbetapentane tannate-pyrilamine tannate
carbetapentane-guaifenesin
carbetapentane-guaifenesin
carbetapentane-guaifenesin
carbetapentane-guaifenesin
carbetapentane-guaifenesin
carbetapentane-guaifenesin
carbetapentane-pseudoephedrine
carbinoxamine maleate
carbinoxamine maleate
cefaclor
cefaclor
cefaclor
cefaclor
cefaclor
cefaclor monohydrate
cefadroxil
cefadroxil
cefadroxil
cefadroxil
cefazolin in d5w
cefazolin sodium
cefazolin sodium
cefazolin sodium
cefazolin sodium
cefazolin sodium
cefazolin sodium
cefazolin sodium
cefazolin sodium and dextrose
cefazolin sodium and dextrose
cefdinir
cefdinir
cefdinir
cefditoren pivoxil
cefditoren pivoxil
cefepime hcl
cefepime hcl
cefepime hcl
cefepime hcl
cefepime hcl
cefepime hcl
cefepime hcl and dextrose
cefepime hcl and dextrose
cefixime
cefixime
cefixime
cefixime
cefixime
cefixime
SOLOTUSS SUS 30MG/5ML
PYRLEX CB SUS
CARBA-XP LIQ
DYNEX VR CAP
EXALL LIQ 10-100MG
EXPECTUSS LIQ 20-75MG/ML
TUSSO-ZMR CAP 8-200MG
TUSSO-ZR SYP 7.5-150
CORZALL LIQ 20-30MG
carbinoxamine maleate liq 4mg/5ml
carbinoxamine maleate tab 4mg
cefaclor cap 250mg
cefaclor cap 500mg
cefaclor sus 125/5ml
cefaclor sus 250/5ml
cefaclor sus 375/5ml
cefaclor er tab 500mg
cefadroxil cap 500mg
cefadroxil sus 250/5ml
cefadroxil sus 500/5ml
cefadroxil tab 1gm
cefazolin sodium inj 1gm/50ml
cefazolin sodium inj 1gm
cefazolin sodium inj 10gm
cefazolin sodium inj 20gm
cefazolin sodium inj 500mg
cefazolin sodium inj 300gm
cefazolin sodium inj 100gm
cefazolin sodium inj 1gm
cefazolin sodium/dextrose sol 1gm
cefazolin sodium/dextrose sol 2gm
cefdinir cap 300mg
cefdinir sus 125/5ml
cefdinir sus 250/5ml
cefditoren pivoxil tab 200mg
cefditoren pivoxil tab 400mg
cefepime inj 1gm
cefepime inj 2gm
maxipime inj 1gm
maxipime inj 2gm
cefepime inj 1gm
cefepime inj 2gm
cefepime inj 1gm
cefepime inj 2gm
SUPRAX SUS 100/5ML
SUPRAX TAB 400MG
SUPRAX CAP 400MG
SUPRAX SUS 200/5ML
SUPRAX CHW 100MG
SUPRAX SUS 500/5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 7 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
cefotaxime sodium
cefotaxime sodium
cefotaxime sodium
cefotaxime sodium
cefotaxime sodium
cefotaxime sodium
cefotetan disodium
cefotetan disodium
cefotetan disodium
cefotetan disodium and dextrose
cefotetan disodium and dextrose
cefoxitin sodium
cefoxitin sodium
cefoxitin sodium
cefoxitin sodium and dextrose
cefoxitin sodium and dextrose
cefoxitin sodium in dextrose
cefoxitin sodium in dextrose
cefpodoxime proxetil
cefpodoxime proxetil
cefpodoxime proxetil
cefpodoxime proxetil
cefprozil
cefprozil
cefprozil
cefprozil
ceftaroline fosamil
ceftaroline fosamil
ceftazidime
ceftazidime
ceftazidime
ceftazidime
ceftazidime
ceftazidime
ceftazidime and dextrose
ceftazidime and dextrose
ceftazidime sodium in d5w
ceftazidime sodium in d5w
ceftibuten
ceftibuten
ceftibuten
ceftriaxone sodium
ceftriaxone sodium
ceftriaxone sodium
ceftriaxone sodium
ceftriaxone sodium
ceftriaxone sodium
ceftriaxone sodium
ceftriaxone sodium and dextrose
ceftriaxone sodium and dextrose
CEFOTAXIME SODIUM INJ 500MG
CEFOTAXIME SODIUM INJ 1GM
CLAFORAN INJ 10GM
CEFOTAXIME SODIUM INJ 2GM
CLAFORAN INJ 1GM
CLAFORAN INJ 2GM
CEFOTETAN INJ 10G
CEFOTETAN INJ 1GM/10ML
CEFOTETAN INJ 2GM/20ML
CEFOTETAN/DEXTROSE INJ 1-3.58%
CEFOTETAN/DEXTROSE INJ 2-2.08%
CEFOXITIN SODIUM INJ 10GM
CEFOXITIN SODIUM INJ 1GM
CEFOXITIN SODIUM INJ 2GM
CEFOXITIN SODIUM INJ 1GM
CEFOXITIN SODIUM INJ 2GM
MEFOXIN INJ 1GM/50ML
MEFOXIN INJ 2GM/50ML
cefpodoxime proxetil sus 50mg/5ml
cefpodoxime proxetil sus 100/5ml
cefpodoxime proxetil tab 100mg
cefpodoxime proxetil tab 200mg
cefprozil sus 125/5ml
cefprozil sus 250/5ml
cefprozil tab 250mg
cefprozil tab 500mg
TEFLARO INJ 400MG
TEFLARO INJ 600MG
TAZICEF INJ 1GM
TAZICEF INJ 2GM
FORTAZ INJ 500MG
TAZICEF INJ 6GM
TAZICEF INJ 1GM
TAZICEF INJ 2GM
CEFTAZIDIME/DEXTROSE SOL D5W 1GM
CEFTAZIDIME/DEXTROSE SOL D5W 2GM
FORTAZ INJ 1GM
FORTAZ INJ 2GM
CEDAX CAP 400MG
CEDAX SUS 90MG/5ML
ceftibuten sus 180/5ml
CEFTRIAXONE SODIUM INJ 1GM
CEFTRIAXONE SODIUM INJ 10GM
CEFTRIAXONE SODIUM INJ 2GM
CEFTRIAXONE SODIUM INJ 250MG
CEFTRIAXONE SODIUM INJ 500MG
CEFTRIAXONE SODIUM INJ 1GM
CEFTRIAXONE SODIUM INJ 2GM
CEFTRIAXONE/DEXTROSE INJ 1GM
CEFTRIAXONE/DEXTROSE INJ 2GM
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 8 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
ceftriaxone sodium in dextrose
ceftriaxone sodium in dextrose
cefuroxime axetil
cefuroxime axetil
cefuroxime axetil
cefuroxime axetil
cefuroxime in sterile water
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium
cefuroxime sodium and dextrose
cefuroxime sodium and dextrose
cephalexin
cephalexin
cephalexin
cephalexin
cephalexin
cephalexin
cephalexin
ceretinib
certolizumab pegol
certolizumab pegol
cetirizine hcl
cetrorelix acetate
cetrorelix acetate
chlophedianol-triprolidine
chloral hydrate
chloral hydrate
chloral hydrate
chlordiazepoxide hcl
chlordiazepoxide hcl
chlordiazepoxide hcl
chlordiazepoxide hcl
chlorpheniramine maleate
chlorpheniramine maleate
chlorpheniramine maleate
chlorpheniramine maleate
chlorpheniramine maleate tannate
chlorpheniramine maleate-pseudoephedrine hcl tannate
chlorpheniramine mal-phenylephrine hcl-methscop tan
chlorpheniramine tannate
chlorpheniramine tannate
chlorpheniramine tannate
chlorpheniramine tannate
chlorpheniramine tannate-carbetapentane tannate
chlorpheniramine tannate-carbetapentane tannate
CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ DEX 1GM
CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ DEX 2GM
cefuroxime axetil tab 250mg
cefuroxime axetil tab 500mg
CEFTIN SUS 125/5ML
CEFTIN SUS 250/5ML
ZINACEF INJ 1.5GM PB
CEFUROXIME SODIUM INJ 1.5GM
CEFUROXIME SODIUM INJ 1.5GM
CEFUROXIME SODIUM INJ 7.5GM
CEFUROXIME SODIUM INJ 7.5GM
CEFUROXIME SODIUM INJ 750MG
CEFUROXIME SODIUM INJ 75GM
ZINACEF INJ 750MG
CEFUROXIME/DEXTROSE INJ 1.5GM
CEFUROXIME/DEXTROSE INJ 750MG
cephalexin cap 250mg
cephalexin cap 500mg
cephalexin sus 125/5ml
cephalexin sus 250/5ml
cephalexin tab 250mg
cephalexin tab 500mg
cephalexin cap 750mg
ZYKADIA CAP 150MG
CIMZIA KIT
CIMZIA KIT 200MG/ML
cetirizine hcl syp 1mg/ml
CETROTIDE KIT 0.25MG
CETROTIDE KIT 3MG
PROHIST CF LIQ
CHLORAL HYDRATE SUP 500MG
CHLORAL HYDRATE SYP 500/5ML
SOMNOTE CAP 500MG
chlordiazepoxide hcl cap 10mg
chlordiazepoxide hcl cap 25mg
chlordiazepoxide hcl cap 5mg
LIBRIUM INJ 100MG
CHLORPHENIRAMINE MALEATE ER CAP 12MG
chlorpheniramine maleate er cap 8mg
CPM CAP 12MG CR
ED CHLORPED LIQ 2MG/ML
PEDIOX-S SUS 4MG/5ML
SUDAL 12 TANNATE CHW 4-30MG
AH-CHEW ULTRA SUS ULTRA
AHIST TAB 12MG
ED CHLORPED SUS 2MG/ML
ED-CHLOR-TAN TAB 8MG
pediaphyl sus 8mg/5ml
c-tanna 12 sus 4-30mg/5ml
TUSSI-12 TAB 5-60MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 9 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
chlorpheniramine tannate-methscopolamine
chlorpheniramine tannate-methscopolamine
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tannate-phenylephrine tannate
chlorpheniramine tan-phenylephrine tan-methscop
chlorpheniramine tan-phenylephrine tan-methscop
chlorpheniramine tan-phenylephrine tan-methscop
chlorpheniramine tan-pseudoephrine tan
chlorpheniramine tan-pyrilamine tan-phenylephrine tan
chlorpheniramine tan-pyrilamine tan-phenylephrine tan
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-codeine
chlorpheniramine-dm-guaifenesin
chlorpheniramine-methscopolamine
chlorpheniramine-methscopolamine
chlorpheniramine-methscopolamine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine
chlorpheniramine-phenylephrine-acetaminophen
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
DEXODRYL CHW 2-1.5MG
DEXODRYL SUS
ALLERX SUS
DALLERGY-JR SUS
ED CHLORPED D SUS
p-tann d sus
r-tanna pediatric sus
r-tanna tab 9-25mg
RYNATAN PEDIATRIC CHW 4.5-5MG
AH-CHEW ULTRA CHW ULTRA
redur-pcm sus
SYMPAK PDX MIS
DICEL SUS
conal sus
nalex-a 12 sus
CODAR AR LIQ
COTAB A TAB 4-10MG
COTAB AX TAB 4-20MG
endacof-c liq 2-10mg/5ml
ZODRYL AC 25 SUS
ZODRYL AC 30 SUS
ZODRYL AC 35 SUS
ZODRYL AC 40 SUS
ZODRYL AC 50 SUS
ZODRYL AC 60 SUS
ZODRYL AC 80 SUS
Z-TUSS AC LIQ 2-9/5ML
ALLFEN DMA TAB 4-20-400
relcof cpm tab 8-2.5mg
respivent df mis
RYNEZE LIQ
ACCUHIST DROP 1-2.5MG
centergy drop 1-2mg/ml
chlorpheniramine-phenylephrine
c-phen drop
DALLERGY JR CAP 4-20MG
ED A-HIST LIQ 4-10/5ML
HISTEX SR TAB 6-15MG
nohist tab 8-20mg
sildec-pe syp
PROTID TAB CR
AEROKID SYP
AH-CHEW II CHW
ALLERX PE MIS
chlor-mes d syp liquid
cpm 8-pe 20-msc 1.25 tab
DALLERGY CHW
DALLERGY PE SYP
DALLERGY PE TAB
DALLERGY SYP
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 10 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-phenylephrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephedrine-methscopolamine
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephrine
chlorpheniramine-pseudoephrine
chlorpheniramine-pyrilamine-phenylephrine
chlorpheniramine-pyrilamine-phenylephrine
chlorpheniramine-pyrilamine-phenylephrine
chlorpheniramine-pyrilamine-phenylephrine
chlorphenir-phenylephrine-methscopol-homeopathic
chlorphenir-phenyltoloxamine-phenylephrine-acetaminophen
chlorphenir-pseudoephedrine-belladonna alkaloids
chlorphenir-pseudoephedrine-homeopathic product
chlorphenir-pyrilamine tan-phenyleph hcl-phenyleph tan
chlorphen-phenyltolox-phenylephrine
chlorphen-phenyltolox-phenylephrine
chlorphen-pse-atropine-hyoscyamine-scopolamine
choriogonadotropin alfa
chorionic gonadotropin
cinacalcet hcl
cinacalcet hcl
cinacalcet hcl
ciprofloxacin
ciprofloxacin
ciprofloxacin
ciprofloxacin
ciprofloxacin hcl
ciprofloxacin hcl
ciprofloxacin hcl
ciprofloxacin in d5w
ciprofloxacin in d5w
ciprofloxacin-ciprofloxacin hcl
DALLERGY TAB
DALLERGY TAB ER
DEHISTINE SYP
OMNIHIST II LA TAB LA
phenylephrine cm tab
re-drylex jr tab
RELCOF DN PE MIS
RESCON TAB
coldamine tab 8-90-2.5
DALLERGY PSE TAB
DRYMAX SYP
pcm la tab
RELCOF DN PSE MIS PSE
relcof pse tab
TIME-HIST QD TAB
visrx dose pack tab dose pac
CHLORPHENIRAMINE/PSEUDOEPHEDRINE SYP
chlorpheniramine-pseudoephedrine cr cap 8-120
DECONAMINE TAB 4-60MG
duratuss da cap 12-100mg
LOHIST-D LIQ
neutrahist drop 0.8-9mg
SUDAHIST TAB 12-120MG
myhist-pd liq
PHENA-PLUS TAB
PHENA-S LIQ
RU-HIST FORTE TAB FORTE
ZINX KIDS SNEEZE KIT SNEEZE
NOREL SR TAB
RESPA-A.R. TAB
ZINX ALLERGY KIT
PHENA-S 12 SUS
chlorpheniramine-phenyltoloxamine-phenylephrine liq
rhinacon a tab
ru-tuss tab
OVIDREL INJ
chorionic gonadotropin inj 10000unt
SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG
CIPRO SUS 250MG/5
CIPRO SUS 500MG/5
CIPROFLOXACIN INJ 400MG
CIPROFLOXACIN INJ 200MG
ciprofloxacin hcl tab 250mg
ciprofloxacin hcl tab 500mg
ciprofloxacin hcl tab 750mg
CIPROFLOXACIN I.V.-IN D5W INJ 200MG
CIPROFLOXACIN I.V.-IN D5W INJ 400MG
ciprofloxacin er tab 500mg er
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 11 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
ciprofloxacin-ciprofloxacin hcl
clemastine fumarate
clemastine fumarate
clemastine fumarate
clomiphene citrate
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clonazepam
clorazepate dipotassium
clorazepate dipotassium
clorazepate dipotassium
clorazepate dipotassium
clorazepate dipotassium
clotrimazole
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
clozapine
codeine phosphate
codeine phosphate
codeine phosphate
codeine sulfate
codeine sulfate
codeine sulfate
codeine sulfate
codeine-brompheniramine
codeine-brompheniramine
codeine-brompheniramine
codeine-chlorcyclizine
codeine-chlorpheniramine-acetaminophen
codeine-phenylephrine-chlorcyclizine
codeine-pseudoephedrine-chlorcyclizine
codeine-pyrilamine
corticotropin
crizotinib
crizotinib
cycloserine
cyproheptadine hcl
cyproheptadine hcl
cysteamine bitartrate
ciprofloxacin er tab 1000mg
clemastine fumarate syp 0.5/5ml
clemastine fumarate tab 2.68mg
TAVIST ALLERGY TAB 1.34MG
clomiphene citrate tab 50mg
clonazepam odt tab 0.125mg
clonazepam odt tab 0.25mg
clonazepam odt tab 0.5mg
clonazepam odt tab 1mg
clonazepam odt tab 2mg
clonazepam tab 0.5mg
clonazepam tab 1mg
clonazepam tab 2mg
clorazepate dipotassium tab 15mg
clorazepate dipotassium tab 3.75mg
clorazepate dipotassium tab 7.5mg
TRANXENE-SD TAB 11.25MG
TRANXENE-SD TAB 22.5MG
clotrimazole tro 10mg
CLOZARIL TAB 25MG
CLOZARIL TAB 100MG
CLOZAPINE TAB 50MG
CLOZAPINE TAB 200MG
FAZACLO TAB 25MG ODT
FAZACLO TAB 100/ODT
FAZACLO TAB 12.5/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
CODEINE PHOSPHATE INJ 30MG/2ML
CODEINE PHOSPHATE INJ 60MG/2ML
CODEINE PHOSPHATE TAB SOL 30MG
CODEINE SULFATE SOL 30MG/5ML
CODEINE SULFATE TAB 15MG
CODEINE SULFATE TAB 30MG
CODEINE SULFATE TAB 60MG
BROVEX CB TAB 10-4MG
BROVEX CBX TAB 20-4MG
NALEX AC SYP
NOTUSS-NX LIQ
COTABFLU TAB 20-4-500
NASOTUSS LIQ
NOTUSS-NXD LIQ
PRO-CLEAR AC SYP
ACTHAR HP INJ 80UNIT
XALKORI CAP 250MG
XALKORI CAP 200MG
cycloserine cap 250mg
cyproheptadine hcl syp 2mg/5ml
cyproheptadine hcl tab 4mg
CYSTAGON CAP 150MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 12 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
cysteamine bitartrate
cysteamine bitartrate
cysteamine bitartrate
dabrafenib mesylate
dabrafenib mesylate
dalfampridine
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
darbepoetin alfa-polysorbate 80
dasatinib
dasatinib
dasatinib
dasatinib
dasatinib
dasatinib
deferasirox
deferasirox
deferasirox
deferiprone
denosumab
denosumab
desflurane
desloratadine
desloratadine
desloratadine
desloratadine
desloratadine-pseudoephedrine
desloratadine-pseudoephedrine
dexbrompheniramine tannate-pyrilamine maleate
dexbrompheniramine tan-pyrilamine mal-phenylephrine tan
dexchlorpheniramine maleate
dexchlorpheniramine maleate
dexchlorpheniramine tannate-pseudoephedrine tannate
dexchlorpheniramine-phenylephrine
dexchlorpheniramine-phenylephrine
dexchlorpheniramine-phenylephrine
dexchlorpheniramine-phenylephrine-methscopolamine
dexchlorpheniramine-pseudoephedrine-methscopolamine
CYSTAGON CAP 50MG
PROCYSBI CAP 25MG
PROCYSBI CAP 75MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
AMPYRA TAB 10MG
ARANESP ALBUMIN FREE INJ 25MCG
ARANESP ALBUMIN FREE INJ 40MCG
ARANESP ALBUMIN FREE INJ 60MCG
ARANESP ALBUMIN FREE INJ 100MCG
ARANESP ALBUMIN FREE INJ 200MCG
ARANESP ALBUMIN FREE INJ 40MCG
ARANESP ALBUMIN FREE INJ 60MCG
ARANESP ALBUMIN FREE INJ 100MCG
ARANESP ALBUMIN FREE INJ 150MCG
ARANESP ALBUMIN FREE INJ 500MCG
ARANESP ALBUMIN FREE INJ 200MCG
ARANESP ALBUMIN FREE INJ 25MCG
ARANESP ALBUMIN FREE INJ 300MCG
ARANESP ALBUMIN FREE INJ 300MCG
ARANESP ALBUMIN FREE INJ 150MCG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 100MG
SPRYCEL TAB 80MG
SPRYCEL TAB 140MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX TAB 500MG
PROLIA SOL 60MG/ML
XGEVA INJ
SUPRANE INH
CLARINEX REDITABS TAB 2.5MG
CLARINEX REDITABS TAB 5MG
CLARINEX SYP 0.5MG/ML
CLARINEX TAB 5MG
CLARINEX-D 12 HOUR TAB 2.5-120
CLARINEX-D 24 HOUR TAB 5-240MG
POLY TAN SUS
POLY TAN D SUS
DEXCHLORPHENIRAMINE MALEATE SYP 2MG/5ML
dexchlorpheniramine maleate tab 6mg cr
SUTAN SUS
NALDEX TAB
RESCON-JR TAB
RESCON-MX TAB
dexphen m sol
DURAHIST D TAB
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 13 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
dexmedetomidine hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine sulfate
dextromethorphan hbr-guaifenesin tannate
dextromethorphan-chlorpheniramine-methscopolamine
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-guaifenesin
dextromethorphan-potassium guaiacolsulfonate
dextromethorphan-potassium guaiacolsulfonate
diazepam
diazepam
diazepam
diazepam
diazepam
diazepam
diazepam (anticonvulsant)
diazepam (anticonvulsant)
diazepam (anticonvulsant)
dicloxacillin sodium
dicloxacillin sodium
dihydrocodeine compound
dihydrocodeine-guaifenesin
dihydroergotamine mesylate
dihydroergotamine mesylate
dimethyl fumarate
dimethyl fumarate
dimethyl fumarate
dimethyl sulfoxide
diphenhydramine hcl
PRECEDEX INJ 100MCG
FOCALIN TAB 10MG
FOCALIN TAB 2.5MG
FOCALIN TAB 5MG
FOCALIN XR CAP 10MG
FOCALIN XR CAP 15MG
FOCALIN XR CAP 20MG
FOCALIN XR CAP 25MG
FOCALIN XR CAP 30MG
FOCALIN XR CAP 35MG
FOCALIN XR CAP 40MG
FOCALIN XR CAP 5MG
dextroamphetamine sulfate er cap 10mg er
dextroamphetamine sulfate er cap 15mg er
dextroamphetamine sulfate er cap 5mg er
dextroamphetamine sulfate tab 10mg
ZENZEDI TAB 2.5MG
zenzedi tab 5mg
ZENZEDI TAB 7.5MG
DURATUSS DM 12 SUS DM
EXTENDRYL DM TAB
allfen dm tab 400-20mg
dm/guai liq 10-300mg
DURATUSS DM ELX
gani-tuss dm nr liq 100-10/5
NORTUSS-EX LIQ 200-20/5
su-tuss dm elx 200-20/5
TRISPEC DMX LIQ
guiadex dm liq
PROLEX DMX LIQ
DIAZEPAM INJ 5MG/ML
DIAZEPAM INTENSOL CON 5MG/ML
DIAZEPAM SOL 1MG/ML
diazepam tab 10mg
diazepam tab 2mg
diazepam tab 5mg
DIASTAT ACUDIAL GEL 12.5-20
DIASTAT ACUDIAL GEL 5-10MG
DIASTAT PEDIATRIC GEL 2.5MG
dicloxacillin sodium cap 250mg
dicloxacillin sodium cap 500mg
SYNALGOS-DC CAP
J-MAX DHC LIQ
dihydroergotamine mesylate inj 1mg/ml
MIGRANAL SPR 4MG/ML
TECFIDERA STARTER PACK MIS STARTER
TECFIDERA CAP 120MG
TECFIDERA CAP 240MG
RIMSO-50 SOL 50%
diphenhydramine hcl cap 25mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 14 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
diphenhydramine hcl
diphenhydramine hcl
diphenhydramine hcl
diphenhydramine hcl
diphenhydramine hcl-phenylephrine hcl tannate
diphenhydramine tannate
diphenhydramine tannate
diphenhydramine tannate-carbetapentane tannate
diphenhydramine tannate-phenylephrine tannate
diphenhydramine tannate-phenylephrine tannate
diphenhydramine-phenylephrine
diphenhydramine-pseudoephrineed
dornase alfa
doxycycline calcium
doxylamine succinate
doxylamine succinate tannate
droperidol
droxidopa
droxidopa
droxidopa
eletriptan hydrobromide
eletriptan hydrobromide
eliglustat
eltrombopag olamine
eltrombopag olamine
eltrombopag olamine
eltrombopag olamine
enflurane
enfuvirtide
enfuvirtide
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enzalutamide
ephedrine-guaifenesin
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
epoetin alfa
ergoloid mesylates
ergotamine tartrate
ergotamine-caffeine
diphenhydramine hcl cap 50mg
diphenhydramine hcl elx 12.5/5ml
diphenhydramine hcl inj 50mg/ml
dytuss syp 12.5/5ml
ALDEX-CT CHW 12.5-5MG
ben-tann sus 25mg/5ml
DYTAN CHW 25MG
D-TANN AT SUS
d-tann chw 25-10mg
d-tann sus 25-7.5mg
zoden pd liq 25-7.5
TEKRAL TAB
PULMOZYME SOL 1MG/ML
VIBRAMYCIN SYP 50MG/5ML
DOXYTEX LIQ
ALDEX AN SUS
droperidol inj 2.5mg/ml
NORTHERA CAP 100MG
NORTHERA CAP 200MG
NORTHERA CAP 300MG
RELPAX TAB 20MG
RELPAX TAB 40MG
CERDELGA 84MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
PROMACTA TAB 12.5MG
ETHRANE INH
FUZEON KIT
FUZEON INJ 90MG
LOVENOX INJ 30/0.3ML
ENOXAPARIN SODIUM INJ 60/0.6ML
LOVENOX INJ 80/0.8ML
LOVENOX INJ 100MG/ML
LOVENOX INJ 300/3ML
LOVENOX INJ 40/0.4ML
LOVENOX INJ 150MG/ML
LOVENOX INJ 120/0.8
XTANDI CAP 40MG
BRONCHOLATE SYP 6.25-100
EPOGEN INJ 2000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
PROCRIT INJ 3000/ML
EPOGEN INJ 20000/ML
PROCRIT INJ 40000/ML
PROCRIT INJ 10000/ML
ergoloid mesylates tab 1mg
ERGOMAR SUB 2MG
ergotamine tartrate-caffeine tab 1/100
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 15 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
ergotamine-caffeine
erlotinib
erlotinib
erlotinib
ertapenem sodium
estazolam
estazolam
estramustine phosphate sodium
eszopiclone
eszopiclone
eszopiclone
etanercept
etanercept
etanercept
etanercept
ethambutol hcl
ethambutol hcl
etomidate
etomidate
everolimus
everolimus
everolimus
everolimus
everolimus
everolimus
everolimus
factor ix complex
factor ix complex
factor ix complex
factor ix complex
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
MIGERGOT SUP 2/100
TARCEVA TAB 150MG
TARCEVA TAB 100MG
TARCEVA TAB 25MG
INVANZ INJ 1GM
estazolam tab 1mg
estazolam tab 2mg
EMCYT CAP 140MG
LUNESTA TAB 1MG
LUNESTA TAB 2MG
LUNESTA TAB 3MG
ENBREL INJ 25/0.5ML
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
ENBREL SURECLICK INJ 50MG/ML
ETHAMBUTOL HCL TAB 100MG
ETHAMBUTOL HCL TAB 400MG
AMIDATE INJ 2MG/ML
etomidate inj 2mg/ml
AFINITOR TAB 5MG
AFINITOR TAB 10MG
AFINITOR TAB 2.5MG
AFINITOR TAB 7.5MG
AFINITOR DISPERZ TAB 2MG
AFINITOR DISPERZ TAB 3MG
AFINITOR DISPERZ TAB 5MG
PROFILNINE SD INJ 1000UNIT
PROFILNINE SD INJ 500UNIT
PROFILNINE SD INJ
PROFILNINE SD INJ 1500UNIT
fentanyl dis 100mcg/hr
fentanyl dis 12mcg/hr
fentanyl dis 25mcg/hr
fentanyl dis 50mcg/hr
fentanyl dis 75mcg/hr
SUBSYS SPR 100MCG
SUBSYS SPR 1200MCG
SUBSYS SPR 1600MCG
SUBSYS SPR 200MCG
SUBSYS SPR 400MCG
SUBSYS SPR 600MCG
SUBSYS SPR 800MCG
ABSTRAL SUB 100MCG
ABSTRAL SUB 200MCG
ABSTRAL SUB 300MCG
ABSTRAL SUB 400MCG
ABSTRAL SUB 600MCG
ABSTRAL SUB 800MCG
fentanyl citrate inj 0.05mg/1ml
fentanyl citrate oral transmucosal loz 1200mcg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 16 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fentanyl citrate
fexofenadine hcl
fexofenadine hcl
fexofenadine hcl
fexofenadine hcl
fexofenadine hcl
fexofenadine-pseudoephedrine
fexofenadine-pseudoephedrine
fidaxomicin
fingolimod hcl
flavocoxid
flavocoxid
flavocoxid-citrated zinc bisglycinate
flavocoxid-citrated zinc bisglycinate
fluconazole
fluconazole
fluconazole
fluconazole
fluconazole
fluconazole
fluconazole in dextrose
fluconazole in dextrose
fluconazole in nacl
fluconazole in nacl
fluconazole in nacl
flurazepam hcl
flurazepam hcl
follitropin alfa
follitropin alfa
follitropin alfa
follitropin alfa
follitropin alfa
fentanyl citrate oral transmucosal loz 1600mcg
fentanyl citrate oral transmucosal loz 200mcg
fentanyl citrate oral transmucosal loz 400mcg
fentanyl citrate oral transmucosal loz 600mcg
fentanyl citrate oral transmucosal loz 800mcg
FENTANYL CITRATE POWDER
FENTORA TAB 100MCG
FENTORA TAB 200MCG
FENTORA TAB 300MCG
FENTORA TAB 400MCG
FENTORA TAB 600MCG
FENTORA TAB 800MCG
LAZANDA SPR 100MCG
LAZANDA SPR 400MCG
ONSOLIS MIS 1200MCG
ONSOLIS MIS 200MCG
ONSOLIS MIS 400MCG
ONSOLIS MIS 600MCG
ONSOLIS MIS 800MCG
ALLEGRA ODT TAB 30MG
ALLEGRA SUS 30MG/5ML
fexofenadine hcl tab 180mg
fexofenadine hcl tab 30mg
fexofenadine hcl tab 60mg
FEXOFENADINE/PSEUDOEPHEDRINE TAB 24 HOUR
FEXOFENADINE/PSEUDOEPHEDRINE TAB 60-120MG
DIFICID TAB 200MG
GILENYA CAP 0.5MG
LIMBREL CAP 250MG
LIMBREL CAP 500MG
LIMBREL250 CAP 250-50MG
LIMBREL500 CAP 500-50MG
fluconazole tab 100mg
fluconazole tab 200mg
fluconazole tab 50mg
fluconazole sus 40mg/ml
fluconazole sus 10mg/ml
fluconazole tab 150mg
FLUCONAZOLE IN DEXTROSE INJ DEX 200
FLUCONAZOLE IN DEXTROSE INJ DEX 400
FLUCONAZOLE IN NACL INJ NACL 200
FLUCONAZOLE IN NACL INJ NACL 400
FLUCONAZOLE IN NACL INJ NACL 100
flurazepam hcl cap 15mg
flurazepam hcl cap 30mg
GONAL-F INJ 1050UNIT
GONAL-F INJ 450UNIT
GONAL-F RFF INJ 75UNIT
GONAL-F RFF PEN INJ 300
GONAL-F RFF PEN INJ 450
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 17 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
follitropin alfa
follitropin beta
follitropin beta
follitropin beta
follitropin beta
follitropin beta
fondaparinux sodium
fondaparinux sodium
fondaparinux sodium
fondaparinux sodium
foscarnet sodium
fosfomycin tromethamine
frovatriptan succinate
fulvestrant
gabapentin (phn)
gabapentin (phn)
gabapentin (phn)
ganciclovir sodium
ganirelix acetate
gefitinib
glatiramer acetate
glatiramer acetate
glatiramer acetate
glycerol phenylbutyrate
golimumab
golimumab
golimumab
griseofulvin microsize
griseofulvin microsize
griseofulvin ultramicrosize
griseofulvin ultramicrosize
guaifenesin-chlorpheniramine maleate
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
guaifenesin-codeine
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
GONAL-F RFF PEN INJ 900
FOLLISTIM AQ INJ 150UNIT
FOLLISTIM AQ INJ 300UNIT
FOLLISTIM AQ INJ 600UNIT
FOLLISTIM AQ INJ 75UNIT
FOLLISTIM AQ INJ 900UNIT
FONDAPARINUX SODIUM SOL 2.5/0.5
FONDAPARINUX SODIUM SOL 10/0.8
ARIXTRA SOL 5.0/0.4
ARIXTRA SOL 7.5/0.6
FOSCARNET SODIUM INJ 24MG/ML
MONUROL PAK GRANULES
FROVA TAB 2.5MG
FASLODEX INJ 250MG
GRALISE STARTER MIS 300/600
GRALISE TAB 300MG
GRALISE TAB 600MG
CYTOVENE INJ 500MG
GANIRELIX ACETATE INJ
IRESSA TAB 250MG
COPAXONE KIT 20MG/ML
COPAXONE KIT 20MG/ML
COPAXONE INJ 40MG/ML
RAVICTI LIQ 1.1GM/ML
SIMPONI ARIA 50MG/4ML
SIMPONI INJ 100MG
SIMPONI INJ 50MG
griseofulvin microsize sus 125/5ml
griseofulvin microsize tab micr 500
griseofulvin ultramicrosi ze tab ultr 125
griseofulvin ultramicrosi ze tab ultr 250
ALLFEN A TAB 400-4MG
ALLFEN CD TAB 400-10MG
ALLFEN CDX LIQ
ALLFEN CDX TAB 400-20MG
BRONTEX LIQ
BRONTEX TAB
dex-tuss liq
guaifenesin ac syp ac
MAR-COF CG EXPECTORANT LIQ
m-clear wc liq
PRO-CLEAR CAP 200-9MG
TUSSO-C LIQ 200-10MG
ZOHYDRO ER CAP 10MG
ZOHYDRO ER CAP 15MG
ZOHYDRO ER CAP 20MG
ZOHYDRO ER CAP 30MG
ZOHYDRO ER CAP 40MG
ZOHYDRO ER CAP 50MG
HYSINGLA ER TAB 20 MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 18 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone bitartrate
hydrocodone polistirex-chlorpheniramine polistirex
hydrocodone polistirex-chlorpheniramine polistirex
hydrocodone polistirex-chlorpheniramine polistirex
hydrocodone w/ homatropine
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen
hydrocodone-acetaminophen-dietary management product
hydrocodone-acetaminophen-dietary management product
hydrocodone-acetaminophen-dietary management product
hydrocodone-chlorpheniramine
hydrocodone-homatropine
hydrocodone-homatropine
hydrocodone-ibuprofen
hydrocodone-ibuprofen
hydrocodone-ibuprofen
hydrocodone-ibuprofen
hydrocodone-ibuprofen
hydromorphone hcl
HYSINGLA ER TAB 30 MG
HYSINGLA ER TAB 40 MG
HYSINGLA ER TAB 60 MG
HYSINGLA ER TAB 80 MG
HYSINGLA ER TAB 100 MG
HYSINGLA ER TAB 120 MG
hydrocodone polistirex and chlorpheniramine polistirex liq
TUSSICAPS CAP 10-8MG
TUSSICAPS CAP 5-4MG
hydrocodone bitartrate/ho matropine methylbromide syp 5-1.5/5
HYCET SOL 7.5-325
HYDROCODONE BITART-ACETAMINOPHEN TAB 2.5-325
hydrocodone bitartrate-acetaminophen sol
hydrocodone bitartrate-acetaminophen sol 5-217/10mg
hydrocodone bitartrate-acetaminophen sol 7.5-325mg
hydrocodone bitartrate-acetaminophen tab 10-300mg
hydrocodone bitartrate-acetaminophen tab 10-750mg
hydrocodone bitartrate-acetaminophen tab 5-300mg
hydrocodone bitartrate-acetaminophen tab 7.5-300mg
hydrocodone-acetaminophen sol
HYDROCODONE-ACETAMINOPHEN SOL 10-325MG
hydrocodone-acetaminophen tab 10-325mg
hydrocodone-acetaminophen tab 10-500mg
hydrocodone-acetaminophen tab 10-650mg
hydrocodone-acetaminophen tab 10-660mg
hydrocodone-acetaminophen tab 2.5-500mg
hydrocodone-acetaminophen tab 5-325mg
hydrocodone-acetaminophen tab 5-500mg
hydrocodone-acetaminophen tab 7.5-325mg
hydrocodone-acetaminophen tab 7.5-500mg
hydrocodone-acetaminophen tab 7.5-650mg
hydrocodone-acetaminophen tab 7.5-750mg
stagesic cap 500-5mg
ZAMICET SOL 10-325MG
ZOLVIT SOL 10-300MG
ZYDONE TAB 10-400MG
ZYDONE TAB 5-400MG
ZYDONE TAB 7.5-400
THERACODOPHEN-325 PAK -325
THERACODOPHEN-650 PAK -650
THERACODOPHEN-LOW-90 PAK -LOW-90
VITUZ SOL 5-4MG
hydromet syp 5-1.5/5
tussigon tab 5mg
hydrocodone-ibuprofen tab 7.5-200
IBUDONE TAB 10-200MG
REPREXAIN TAB 2.5-200
REPREXAIN TAB 5-200MG
VICOPROFEN TAB
DILAUDID-5 LIQ 1MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 19 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl-sodium chloride
hydroxyprogesterone caproate
ibrutinib
icatibant acetate
idelalisib
idelalisib
iloprost
iloprost
imatinib mesylate
imatinib mesylate
imiglucerase
imiglucerase
infliximab
interferon alfa-2b
interferon alfa-2b
interferon alfa-2b
interferon alfa-2b
interferon alfa-2b
interferon alfa-2b
interferon alfa-2b
interferon alfa-2b
interferon alfacon-1
interferon alfacon-1
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1a
interferon beta-1a
DILAUDID-HP INJ 10MG/ML
DILAUDID-HP INJ 250MG
EXALGO TAB 12MG
EXALGO TAB 16MG
EXALGO TAB 32MG
EXALGO TAB 8MG
hydromorphone hcl dosette inj 2mg/ml
hydromorphone hcl inj 1mg/ml
hydromorphone hcl inj 2mg/ml
hydromorphone hcl inj 4mg/ml
hydromorphone hcl inj 500/50ml
HYDROMORPHONE HCL SUP 3MG
hydromorphone hcl tab 2mg
hydromorphone hcl tab 4mg
hydromorphone hcl tab 8mg
HYDROMORPHONE HCL INJ 1MG/ML
HYDROMORPHONE HCL INJ 2MG/ML
HYDROMORPHONE HCL INJ 4MG/ML
HYDROMORPHONE-SODIUM CHLORIDE INJ /NACL
MAKENA INJ 250MG/ML
IMBRUVICA CAP 140MG
FIRAZYR INJ 30MG/3ML
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
GLEEVEC TAB 400MG
GLEEVEC TAB 100MG
CEREZYME INJ 400UNIT
CEREZYME INJ 200UNIT
REMICADE INJ 100MG
INTRON-A W/DILUENT INJ 10MU
INTRON-A W/DILUENT INJ 50MU
INTRON-A W/DILUENT INJ 18MU
INTRON-A INJ 18MU
INTRON-A INJ 25MU
INTRON-A INJ 5MU PEN
INTRON-A INJ 10MU PEN
INTRON-A INJ 3MU PEN
INFERGEN INJ 9MCG
INFERGEN INJ 15MCG
AVONEX KIT 30MCG
REBIF INJ 22/0.5
REBIF INJ 44/0.5
AVONEX KIT 30MCG
REBIF TITRATION PACK SOL PACK
AVONEX PEN KIT 30MCG
REBIF REBIDOSE TITRATION PACK SOL TITRATN
REBIF REBIDOSE INJ 22/0.5
REBIF REBIDOSE INJ 44/0.5
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 20 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
interferon beta-1b
interferon beta-1b
interferon gamma-1b
iodine strong (lugol's)
isoflurane
isoniazid
isoniazid
isoniazid
isoniazid & rifampin
isoniazid-rifampin w/ pyrazinamide
itraconazole
itraconazole
ivacaftor
ivermectin
ketamine hcl
ketamine hcl
ketamine hcl
ketoconazole
lanreotide acetate
lanreotide acetate
lanreotide acetate
lapatinib ditosylate
ledipasvir/sofosbuvir
lenalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
lenalidomide
levocetirizine dihydrochloride
levocetirizine dihydrochloride
levofloxacin
levofloxacin
levofloxacin
levofloxacin
levofloxacin
levofloxacin in d5w
levofloxacin in d5w
levofloxacin in d5w
levorphanol tartrate
levorphanol tartrate
linezolid
linezolid
linezolid
lisdexamfetamine dimesylate
lisdexamfetamine dimesylate
lisdexamfetamine dimesylate
lisdexamfetamine dimesylate
lisdexamfetamine dimesylate
lisdexamfetamine dimesylate
EXTAVIA INJ 0.3MG
BETASERON INJ 0.3MG
ACTIMMUNE INJ 2MU/0.5
IODINE STRONG SOL STRONG
FORANE SOL
isoniazid syp 50mg/5ml
isoniazid tab 100mg
isoniazid tab 300mg
RIFAMATE CAP
RIFATER TAB
SPORANOX SOL 10MG/ML
ONMEL TAB 200MG
KALYDECO TAB 150MG
STROMECTOL TAB 3MG
ketamine hcl inj 100mg/ml
ketamine hcl inj 10mg/ml
ketamine hcl inj 50mg/ml
KETOCONAZOLE TAB 200MG
SOMATULINE DEPOT INJ 90/0.3ML
SOMATULINE DEPOT INJ 120/.5ML
SOMATULINE DEPOT INJ 60/0.2ML
TYKERB TAB 250MG
HARVONI TAB 90-400MG
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 25MG
REVLIMID CAP 2.5MG
REVLIMID CAP 20MG
levocetirizine dihydrochloride tab 5mg
XYZAL SOL
LEVOFLOXACIN INJ 25MG/ML
levofloxacin tab 250mg
levofloxacin tab 500mg
levofloxacin tab 750mg
LEVOFLOXACIN SOL 25MG/ML
LEVOFLOXACIN IN D5W INJ 250/50ML
LEVOFLOXACIN IN D5W INJ 500/100M
LEVOFLOXACIN IN D5W INJ 750/150
LEVO DROMORAN INJ 2MG/ML
LEVORPHANOL TARTRATE TAB 2MG
ZYVOX TAB 600MG
ZYVOX SUS 100MG/5M
ZYVOX SOL 2MG/ML
VYVANSE CAP 20MG
VYVANSE CAP 30MG
VYVANSE CAP 40MG
VYVANSE CAP 50MG
VYVANSE CAP 60MG
VYVANSE CAP 70MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 21 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
l-methylfolate-algae
l-methylfolate-algae
lomitapide mesylate
lomitapide mesylate
lomitapide mesylate
lorazepam
lorazepam
lorazepam
lorazepam
lorazepam
lorazepam
lutropin alfa
macitentan
mecamylamine hcl
mecasermin
mecasermin rinfabate (rdna)
Mechlorethamine hcl (topical)
mefloquine hcl
menotropins
menotropins
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine hcl
meperidine-promethazine
mephobarbital
mephobarbital
mephobarbital
meprobamate
meprobamate
meprobamate-aspirin
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methamphetamine hcl
DEPLIN 15 CAP
L-METHYLFOLATE FORTE CAP FORTE
JUXTAPID CAP 5MG
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
lorazepam inj 2mg/ml
lorazepam inj 4mg/ml
LORAZEPAM INTENSOL CON 2MG/ML
lorazepam tab 0.5mg
lorazepam tab 1mg
lorazepam tab 2mg
LUVERIS INJ 75UNIT
OPSUMIT TAB 10MG
VECAMYL TAB 2.5MG
INCRELEX INJ 40MG/4ML
IPLEX INJ 36/0.6ML
VALCHLOR GEL 0.016%
mefloquine hcl tab 250mg
MENOPUR INJ 75UNIT
REPRONEX INJ 75UNIT
DEMEROL INJ 100/2ML
DEMEROL INJ 100MG/ML
DEMEROL INJ 25MG/0.5ML
DEMEROL INJ 25MG/ML
DEMEROL INJ 50MG/ML
DEMEROL INJ 75MG/1.5ML
DEMEROL INJ 75MG/ML
meperidine hcl inj 100mg/ml
meperidine hcl inj 10mg/ml
meperidine hcl inj 25mg/ml
meperidine hcl inj 50mg/ml
meperidine hcl inj 75mg/ml
MEPERIDINE HCL SOL 50MG/5ML
meperidine hcl tab 50mg
meperitab tab 100mg
meperidine/promethazine cap
MEBARAL TAB 100MG
MEBARAL TAB 32MG
MEBARAL TAB 50MG
meprobamate tab 200mg
meprobamate tab 400mg
EQUAGESIC TAB 200-325
METHADONE HCL INJ 10MG/ML
methadone hcl sol 10mg/5ml
methadone hcl sol 5mg/5ml
methadone hcl tab 10mg
methadone hcl tab 5mg
methadose sugar-free con 10mg/ml
methadose tab 40mg
DESOXYN TAB 5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 22 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
methohexital sodium
methohexital sodium
methohexital sodium
methylphenidate
methylphenidate
methylphenidate
methylphenidate
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
metreleptin
metyrosine
micafungin sodium
micafungin sodium
midazolam hcl
midazolam hcl
midazolam hcl
midazolam hcl
midazolam hcl
midazolam hcl
mifepristone (hyperglycemia)
miglustat
mipomersen sodium
mitotane
modafinil
modafinil
morphine sulfate
morphine sulfate
BREVITAL SODIUM INJ 2.5GM
BREVITAL SODIUM INJ 200MG
BREVITAL SODIUM INJ 500MG
DAYTRANA DIS 10MG/9HR
DAYTRANA DIS 15MG/9HR
DAYTRANA DIS 20MG/9HR
DAYTRANA DIS 30MG/9HR
METHYLIN CHW 10MG
METHYLIN CHW 2.5MG
METHYLIN CHW 5MG
methylphenidate hcl cd cap 10mg
methylphenidate hcl cd cap 20mg
methylphenidate hcl cd cap 30mg
methylphenidate hcl cd cap 40mg
methylphenidate hcl cd cap 50mg
methylphenidate hcl cd cap 60mg
METHYLPHENIDATE HCL ER TAB 10MG
methylphenidate hcl er tab 18mg
methylphenidate hcl er tab 20mg
methylphenidate hcl er tab 27mg
methylphenidate hcl er tab 36mg
methylphenidate hcl er tab 54mg
methylphenidate hcl tab 10mg
methylphenidate hcl tab 20mg
methylphenidate hcl tab 5mg
methylphenidate hydrochloride sol 10mg/5ml
methylphenidate hydrochloride sol 5mg/5ml
QUILLIVANT XR SUS XR
RITALIN LA CAP 10MG
RITALIN LA CAP 20MG
RITALIN LA CAP 30MG
RITALIN LA CAP 40MG
MYALEPT INJ 11.3MG
DEMSER CAP 250MG
MYCAMINE INJ 50MG
MYCAMINE INJ 100MG
midazolam hcl inj 10mg/2ml
midazolam hcl inj 1mg/ml
midazolam hcl inj 2mg/2ml
midazolam hcl inj 5mg/5ml
midazolam hcl inj 5mg/ml
midazolam hcl syp 2mg/ml
KORLYM TAB 300MG
ZAVESCA CAP 100MG
KYNAMRO INJ 200MG/ML
LYSODREN TAB 500MG
PROVIGIL TAB 100MG
PROVIGIL TAB 200MG
duramorph inj 0.5mg/ml
duramorph inj 1mg/ml
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 23 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
KADIAN CAP 100MG CR
KADIAN CAP 10MG CR
KADIAN CAP 130MG CR
KADIAN CAP 150MG CR
KADIAN CAP 200MG CR
KADIAN CAP 20MG CR
KADIAN CAP 30MG CR
KADIAN CAP 40MG CR
KADIAN CAP 50MG CR
KADIAN CAP 60MG CR
KADIAN CAP 70MG CR
KADIAN CAP 80MG CR
morphine sulfate dilute-a-jet inj 25mg/ml
morphine sulfate er cap 100mg
morphine sulfate er cap 20mg
morphine sulfate er cap 30mg
morphine sulfate er cap 50mg
morphine sulfate er cap 60mg
morphine sulfate er cap 80mg
morphine sulfate er tab 100mg
morphine sulfate er tab 15mg
morphine sulfate er tab 200mg
morphine sulfate er tab 30mg
morphine sulfate er tab 60mg
morphine sulfate inj 0.5mg/ml
MORPHINE SULFATE INJ 10/0.7ML
morphine sulfate inj 10mg/ml
MORPHINE SULFATE INJ 150/30ML
morphine sulfate inj 15mg/ml
morphine sulfate inj 1mg/ml
morphine sulfate inj 25mg/ml
MORPHINE SULFATE INJ 2MG/ML
MORPHINE SULFATE INJ 4MG/ML
morphine sulfate inj 50mg/ml
MORPHINE SULFATE INJ 5MG/ML
morphine sulfate inj 8mg/ml
morphine sulfate sol 10/0.5ml
MORPHINE SULFATE SOL 10MG/5ML
MORPHINE SULFATE SOL 20MG/5ML
morphine sulfate sol 20mg/ml
morphine sulfate sol 5/0.25ml
MORPHINE SULFATE SUP 10MG
MORPHINE SULFATE SUP 20MG
MORPHINE SULFATE SUP 30MG
MORPHINE SULFATE SUP 5MG
MORPHINE SULFATE TAB 10MG
morphine sulfate tab 15mg
MORPHINE SULFATE TAB 30MG
MORPHINE SULFATE INJ 5MG/ML
MORPHINE SULFATE INJ 25MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 24 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate beads
morphine sulfate beads
morphine sulfate beads
morphine sulfate beads
morphine sulfate beads
morphine sulfate beads
morphine sulfate for continuous microinfusion
morphine sulfate for continuous microinfusion
morphine sulfate in dextrose
morphine sulfate liposome
morphine sulfate liposome
morphine-naltrexone
morphine-naltrexone
morphine-naltrexone
morphine-naltrexone
morphine-naltrexone
morphine-naltrexone
moxifloxacin hcl
moxifloxacin hcl in sodium chloride
nafarelin acetate
nalbuphine hcl
nalbuphine hcl
nalmefene hcl
nalmefene hcl
naloxone hcl
naloxone hcl
naloxone hcl
naltrexone
naltrexone hcl
naratriptan hcl
naratriptan hcl
netupitant-palonosetron
nicotine
nicotine
nicotine
nicotine
nicotine
nicotine
nicotine polacrilex
nicotine polacrilex
nicotine polacrilex
nicotine polacrilex
nilotinib
nilotinib
nintedanib esylate
MORPHINE SULFATE INJ 50MG/ML
MORPHINE SULFATE INJ 2MG/ML
MORPHINE SULFATE INJ 4MG/ML
MORPHINE SULFATE INJ 8MG/ML
MORPHINE SULFATE INJ 10MG/ML
AVINZA CAP 120MG
AVINZA CAP 30MG
AVINZA CAP 45MG
AVINZA CAP 60MG
AVINZA CAP 75MG
AVINZA CAP 90MG
INFUMORPH 200 INJ 10MG/ML
INFUMORPH 500 INJ 25MG/ML
MORPHINE SULF IN DEXTROSE 5% INJ 1MG/ML
DEPODUR INJ 10MG/ML
DEPODUR INJ 15/1.5ML
EMBEDA CAP 100-4MG
EMBEDA CAP 20-0.8MG
EMBEDA CAP 30-1.2MG
EMBEDA CAP 50-2MG
EMBEDA CAP 60-2.4MG
EMBEDA CAP 80-3.2MG
moxifloxacin hcl tab 400mg
AVELOX INJ
SYNAREL SOL 2MG/ML
nalbuphine hcl inj 10mg/ml
nalbuphine hcl inj 20mg/ml
REVEX INJ 100MCG
REVEX INJ 1MG/ML
EVZIO INJ
NALOXONE HCL INJ 0.4MG/ML
naloxone hcl inj 1mg/ml
VIVITROL INJ 380MG
naltrexone hcl tab 50mg
naratriptan hcl tab 1mg
naratriptan hcl tab 2.5mg
AKYNZEO CAP
nicotine transdermal system dis 14mg/24h
nicotine transdermal system dis 21mg/24h
nicotine transdermal system dis 7mg/24hr
NICOTINE TRANSDERMAL SYSTEM KIT
NICOTROL INHALER INH
NICOTROL NS SPR 10MG/ML
COMMIT LOZ 4MG
NICORETTE LOZ 2MG
nicotine polacrilex gum 2mg orig
nicotine polacrilex gum 4mg
TASIGNA CAP 200MG
TASIGNA CAP 150MG
OFEV CAP 100MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 25 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
nintedanib esylate
nitisinone
nitisinone
nitisinone
nystatin
nystatin (mouth-throat)
obinutuzumab
octreotide acetate
octreotide acetate
octreotide acetate
ofloxacin
omacetaxine mepesuccinate
omalizumab
orphenadrine-aspirin-caffeine
orphenadrine-aspirin-caffeine
oseltamivir phosphate
oseltamivir phosphate
oseltamivir phosphate
oseltamivir phosphate
oxacillin sodium
oxacillin sodium
oxacillin sodium
oxacillin sodium in dextrose
oxacillin sodium in dextrose
oxazepam
oxazepam
oxazepam
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone hcl
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
OFEV CAP 150MG
ORFADIN CAP 10MG
ORFADIN CAP 2MG
ORFADIN CAP 5MG
nystatin tab 500000
nystatin sus 100000
GAZYVA INJ 25MG/ML
SANDOSTATIN LAR DEPOT KIT LAR 10MG
SANDOSTATIN LAR DEPOT KIT LAR 20MG
SANDOSTATIN LAR DEPOT KIT LAR 30MG
ofloxacin tab 400mg
SYNRIBO INJ 3.5MG
XOLAIR SOL 150MG
ORPHENADRINE COMPOUND DS TAB DS
orphenadrine/aspirin/caffeine tab
TAMIFLU CAP 75MG
TAMIFLU CAP 30MG
TAMIFLU CAP 45MG
TAMIFLU SUS 6MG/ML
OXACILLIN SODIUM INJ 1GM
OXACILLIN SODIUM INJ 10GM
OXACILLIN SODIUM INJ 2GM
BACTOCILL IN DEXTROSE INJ DEX 1GM
BACTOCILL IN DEXTROSE INJ DEX 2GM
oxazepam cap 10mg
oxazepam cap 15mg
oxazepam cap 30mg
DAZIDOX TAB 10MG
eth-oxydose con 20mg/ml
OXECTA TAB 5MG
OXECTA TAB 7.5MG
OXYCODONE HCL CAP 5MG
oxycodone hcl con 20mg/ml
oxycodone hcl sol 5mg/5ml
oxycodone hcl tab 10mg
oxycodone hcl tab 15mg
OXYCODONE HCL TAB 20MG
oxycodone hcl tab 30mg
oxycodone hcl tab 5mg
OXYCONTIN TAB 10MG CR
OXYCONTIN TAB 15MG CR
OXYCONTIN TAB 20MG CR
OXYCONTIN TAB 30MG CR
OXYCONTIN TAB 40MG CR
OXYCONTIN TAB 60MG CR
OXYCONTIN TAB 80MG CR
MAGNACET TAB 10-400MG
MAGNACET TAB 2.5-400MG
MAGNACET TAB 5-400MG
MAGNACET TAB 7.5-400MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 26 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-acetaminophen
oxycodone-aspirin
oxycodone-aspirin
oxycodone-ibuprofen
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
palifermin
paliperidone palmitate
paliperidone palmitate
paliperidone palmitate
paliperidone palmitate
paliperidone palmitate
pasireotide diaspartate
pasireotide diaspartate
pasireotide diaspartate
oxycodone-acetaminophen cap 5-500mg
oxycodone-acetaminophen tab 10-325mg
oxycodone-acetaminophen tab 10-650mg
oxycodone-acetaminophen tab 2.5-325mg
oxycodone-acetaminophen tab 5-325mg
oxycodone-acetaminophen tab 7.5-325mg
oxycodone-acetaminophen tab 7.5-500mg
PRIMALEV TAB 2.5-300
PRIMLEV TAB 10-300MG
PRIMLEV TAB 5-300MG
PRIMLEV TAB 7.5-300
ROXICET SOL 5-325/5
ROXICET TAB 5-500MG
XOLOX TAB 10-500MG
endodan tab
oxycodone-aspirin tab
oxycodone-ibuprofen tab 5-400mg
OPANA ER (CRUSH RESISTANT) TAB 10MG
OPANA ER (CRUSH RESISTANT) TAB 15MG
OPANA ER (CRUSH RESISTANT) TAB 20MG
OPANA ER (CRUSH RESISTANT) TAB 30MG
OPANA ER (CRUSH RESISTANT) TAB 40MG
OPANA ER (CRUSH RESISTANT) TAB 5MG
OPANA ER (CRUSH RESISTANT) TAB 7.5MG
OPANA ER TAB 10MG
OPANA ER TAB 15MG
OPANA ER TAB 20MG
OPANA ER TAB 30MG
OPANA ER TAB 40MG
OPANA ER TAB 5MG
OPANA ER TAB 7.5MG
OPANA INJ 1MG/ML
oxymorphone hydrochloride ER tab 10mg
oxymorphone hydrochloride ER tab 15mg
oxymorphone hydrochloride ER tab 20mg
oxymorphone hydrochloride ER tab 30mg
oxymorphone hydrochloride ER tab 40mg
oxymorphone hydrochloride ER tab 5mg
oxymorphone hydrochloride ER tab 7.5mg
oxymorphone hydrochloride tab 10mg
oxymorphone hydrochloride tab 5mg
KEPIVANCE INJ 6.25MG
INVEGA SUSTENNA INJ 39/0.25
INVEGA SUSTENNA INJ 78/0.5ML
INVEGA SUSTENNA INJ 117/0.75
INVEGA SUSTENNA INJ 156MG/ML
INVEGA SUSTENNA INJ 234/1.5
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 27 of 28
Revision date: January, 2015
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name
Product Description
pazopanib hcl
peginterferon alfa-2a
peginterferon alfa-2a
peginterferon alfa-2a
peginterferon alfa-2a
peginterferon alfa-2b
peginterferon alfa-2b
peginterferon alfa-2b
peginterferon alfa-2b
peginterferon alfa-2b (antineoplastic)
peginterferon alfa-2b (antineoplastic)
peginterferon alfa-2b (antineoplastic)
peginterferon alfa-2b (antineoplastic)
peginterferon alfa-2b (antineoplastic)
peginterferon alfa-2b (antineoplastic)
VOTRIENT TAB 200MG
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS KIT
PEGASYS PROCLICK INJ PROCLICK
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 80MCG
PEG-INTRON KIT 120MCG
PEG-INTRON KIT 150MCG
SYLATRON KIT 296MCG
SYLATRON KIT 296MCG
SYLATRON KIT 888MCG
SYLATRON KIT 888MCG
SYLATRON KIT 444MCG
SYLATRON KIT 444MCG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 28 of 28
Revision date: January, 2015

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