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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