Maintenance Medication Exclusion List
Maintenance Medication
Exclusion List
The following is a list of drugs that are excluded as maintenance medications. Medications which are listed here cannot be filled through the mail order pharmacy for the mail order incentive.
This list includes both formulary/preferred and non-formulary/non-preferred medications, and does not provide information regarding the specific coverage, limitations, exclusions or quotas an individual member may have. Some dosage forms and strengths of a particular drug may be considered maintenance medications, whereas others may not.
This list is sorted alphabetically by generic drug name. Generic drug names are written in lower case letters. Brand drug names (or some generic drugs with a trade name) are written in CAPITAL letters. Some drugs do not have a brand name available, in such cases the generic name is listed in the “Brand Name” column.
This list of drugs should not be used to determine pharmacy benefits, such as prescription copay/coinsurance amounts or formulary status. If you have questions about the formulary status of a medication, or your prescription benefits, please call our Member Services Department at 1-888-681-7878 (toll free). For the hearing or speech impaired: 1-800-521-4874 (toll free TTY). The medications on this list are subject to change at any time.
Exclusions: Any formulation that is required to be administered by a skilled medical professional or in a medical office, drugs infused in the home or in an infusion center, drugs that may have other quantity restrictions, any state law that may prohibit the mailing of certain dosage formulation of a drug, drugs that have a high potential for waste and diversion, drugs that require temperature control upon mailing and drugs that require refrigeration.
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description abatacept ORENCIA INJ 125MG/ML abatacept ORENCIA INJ 250MG abiraterone acetate ZYTIGA TAB 250MG acetaminophen OFIRMEV INJ 10MG/ML acetaminophen w/ codeine CAPITAL/CODEINE SUS 120-12/5 acetaminophen w/ codeine TYLENOL/CODEINE #3 TAB acetaminophen w/ codeine TYLENOL/CODEINE #4 TAB acetaminophen-caff-dihydrocod acetaminophen-caffeine-dihydrocodeine bitart tab acetaminophen-caff-dihydrocod TREZIX CAP acetaminophen-codeine acetaminophen-codeine #2 tab 300-15mg acetaminophen-codeine acetaminophen-codeine #3 tab 300-30mg acetaminophen-codeine acetaminophen-codeine #4 tab 300-60mg acetaminophen-codeine acetaminophen-codeine sol 120-12/5 acetaminophen-codeine CAPITAL-CODEINE SUS 120-12/5 acetaminophen-codeine COCET PLUS TAB 650-60MG acetaminophen-codeine COCET TAB 650-30MG acetaminophen-codeine & dietary management product THERACODEINE-300 PAK acetaminophen-isometheptene-caffeine MIGRALAM CAP acetaminophen-isometheptene-caffeine PRODRIN TAB acetaminophen-isometheptene-dichloralphenazone MIDRIN CAP acetaminophen-mag salicylate-phenyltolox-caffeine cafgesic forte tab acetaminophen-phenyltoloxamine-caffeine FLEXTRA CAP acetaminophen-salicylamide FRENADOL TAB acetaminophen-salicylamide-phenyltoloxamine ANABAR TAB acetaminophen-salicylamide-phenyltoloxamine dolorex cap acetaminophen-salicylamide-phenyltoloxamine duraxin cap acetaminophen-salicylamide-phenyltoloxamine-caffeine cafgesic cap acrivastine-pseudoephedrine SEMPREX-D CAP 8-60MG acyclovir sodium ACYCLOVIR SODIUM INJ 1000MG acyclovir sodium ACYCLOVIR SODIUM INJ 500MG acyclovir sodium ACYCLOVIR SODIUM INJ 50MG/ML adalimumab HUMIRA KIT 10MG/0.2ML adalimumab HUMIRA KIT 20MG/0.4ML adalimumab HUMIRA KIT 40MG/0.8ML adalimumab HUMIRA PEN KIT 40MG/0.8ML adefovir dipivoxil HEPSERA TAB 10MG alectnib hcl ALECENSA CAPS 150MG afatinib dimaleate GILOTRIF TAB 20MG afatinib dimaleate GILOTRIF TAB 30MG afatinib dimaleate GILOTRIF TAB 40MG alfentanil alfentanil inj 500/ml alirocumab PRALUENT INJ 150MG/ML alirocumab PRALUENT INJ 150MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 2 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description alirocumab PRALUENT INJ 75MG/ML alirocumab PRALUENT INJ 75MG/ML almotriptan malate AXERT TAB 12.5MG almotriptan malate AXERT TAB 6.25MG alprazolam alprazolam er tab 0.5mg alprazolam alprazolam er tab 1mg alprazolam alprazolam er tab 2mg alprazolam alprazolam er tab 3mg alprazolam ALPRAZOLAM INTENSOL CON 1MG/ML alprazolam alprazolam odt tab 0.25mg alprazolam alprazolam odt tab 0.5mg alprazolam alprazolam odt tab 1mg alprazolam alprazolam odt tab 2mg alprazolam alprazolam tab 0.25mg alprazolam alprazolam tab 0.5mg alprazolam alprazolam tab 1mg alprazolam alprazolam tab 2mg alprazolam NIRAVAM TAB 0.25MG alprazolam XANAX TAB 0.25MG alprazolam XANAX TAB 0.5MG alprazolam XANAX TAB 1MG alprazolam XANAX TAB 2MG alprazolam XANAX XR TAB 0.5MG alprazolam XANAX XR TAB 1MG alprazolam XANAX XR TAB 2MG alprazolam XANAX XR TAB 3MG alprazolam-dietary management product GABAZOLAMINE PAK alprazolam-dietary management product GABAZOLAMINE PAK alprazolam-dietary management product GABAZOLAMINE-0.5 PAK alprazolam-dietary management product SENTRAZOLAM AM 0.25 PAK ambrisentan LETAIRIS TAB 10MG ambrisentan LETAIRIS TAB 5MG amobarbital sodium AMYTAL SODIUM INJ 500MG amoxicillin amoxicillin cap 250mg amoxicillin amoxicillin cap 500mg amoxicillin amoxicillin chw 125mg amoxicillin amoxicillin chw 250mg amoxicillin amoxicillin er tab 775mg amoxicillin amoxicillin sus 125/5ml amoxicillin amoxicillin sus 200/5ml amoxicillin amoxicillin sus 250/5ml amoxicillin amoxicillin sus 400/5ml amoxicillin amoxicillin tab 500mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 3 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description amoxicillin amoxicillin tab 875mg amoxicillin MOXATAG TAB 775MG amoxicillin & pot clavulanate amoxicillin/clavulanate potassium chw 200mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium chw 400mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium er tab amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 200/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 250/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 400/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium sus 600/5ml amoxicillin & pot clavulanate amoxicillin/clavulanate potassium tab 250mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium tab 500mg amoxicillin & pot clavulanate amoxicillin/clavulanate potassium tab 875mg amoxicillin & pot clavulanate AUGMENTIN CHW 125MG amoxicillin & pot clavulanate AUGMENTIN CHW 250MG amoxicillin & pot clavulanate AUGMENTIN ES-600 SUS ES-600 amoxicillin & pot clavulanate AUGMENTIN SUS 125/5ML amoxicillin & pot clavulanate AUGMENTIN SUS 200/5ML amoxicillin & pot clavulanate AUGMENTIN SUS 400/5ML amoxicillin & pot clavulanate AUGMENTIN TAB 250MG amoxicillin & pot clavulanate AUGMENTIN TAB 500MG amoxicillin & pot clavulanate AUGMENTIN TAB 875MG amoxicillin & pot clavulanate AUGMENTIN XR TAB 12HR amphetamine DYANAVEL XR SUER 2.5 MG/ML amphetamine sulfate EVEKEO TAB 10MG amphetamine sulfate EVEKEO TAB 5MG amphetamine-dextroamphetamine ADDERALL TAB 12.5MG amphetamine-dextroamphetamine ADDERALL TAB 15MG amphetamine-dextroamphetamine ADDERALL TAB 7.5MG amphetamine-dextroamphetamine ADDERALL XR CAP 10MG amphetamine-dextroamphetamine ADDERALL XR CAP 15MG amphetamine-dextroamphetamine ADDERALL XR CAP 20MG amphetamine-dextroamphetamine ADDERALL XR CAP 25MG amphetamine-dextroamphetamine ADDERALL XR CAP 30MG amphetamine-dextroamphetamine ADDERALL XR CAP 5MG amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 10mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 15mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 20mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 25mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 30mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine cap 5mg er amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 10mg amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 20mg amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 30mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 4 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description amphetamine-dextroamphetamine amphetamine-dextroamphetamine tab 5mg amphotericin b AMPHOTERICIN B INJ 50MG amphotericin b cholesteryl sulfate complex AMPHOTEC INJ 100MG amphotericin b cholesteryl sulfate complex AMPHOTEC INJ 50MG amphotericin b lipid ABELCET INJ 5MG/ML amphotericin b liposome AMBISOME INJ 50MG ampicillin ampicillin cap 250mg ampicillin ampicillin cap 500mg ampicillin ampicillin sus 125/5ml ampicillin ampicillin sus 250/5ml ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 1.5GM ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 1-0.5GM ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 2-1GM ampicillin & sulbactam sodium AMPICILLIN-SULBACTAM INJ 3GM ampicillin & sulbactam sodium UNASYN INJ 1.5GM ampicillin & sulbactam sodium UNASYN INJ 3GM ampicillin sodium AMPICILLIN SODIUM INJ 10GM ampicillin sodium AMPICILLIN SODIUM INJ 125MG ampicillin sodium AMPICILLIN SODIUM INJ 1GM ampicillin sodium AMPICILLIN SODIUM INJ 250MG ampicillin sodium AMPICILLIN SODIUM INJ 2GM ampicillin sodium AMPICILLIN SODIUM INJ 500MG anakinra KINERET INJ apomorphine hydrochloride APOKYN INJ apremilast OTEZLA TAB 10/20/30 apremilast OTEZLA TAB 30MG aripiprazole lauroxil ARISTADA PRSY armodafinil NUVIGIL TAB 150MG armodafinil NUVIGIL TAB 250MG armodafinil NUVIGIL TAB 50MG asfotase alfa STRENSIQ SOLN 18 MG/0.45ML asfotase alfa STRENSIQ SOLN 28 MG/0.7ML asfotase alfa STRENSIQ SOLN 40 MG/ML asfotase alfa STRENSIQ SOLN 80 MG/0.8ML aspirin-acetaminophen-salicyl-caff LEVACET TAB aspirin-codeine aspirin-codeine tab 325-30mg aspirin-codeine aspirin-codeine tab 325-60mg atovaquone MEPRON SUS atovaquone-proguanil hcl atovaquone/proguanil hcl tab 250-100 atovaquone-proguanil hcl MALARONE TAB 62.5-25 avanafil STENDRA TAB 100MG avanafil STENDRA TAB 200MG avanafil STENDRA TAB 50MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 5 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description axitinib INLYTA TAB 1MG axitinib INLYTA TAB 5MG azithromycin azithromycin inj 500mg azithromycin azithromycin pow 1gm pak azithromycin azithromycin sus 100/5ml azithromycin azithromycin sus 200/5ml azithromycin azithromycin tab 250mg azithromycin azithromycin tab 500mg azithromycin azithromycin tab 600mg azithromycin ZITHROMAX INJ 500MG azithromycin ZITHROMAX POW 1GM PAK azithromycin ZITHROMAX SUS 100/5ML azithromycin ZITHROMAX SUS 200/5ML azithromycin ZITHROMAX TAB 250MG azithromycin ZITHROMAX TAB 500MG azithromycin ZITHROMAX TAB 600MG azithromycin ZITHROMAX TRI-PAK TAB azithromycin ZITHROMAX Z-PAK TAB azithromycin ZMAX SUS 2GM azithromycin (ophth) AZASITE SOL 1% aztreonam AZACTAM INJ 1GM aztreonam AZACTAM INJ 2GM aztreonam AZTREONAM INJ 1GM aztreonam AZTREONAM INJ 2GM aztreonam in dextrose AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM aztreonam lysine CAYSTON INH 75MG bacitracin (ophthalmic) BACITRACIN OIN OP bacitracin-polymyxin b OCUMYCIN OIN OP bacitracin-polymyxin b (ophth) AK-POLY-BAC OIN OP bacitracin-polymyxin b (ophth) bacitracin/polymyxin b oin op bacitracin-polymyxin b (ophth) POLYCIN B OIN OP bacitracin-polymyxin b (ophth) POLYCIN OIN OP bacitracin-poly-neomycin-hc neo-polycin hc oin hc 1%op bedaquiline fumarate SIRTURO TAB 100MG benzonatate benzonatate cap 100mg benzonatate benzonatate cap 200mg benzonatate TESSALON CAP 200MG benzonatate TESSALON PERLES CAP 100MG benzonatate ZONATUSS CAP 150MG besifloxacin hcl BESIVANCE SUS 0.6% betaine CYSTADANE bexarotene TARGRETIN CAP 75MG bexarotene (topical) TARGRETIN GEL 1%
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 6 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description boceprevir VICTRELIS CAP 200MG bosentan TRACLEER TAB 125MG bosentan TRACLEER TAB 62.5MG bosutinib BOSULIF TAB 100MG bosutinib BOSULIF TAB 500MG brompheniramine maleate bromspiro liq 2mg/5ml brompheniramine maleate J-TAN PD DROP 1MG/ML brompheniramine maleate LODRANE 24 CAP brompheniramine maleate lohist-12 tab 12 hour brompheniramine maleate RESPA-BR TAB 11MG brompheniramine maleate-phenylephrine hcl tannate VAZOTAB CHW brompheniramine tannate BROVEX CT CHW 12MG brompheniramine tannate BROVEX SUS 12MG/5ML brompheniramine tannate J-TAN SUS brompheniramine tannate P-TEX SUS 10MG/5ML brompheniramine tannate TANACOF-XR SUS 8MG/5ML brompheniramine tannate-phenylephrine tannate brompheniramine tann/phenylephrine tann sus 4-5mg brompheniramine tannate-phenylephrine tannate brompheniramine/phenylephrine tannate sus brompheniramine tannate-phenylephrine tannate BROVEX ADT SUS 12-10 brompheniramine tannate-phenylephrine tannate C-TAN D PLUS SUS brompheniramine tannate-phenylephrine tannate J-TAN D SUS brompheniramine tannate-phenylephrine tannate RELHIST CHW brompheniramine tannate-phenylephrine tannate tanabid chw 2.2-1.58 brompheniramine tannate-pseudoephedrine tannate BROVEX PD SUS brompheniramine tannate-pseudoephedrine tannate LODRANE D SUS brompheniramine-diphenhydramine ALA-HIST TAB 6-25MG brompheniramine-diphenhydramine-phenylephrine ALA-HIST D TAB 6-25-20 brompheniramine-dm-guaifenesin TRISPEC SFX LIQ brompheniramine-dm-guaifenesin TUSNEL CAP brompheniramine-phenylephrine ALACOL DROP 0.4-1MG brompheniramine-phenylephrine ALACOL SYP 2-5MG brompheniramine-phenylephrine andehist nr syp 4-45mg/ml brompheniramine-phenylephrine bpm pe liq brompheniramine-phenylephrine bpm pseudo tab 6-45mg brompheniramine-phenylephrine bromax d tab brompheniramine-phenylephrine bromfenex cap 12-120cr brompheniramine-phenylephrine bromhist pediatric drop brompheniramine-phenylephrine bromhist-nr drop brompheniramine-phenylephrine brompheniramine/pse cap 9-90mg brompheniramine-phenylephrine BROVEX PEB LIQ brompheniramine-phenylephrine BROVEX PSB LIQ brompheniramine-phenylephrine BROVEX PSE TAB 4-40MG brompheniramine-phenylephrine DECON-A ELX 2-5MG/5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 7 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description brompheniramine-phenylephrine entre-b sus 6-10mg/5ml brompheniramine-phenylephrine HISTEX SR TAB 10-120MG brompheniramine-phenylephrine J-TAN D PD DROP 1-7.5MG brompheniramine-phenylephrine LODRANE 24D CAP 12-90MG brompheniramine-phenylephrine phenylephrine hcl/bromphenir mal cap 15-12mg brompheniramine-phenylephrine phenylephrine hcl/bromphenir mal cap 7.5-6mg brompheniramine-phenylephrine pse bpm liq brompheniramine-phenylephrine respahist cap 6-60mgcr brompheniramine-phenylephrine tanabid sr tab 6-30mg brompheniramine-phenylephrine vazotab tab brompheniramine-phenylephrine ZOTEX PE TAB bromphen-pseudoephed-chlorphen-phenyleph-methscopol SYMPAK II MIS budesonide UCERIS TAB 9MG bulk chemicals BULK CHEMICALS buprenorphine BUTRANS DIS 10MCG/HR buprenorphine BUTRANS DIS 15MCG/HR buprenorphine BUTRANS DIS 20MCG/HR buprenorphine BUTRANS DIS 5MCG/HR buprenorphine BUTRANS DIS 7.5MCG/HR buprenorphine hcl BELBUCA FILM 150 MCG buprenorphine hcl BELBUCA FILM 300 MCG buprenorphine hcl BELBUCA FILM 450 MCG buprenorphine hcl BELBUCA FILM 600 MCG buprenorphine hcl BELBUCA FILM 75 MCG buprenorphine hcl BELBUCA FILM 750 MCG buprenorphine hcl BELBUCA FILM 900 MCG buprenorphine hcl BUPRENEX INJ 0.3MG/ML buprenorphine hcl buprenorphine hcl inj 0.3mg/ml buprenorphine hcl buprenorphine hcl sub 2mg buprenorphine hcl buprenorphine hcl sub 8mg buprenorphine hcl-naloxone hcl dihydrate BUNAVAIL MIS 2.1-0.3 buprenorphine hcl-naloxone hcl dihydrate BUNAVAIL MIS 4.2-0.7 buprenorphine hcl-naloxone hcl dihydrate BUNAVAIL MIS 6.3-1MG buprenorphine hcl-naloxone hcl dihydrate buprenorphine hcl-naloxone hcl dihydrate sub 2-0.5mg buprenorphine hcl-naloxone hcl dihydrate buprenorphine hcl-naloxone hcl dihydrate sub 8-2mg buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 12-3MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 2-0.5MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 4-1MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 8-2MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE SUB 2-0.5MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE SUB 8-2MG buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUB 1.4-0.36 buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUB 5.7-1.4
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 8 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUBL 11.4-2.9 MG buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUBL 2.9-0.71 MG buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUBL 8.6-2.1 MG butabarbital sodium BUTISOL SODIUM ELX 30MG/5ML butabarbital sodium BUTISOL SODIUM TAB 30MG butabarbital sodium BUTISOL SODIUM TAB 50MG butalbital-acetaminophen butalbital/acetaminophen tab 50-325 butalbital-acetaminophen ORBIVAN CF TAB 50-300MG butalbital-acetaminophen PHRENILIN FORTE CAP FORTE butalbital-acetaminophen promacet tab 50-650mg butalbital-acetaminophen-caffeine ALAGESIC LQ SOL butalbital-acetaminophen-caffeine butalbital/acetaminophen/caffeine cap butalbital-acetaminophen-caffeine butalbital/acetaminophen/caffeine tab butalbital-acetaminophen-caffeine DOLGIC PLUS TAB butalbital-acetaminophen-caffeine ORBIVAN CAP butalbital-acetaminophen-caffeine zebutal cap butalbital-acetaminophen-caffeine-codeine butalbital-acetaminophen-caffeine-codeine cap butalbital-acetaminophen-caffeine-codeine FIORICET-CODEINE CAP butalbital-aspirin-caffeine butalbital-aspirin-caffeine cap butalbital-aspirin-caffeine butalbital-aspirin-caffeine tab butalbital-aspirin-caffeine-codeine ascomp-codeine cap 30mg butorphanol tartrate butorphanol tartrate inj 1mg/ml butorphanol tartrate butorphanol tartrate inj 2mg/ml butorphanol tartrate butorphanol tartrate sol 10mg/ml butorphanol tartrate STADOL INJ 2MG/ML c1 esterase inhibitor (recombinant) RUCONEST INJ 2100UNIT cabozantinib s-malate COMETRIQ KIT 100MG cabozantinib s-malate COMETRIQ KIT 140MG cabozantinib s-malate COMETRIQ KIT 60MG canakinumab ILARIS INJ 180MG carbetapentane citrate-carbetapentane tan-pe hcl-pe tan CARBATUSS-12 SUS carbetapentane citrate-guaifenesin tannate RESPI-TANN G SUS carbetapentane citrate-pseudoephedrine hcl tannate RESPI-TANN CHW carbetapentane citrate-pseudoephedrine hcl tannate RESPI-TANN PD SUS carbetapentane citrate-pseudoephedrine hcl tannate RESPI-TANN SUS carbetapentane tannate SOLOTUSS SUS 30MG/5ML carbetapentane tannate-pyrilamine tannate PYRLEX CB SUS carbetapentane-guaifenesin CARBA-XP LIQ carbetapentane-guaifenesin DYNEX VR CAP carbetapentane-guaifenesin EXALL LIQ 10-100MG carbetapentane-guaifenesin EXPECTUSS LIQ 20-75MG/ML carbetapentane-guaifenesin TUSSO-ZMR CAP 8-200MG carbetapentane-guaifenesin TUSSO-ZR SYP 7.5-150
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 9 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description carbetapentane-pseudoephedrine CORZALL LIQ 20-30MG carbinoxamine maleate carbinoxamine maleate liq 4mg/5ml carbinoxamine maleate carbinoxamine maleate tab 4mg carbinoxamine maleate KARBINAL ER SUS 4MG/5ML carbinoxamine maleate PALGIC SOL 4MG/5ML carbinoxamine maleate PALGIC TAB 4MG cefaclor cefaclor cap 250mg cefaclor cefaclor cap 500mg cefaclor CEFACLOR SUS 125/5ML cefaclor CEFACLOR SUS 187/5ML cefaclor CEFACLOR SUS 250/5ML cefaclor CEFACLOR SUS 375/5ML cefaclor RANICLOR CHW 250MG cefaclor RANICLOR CHW 375MG cefaclor monohydrate CEFACLOR ER TAB 500MG cefadroxil cefadroxil cap 500mg cefadroxil cefadroxil sus 250/5ml cefadroxil cefadroxil sus 500/5ml cefadroxil cefadroxil tab 1gm cefazolin in d5w cefazolin sodium inj 1gm/50ml cefazolin sodium ANCEF INJ 1GM cefazolin sodium CEFAZOLIN SODIUM INJ 100GM cefazolin sodium CEFAZOLIN SODIUM INJ 10GM cefazolin sodium CEFAZOLIN SODIUM INJ 1GM cefazolin sodium CEFAZOLIN SODIUM INJ 20GM cefazolin sodium CEFAZOLIN SODIUM INJ 300gm cefazolin sodium CEFAZOLIN SODIUM INJ 500mg cefazolin sodium and dextrose CEFAZOLIN SODIUM/DEXTROSE SOL 1GM cefazolin sodium and dextrose CEFAZOLIN SODIUM/DEXTROSE SOL 2GM cefdinir cefdinir cap 300mg cefdinir cefdinir sus 125/5ml cefdinir cefdinir sus 250/5ml cefdinir OMNICEF CAP 300MG cefdinir OMNICEF SUS 125/5ML cefdinir OMNICEF SUS 250/5ML cefdinir OMNI-PAC CAP 300MG cefditoren pivoxil cefditoren pivoxil tab 200mg cefditoren pivoxil cefditoren pivoxil tab 400mg cefditoren pivoxil SPECTRACEF TAB 200MG cefditoren pivoxil SPECTRACEF TAB 400MG cefepime hcl CEFEPIME INJ 1GM cefepime hcl CEFEPIME INJ 2gm cefepime hcl MAXIPIME INJ 1GM
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 10 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description cefepime hcl MAXIPIME INJ 2GM cefepime hcl and dextrose CEFEPIME AND DEXTROSE INJ 1GM cefepime hcl and dextrose CEFEPIME AND DEXTROSE INJ 2GM cefixime SUPRAX CAP 400MG cefixime SUPRAX CHW 100MG cefixime SUPRAX SUS 100/5ML cefixime SUPRAX SUS 200/5ML cefixime SUPRAX SUS 500/5ML cefixime SUPRAX TAB 400MG cefotaxime sodium CEFOTAXIME SODIUM INJ 1GM cefotaxime sodium CEFOTAXIME SODIUM INJ 2GM cefotaxime sodium CEFOTAXIME SODIUM INJ 500MG cefotaxime sodium CLAFORAN INJ 10GM cefotaxime sodium CLAFORAN INJ 1GM cefotaxime sodium CLAFORAN INJ 2GM cefotetan disodium CEFOTETAN INJ 10G cefotetan disodium CEFOTETAN INJ 1GM/10ML cefotetan disodium CEFOTETAN INJ 2GM/20ML cefotetan disodium and dextrose CEFOTETAN/DEXTROSE INJ 1-3.58% cefotetan disodium and dextrose CEFOTETAN/DEXTROSE INJ 2-2.08% cefoxitin sodium CEFOXITIN SODIUM INJ 10GM cefoxitin sodium CEFOXITIN SODIUM INJ 1GM cefoxitin sodium and dextrose CEFOXITIN SODIUM INJ 2GM cefoxitin sodium in dextrose MEFOXIN INJ 1GM/50ML cefoxitin sodium in dextrose MEFOXIN INJ 2GM/50ML cefpodoxime proxetil cefpodoxime proxetil sus 100/5ml cefpodoxime proxetil cefpodoxime proxetil sus 50mg/5ml cefpodoxime proxetil cefpodoxime proxetil tab 100mg cefpodoxime proxetil cefpodoxime proxetil tab 200mg cefprozil cefprozil sus 125/5ml cefprozil cefprozil sus 250/5ml cefprozil cefprozil tab 250mg cefprozil cefprozil tab 500mg ceftaroline fosamil TEFLARO INJ 400MG ceftaroline fosamil TEFLARO INJ 600MG ceftazidime FORTAZ INJ 500MG ceftazidime TAZICEF INJ 1GM ceftazidime TAZICEF INJ 2GM ceftazidime TAZICEF INJ 6GM ceftazidime and dextrose CEFTAZIDIME/DEXTROSE SOL D5W 1GM ceftazidime and dextrose CEFTAZIDIME/DEXTROSE SOL D5W 2GM ceftazidime sodium in d5w FORTAZ INJ 1GM ceftazidime sodium in d5w FORTAZ INJ 2GM
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 11 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description ceftibuten CEDAX CAP 400MG ceftibuten CEDAX SUS 180/5ML ceftibuten CEDAX SUS 90MG/5ML ceftibuten ceftibuten sus 180/5ml ceftriaxone sodium CEFTRIAXONE SODIUM INJ 10GM ceftriaxone sodium CEFTRIAXONE SODIUM INJ 1GM ceftriaxone sodium CEFTRIAXONE SODIUM INJ 250MG ceftriaxone sodium CEFTRIAXONE SODIUM INJ 2GM ceftriaxone sodium CEFTRIAXONE SODIUM INJ 500MG ceftriaxone sodium ROCEPHIN INJ 1GM ceftriaxone sodium ROCEPHIN INJ 500MG ceftriaxone sodium and dextrose CEFTRIAXONE/DEXTROSE INJ 1GM ceftriaxone sodium and dextrose CEFTRIAXONE/DEXTROSE INJ 2GM ceftriaxone sodium in dextrose CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ 1GM ceftriaxone sodium in dextrose CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE INJ 2GM cefuroxime axetil CEFTIN SUS 125/5ML cefuroxime axetil CEFTIN SUS 250/5ML cefuroxime axetil CEFTIN TAB 250MG cefuroxime axetil CEFTIN TAB 500MG cefuroxime axetil cefuroxime axetil tab 250mg cefuroxime axetil cefuroxime axetil tab 500mg cefuroxime in sterile water ZINACEF INJ 1.5GM PB cefuroxime sodium CEFUROXIME SODIUM INJ 1.5GM cefuroxime sodium CEFUROXIME SODIUM INJ 7.5GM cefuroxime sodium CEFUROXIME SODIUM INJ 750MG cefuroxime sodium CEFUROXIME SODIUM INJ 75GM cefuroxime sodium ZINACEF INJ 1.5GM cefuroxime sodium ZINACEF INJ 7.5GM cefuroxime sodium ZINACEF INJ 750MG cefuroxime sodium and dextrose CEFUROXIME/DEXTROSE INJ 1.5GM cefuroxime sodium and dextrose CEFUROXIME/DEXTROSE INJ 750MG cephalexin cephalexin cap 250mg cephalexin cephalexin cap 500mg cephalexin cephalexin cap 750mg cephalexin cephalexin sus 125/5ml cephalexin cephalexin sus 250/5ml cephalexin cephalexin tab 250mg cephalexin cephalexin tab 500mg cephalexin KEFLEX CAP 250MG cephalexin KEFLEX CAP 500MG cephalexin KEFLEX CAP 750MG cephalexin KEFLEX SUS 125/5ML cephalexin KEFLEX SUS 250/5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 12 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description ceretinib ZYKADIA CAP 150MG certolizumab pegol CIMZIA KIT certolizumab pegol CIMZIA KIT 200MG/ML cetirizine hcl cetirizine hcl syp 1mg/ml cetirizine hcl ZYRTEC ALLERGY CAP 10MG cetirizine hcl ZYRTEC ALLERGY CHILDRENS TAB 10MG cetirizine hcl ZYRTEC ALLERGY TAB 10MG cetirizine hcl ZYRTEC CHILDRENS ALLERGY CHW ALG 10MG cetirizine hcl ZYRTEC CHILDRENS ALLERGY CHW ALG 5MG cetirizine hcl ZYRTEC CHILDRENS ALLERGY SYP 1MG/ML cetirizine hcl ZYRTEC CHILDRENS HIVES RELIEF SYP 1MG/ML cetirizine hcl ZYRTEC HIVES RELIEF TAB 10MG cetrorelix acetate CETROTIDE KIT 0.25MG cetrorelix acetate CETROTIDE KIT 3MG chlophedianol-triprolidine PROHIST CF LIQ chloral hydrate CHLORAL HYDRATE SUP 500MG chloral hydrate CHLORAL HYDRATE SYP 500/5ML chloral hydrate SOMNOTE CAP 500MG chlordiazepoxide hcl chlordiazepoxide hcl cap 10mg chlordiazepoxide hcl chlordiazepoxide hcl cap 25mg chlordiazepoxide hcl chlordiazepoxide hcl cap 5mg chlordiazepoxide hcl LIBRIUM INJ 100MG chlordiazepoxide hcl-clidinium bromide LIBRAX CAP 5-2.5MG chlorpheniramine maleate CHLORPHENIRAMINE MALEATE ER CAP 12MG chlorpheniramine maleate chlorpheniramine maleate er cap 8mg chlorpheniramine maleate CPM CAP 12MG CR chlorpheniramine maleate ED CHLORPED LIQ 2MG/ML chlorpheniramine maleate tannate PEDIOX-S SUS 4MG/5ML chlorpheniramine maleate-pseudoephedrine hcl tannate SUDAL 12 TANNATE CHW 4-30MG chlorpheniramine mal-phenylephrine hcl-methscop tan AH-CHEW ULTRA SUS ULTRA chlorpheniramine tannate AHIST TAB 12MG chlorpheniramine tannate ED CHLORPED SUS 2MG/ML chlorpheniramine tannate ED-CHLOR-TAN TAB 8MG chlorpheniramine tannate pediaphyl sus 8mg/5ml chlorpheniramine tannate-carbetapentane tannate c-tanna 12 sus 4-30mg/5ml chlorpheniramine tannate-carbetapentane tannate TUSSI-12 TAB 5-60MG chlorpheniramine tannate-methscopolamine DEXODRYL CHW 2-1.5MG chlorpheniramine tannate-methscopolamine DEXODRYL SUS chlorpheniramine tannate-phenylephrine tannate ALLERX SUS chlorpheniramine tannate-phenylephrine tannate DALLERGY-JR SUS chlorpheniramine tannate-phenylephrine tannate ED CHLORPED D SUS chlorpheniramine tannate-phenylephrine tannate p-tann d sus chlorpheniramine tannate-phenylephrine tannate r-tanna pediatric sus
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 13 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description chlorpheniramine tannate-phenylephrine tannate r-tanna tab 9-25mg chlorpheniramine tannate-phenylephrine tannate RYNATAN PEDIATRIC CHW 4.5-5MG chlorpheniramine tan-phenylephrine tan-methscop AH-CHEW ULTRA CHW ULTRA chlorpheniramine tan-phenylephrine tan-methscop redur-pcm sus chlorpheniramine tan-phenylephrine tan-methscop SYMPAK PDX MIS chlorpheniramine tan-pseudoephrine tan DICEL SUS chlorpheniramine tan-pyrilamine tan-phenylephrine tan conal sus chlorpheniramine tan-pyrilamine tan-phenylephrine tan nalex-a 12 sus chlorpheniramine-codeine CODAR AR LIQ chlorpheniramine-codeine COTAB A TAB 4-10MG chlorpheniramine-codeine COTAB AX TAB 4-20MG chlorpheniramine-codeine endacof-c liq 2-10mg/5ml chlorpheniramine-codeine ZODRYL AC 25 SUS chlorpheniramine-codeine ZODRYL AC 30 SUS chlorpheniramine-codeine ZODRYL AC 35 SUS chlorpheniramine-codeine ZODRYL AC 40 SUS chlorpheniramine-codeine ZODRYL AC 50 SUS chlorpheniramine-codeine ZODRYL AC 60 SUS chlorpheniramine-codeine ZODRYL AC 80 SUS chlorpheniramine-codeine Z-TUSS AC LIQ 2-9/5ML chlorpheniramine-dm-guaifenesin ALLFEN DMA TAB 4-20-400 chlorpheniramine-methscopolamine relcof cpm tab 8-2.5mg chlorpheniramine-methscopolamine respivent df mis chlorpheniramine-methscopolamine RYNEZE LIQ chlorpheniramine-phenylephrine ACCUHIST DROP 1-2.5MG chlorpheniramine-phenylephrine centergy drop 1-2mg/ml chlorpheniramine-phenylephrine chlorpheniramine-phenylephrine chlorpheniramine-phenylephrine c-phen drop chlorpheniramine-phenylephrine DALLERGY JR CAP 4-20MG chlorpheniramine-phenylephrine ED A-HIST LIQ 4-10/5ML chlorpheniramine-phenylephrine HISTEX SR TAB 6-15MG chlorpheniramine-phenylephrine nohist tab 8-20mg chlorpheniramine-phenylephrine sildec-pe syp chlorpheniramine-phenylephrine-acetaminophen PROTID TAB CR chlorpheniramine-phenylephrine-methscopolamine AEROKID SYP chlorpheniramine-phenylephrine-methscopolamine AH-CHEW II CHW chlorpheniramine-phenylephrine-methscopolamine ALLERX PE MIS chlorpheniramine-phenylephrine-methscopolamine chlor-mes d syp liquid chlorpheniramine-phenylephrine-methscopolamine cpm 8-pe 20-msc 1.25 tab chlorpheniramine-phenylephrine-methscopolamine DALLERGY CHW chlorpheniramine-phenylephrine-methscopolamine DALLERGY PE SYP chlorpheniramine-phenylephrine-methscopolamine DALLERGY PE TAB chlorpheniramine-phenylephrine-methscopolamine DALLERGY SYP
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 14 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description chlorpheniramine-phenylephrine-methscopolamine DALLERGY TAB chlorpheniramine-phenylephrine-methscopolamine DALLERGY TAB ER chlorpheniramine-phenylephrine-methscopolamine DEHISTINE SYP chlorpheniramine-phenylephrine-methscopolamine OMNIHIST II LA TAB LA chlorpheniramine-phenylephrine-methscopolamine phenylephrine cm tab chlorpheniramine-phenylephrine-methscopolamine re-drylex jr tab chlorpheniramine-phenylephrine-methscopolamine RELCOF DN PE MIS chlorpheniramine-phenylephrine-methscopolamine RESCON TAB chlorpheniramine-pseudoephedrine-methscopolamine coldamine tab 8-90-2.5 chlorpheniramine-pseudoephedrine-methscopolamine DALLERGY PSE TAB chlorpheniramine-pseudoephedrine-methscopolamine DRYMAX SYP chlorpheniramine-pseudoephedrine-methscopolamine pcm la tab chlorpheniramine-pseudoephedrine-methscopolamine RELCOF DN PSE MIS PSE chlorpheniramine-pseudoephedrine-methscopolamine relcof pse tab chlorpheniramine-pseudoephedrine-methscopolamine TIME-HIST QD TAB chlorpheniramine-pseudoephedrine-methscopolamine visrx dose pack tab dose pac chlorpheniramine-pseudoephrine CHLORPHENIRAMINE/PSEUDOEPHEDRINE SYP chlorpheniramine-pseudoephrine chlorpheniramine-pseudoephedrine cr cap 8-120 chlorpheniramine-pseudoephrine DECONAMINE TAB 4-60MG chlorpheniramine-pseudoephrine duratuss da cap 12-100mg chlorpheniramine-pseudoephrine LOHIST-D LIQ chlorpheniramine-pseudoephrine neutrahist drop 0.8-9mg chlorpheniramine-pseudoephrine SUDAHIST TAB 12-120MG chlorpheniramine-pyrilamine-phenylephrine myhist-pd liq chlorpheniramine-pyrilamine-phenylephrine PHENA-PLUS TAB chlorpheniramine-pyrilamine-phenylephrine PHENA-S LIQ chlorpheniramine-pyrilamine-phenylephrine RU-HIST FORTE TAB chlorphenir-phenylephrine-methscopol-homeopathic ZINX KIDS SNEEZE KIT chlorphenir-phenyltoloxamine-phenylephrine-acetaminophen NOREL SR TAB chlorphenir-pseudoephedrine-belladonna alkaloids RESPA-A.R. TAB chlorphenir-pseudoephedrine-homeopathic product ZINX ALLERGY KIT chlorphenir-pyrilamine tan-phenyleph hcl-phenyleph tan PHENA-S 12 SUS chlorphen-phenyltolox-phenylephrine chlorpheniramine-phenyltoloxamine-phenylephrine liq chlorphen-phenyltolox-phenylephrine rhinacon a tab chlorphen-pse-atropine-hyoscyamine-scopolamine ru-tuss tab cholic acid CHOLBAM CAP 250MG cholic acid CHOLBAM CAP 50MG choriogonadotropin alfa OVIDREL INJ chorionic gonadotropin chorionic gonadotropin inj 10000unt cinacalcet hcl SENSIPAR TAB 30MG cinacalcet hcl SENSIPAR TAB 60MG cinacalcet hcl SENSIPAR TAB 90MG ciprofloxacin CIPRO SUS 250MG/5
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 15 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description ciprofloxacin CIPRO SUS 500MG/5 ciprofloxacin CIPROFLOXACIN INJ 200MG ciprofloxacin CIPROFLOXACIN INJ 400MG ciprofloxacin hcl CIPRO TAB 250MG ciprofloxacin hcl CIPRO TAB 500MG ciprofloxacin hcl ciprofloxacin hcl tab 100mg ciprofloxacin hcl ciprofloxacin hcl tab 250mg ciprofloxacin hcl ciprofloxacin hcl tab 500mg ciprofloxacin hcl ciprofloxacin hcl tab 750mg ciprofloxacin hcl (ophth) CILOXAN OIN 0.3% OP ciprofloxacin hcl (ophth) ciprofloxacin hcl sol 0.3% op ciprofloxacin hcl (otic) CETRAXAL SOL 0.2% ciprofloxacin hcl (otic) ciprofloxacin sol 0.2% ciprofloxacin in d5w CIPRO I.V.-IN D5W INJ 200MG ciprofloxacin in d5w CIPRO I.V.-IN D5W INJ 400MG ciprofloxacin in d5w CIPROFLOXACIN I.V.-IN D5W INJ 200MG ciprofloxacin in d5w CIPROFLOXACIN I.V.-IN D5W INJ 400MG ciprofloxacin-ciprofloxacin hcl CIPRO XR TAB 1000MG ciprofloxacin-ciprofloxacin hcl CIPRO XR TAB 500MG ciprofloxacin-ciprofloxacin hcl ciprofloxacin er tab 1000mg ciprofloxacin-ciprofloxacin hcl ciprofloxacin er tab 500mg er ciprofloxacin-dexamethasone CIPRODEX SUS 0.3-0.1% ciprofloxacin-hydrocortisone CIPRO HC SUS OTIC clemastine fumarate clemastine fumarate syp 0.5/5ml clemastine fumarate clemastine fumarate tab 2.68mg clemastine fumarate TAVIST ALLERGY TAB 1.34MG clomiphene citrate clomiphene citrate tab 50mg clonazepam clonazepam odt tab 0.125mg clonazepam clonazepam odt tab 0.25mg clonazepam clonazepam odt tab 0.5mg clonazepam clonazepam odt tab 1mg clonazepam clonazepam odt tab 2mg clonazepam clonazepam tab 0.5mg clonazepam clonazepam tab 1mg clonazepam clonazepam tab 2mg clonazepam KLONOPIN TAB 0.5MG clonazepam KLONOPIN TAB 1MG clonazepam KLONOPIN TAB 2MG clorazepate dipotassium clorazepate dipotassium tab 15mg clorazepate dipotassium clorazepate dipotassium tab 3.75mg clorazepate dipotassium clorazepate dipotassium tab 7.5mg clorazepate dipotassium TRANXENE-SD TAB 11.25MG clorazepate dipotassium TRANXENE-SD TAB 22.5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 16 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description clotrimazole clotrimazole tro 10mg clozapine clozapine odt tab 100/odt clozapine clozapine odt tab 12.5/odt clozapine clozapine odt tab 25mg odt clozapine CLOZAPINE TAB 200MG clozapine CLOZAPINE TAB 50MG clozapine CLOZARIL TAB 100MG clozapine CLOZARIL TAB 25MG clozapine FAZACLO TAB 100/ODT clozapine FAZACLO TAB 12.5/ODT clozapine FAZACLO TAB 150MG clozapine FAZACLO TAB 200MG clozapine FAZACLO TAB 25MG ODT clozapine VERSACLOZ SUS 50MG/ML cobimetinib fumarate COTELLIC TABS 20 MG codeine phosphate CODEINE PHOSPHATE INJ 30MG/2ML codeine phosphate CODEINE PHOSPHATE INJ 60MG/2ML codeine phosphate CODEINE PHOSPHATE TAB SOL 30MG codeine polistirex-chlorpheniramine polistirex TUZISTRA XR SUS codeine sulfate CODEINE SULFATE SOL 30MG/5ML codeine sulfate CODEINE SULFATE TAB 15MG codeine sulfate CODEINE SULFATE TAB 30MG codeine sulfate CODEINE SULFATE TAB 60MG codeine-brompheniramine BROVEX CB TAB 10-4MG codeine-brompheniramine BROVEX CBX TAB 20-4MG codeine-brompheniramine NALEX AC SYP codeine-chlorcyclizine NOTUSS-NX LIQ codeine-chlorpheniramine-acetaminophen COTABFLU TAB 20-4-500 codeine-phenylephrine-chlorcyclizine NASOTUSS LIQ codeine-pseudoephedrine-chlorcyclizine NOTUSS-NXD LIQ codeine-pyrilamine PRO-CLEAR AC SYP corticotropin ACTHAR HP INJ 80UNIT crizotinib XALKORI CAP 200MG crizotinib XALKORI CAP 250MG cycloserine cycloserine cap 250mg cyproheptadine hcl cyproheptadine hcl syp 2mg/5ml cyproheptadine hcl cyproheptadine hcl tab 4mg cysteamine bitartrate CYSTAGON CAP 150MG cysteamine bitartrate CYSTAGON CAP 50MG cysteamine bitartrate PROCYSBI CAP 25MG cysteamine bitartrate PROCYSBI CAP 75MG dabrafenib mesylate TAFINLAR CAP 50MG dabrafenib mesylate TAFINLAR CAP 75MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 17 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description daclatasvir dihydrochloride DAKLINZA TAB 30MG daclatasvir dihydrochloride DAKLINZA TAB 60MG dalfampridine AMPYRA TAB 10MG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 100MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 10MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 150MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 200MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 25MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 300MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 40MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 500MCG darbepoetin alfa-polysorbate 80 ARANESP ALBUMIN FREE INJ 60MCG dasatinib SPRYCEL TAB 100MG dasatinib SPRYCEL TAB 140MG dasatinib SPRYCEL TAB 20MG dasatinib SPRYCEL TAB 50MG dasatinib SPRYCEL TAB 70MG dasatinib SPRYCEL TAB 80MG deferasirox EXJADE TAB 125MG deferasirox EXJADE TAB 250MG deferasirox EXJADE TAB 500MG deferasirox JADENU TAB 180MG deferasirox JADENU TAB 360MG deferasirox JADENU TAB 90MG deferiprone FERRIPROX TAB 500MG denosumab PROLIA SOL 60MG/ML denosumab XGEVA INJ desflurane SUPRANE INH desloratadine CLARINEX REDITABS TAB 2.5MG desloratadine CLARINEX REDITABS TAB 5MG desloratadine CLARINEX SYP 0.5MG/ML desloratadine CLARINEX TAB 5MG desloratadine DESLORATADINE ODT TAB 2.5 ODT desloratadine DESLORATADINE ODT TAB 5MG ODT desloratadine DESLORATADINE TAB 5MG desloratadine-pseudoephedrine CLARINEX-D 12 HOUR TAB 2.5-120 desloratadine-pseudoephedrine CLARINEX-D 24 HOUR TAB 5-240MG dexamethasone BAYCADRON ELX 0.5/5ML dexamethasone dexamethasone elx 0.5/5ml dexamethasone DEXAMETHASONE INTENSOL CON 1MG/ML dexamethasone DEXAMETHASONE SOL 0.5/5ML dexamethasone DEXAMETHASONE TAB 0.25MG dexamethasone dexamethasone tab 0.5mg
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 18 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description dexamethasone dexamethasone tab 0.75mg dexamethasone dexamethasone tab 1.5mg dexamethasone DEXAMETHASONE TAB 1MG dexamethasone DEXAMETHASONE TAB 2MG dexamethasone dexamethasone tab 4mg dexamethasone dexamethasone tab 6mg dexamethasone DEXPAK 10 DAY PAK 10 DAY dexamethasone DEXPAK 13 DAY PAK 13 DAY dexamethasone DEXPAK 6 DAY PAK 6 DAY dexamethasone zema-pak 10 day pak 10 day dexamethasone zema-pak 13 day pak 13 day dexamethasone zema-pak 6 day pak 6 day dexamethasone (ophth) MAXIDEX SUS 0.1% OP dexamethasone (ophth) OZURDEX IMP 0.7MG dexamethasone sodium phosphate (ophth) dexamethasone sodium phosphate sol 0.1% op dexbrompheniramine tannate-pyrilamine maleate POLY TAN SUS dexbrompheniramine tan-pyrilamine mal-phenylephrine tan POLY TAN D SUS dexchlorpheniramine maleate DEXCHLORPHENIRAMINE MALEATE SYP 2MG/5ML dexchlorpheniramine maleate dexchlorpheniramine maleate tab 6mg cr dexchlorpheniramine tannate-pseudoephedrine tannate SUTAN SUS dexchlorpheniramine-phenylephrine NALDEX TAB dexchlorpheniramine-phenylephrine RESCON-JR TAB dexchlorpheniramine-phenylephrine RESCON-MX TAB dexchlorpheniramine-phenylephrine-methscopolamine dexphen m sol dexchlorpheniramine-pseudoephedrine-methscopolamine DURAHIST D TAB dexmedetomidine hcl PRECEDEX INJ 100MCG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL CAP 10MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL CAP 5MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL ER CAP 10MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL ER CAP 15MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL ER CAP 30MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL ER CAP 40MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL ER CAP 5MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL ER CAP 5MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL TAB 10MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL TAB 2.5MG dexmethylphenidate hcl DEXMETHYLPHENIDATE HCL TAB 5MG dexmethylphenidate hcl FOCALIN TAB 10MG dexmethylphenidate hcl FOCALIN TAB 2.5MG dexmethylphenidate hcl FOCALIN TAB 5MG dexmethylphenidate hcl FOCALIN XR CAP 10MG dexmethylphenidate hcl FOCALIN XR CAP 15MG dexmethylphenidate hcl FOCALIN XR CAP 20MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 19 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description dexmethylphenidate hcl FOCALIN XR CAP 25MG dexmethylphenidate hcl FOCALIN XR CAP 30MG dexmethylphenidate hcl FOCALIN XR CAP 35MG dexmethylphenidate hcl FOCALIN XR CAP 40MG dexmethylphenidate hcl FOCALIN XR CAP 5MG dextroamphetamine sulfate DEXEDRINE CAP 10MG CR dextroamphetamine sulfate DEXEDRINE CAP 15MG CR dextroamphetamine sulfate DEXEDRINE CAP 5MG CR dextroamphetamine sulfate dextroamphetamine sulfate er cap 10mg dextroamphetamine sulfate dextroamphetamine sulfate er cap 15mg dextroamphetamine sulfate dextroamphetamine sulfate er cap 5mg dextroamphetamine sulfate dextroamphetamine sulfate tab 10mg dextroamphetamine sulfate PROCENTRA SOL 5MG/5ML dextroamphetamine sulfate ZENZEDI TAB 15MG dextroamphetamine sulfate ZENZEDI TAB 2.5MG dextroamphetamine sulfate ZENZEDI TAB 20MG dextroamphetamine sulfate ZENZEDI TAB 30MG dextroamphetamine sulfate ZENZEDI TAB 5mg dextroamphetamine sulfate ZENZEDI TAB 7.5MG dextromethorphan hbr-guaifenesin tannate DURATUSS DM 12 SUS DM dextromethorphan-chlorpheniramine-methscopolamine EXTENDRYL DM TAB dextromethorphan-guaifenesin allfen dm tab 400-20mg dextromethorphan-guaifenesin dm/guai liq 10-300mg dextromethorphan-guaifenesin DURATUSS DM ELX dextromethorphan-guaifenesin gani-tuss dm nr liq 100-10/5 dextromethorphan-guaifenesin NORTUSS-EX LIQ 200-20/5 dextromethorphan-guaifenesin su-tuss dm elx 200-20/5 dextromethorphan-guaifenesin TRISPEC DMX LIQ dextromethorphan-potassium guaiacolsulfonate guiadex dm liq dextromethorphan-potassium guaiacolsulfonate PROLEX DMX LIQ diazepam DIAZEPAM INJ 10MG/2ML diazepam DIAZEPAM INJ 5MG/ML diazepam DIAZEPAM INTENSOL CON 5MG/ML diazepam DIAZEPAM SOL 1MG/ML diazepam DIAZEPAM SOL 1MG/ML diazepam diazepam tab 10mg diazepam diazepam tab 2mg diazepam diazepam tab 5mg diazepam VALIUM TAB 10MG diazepam VALIUM TAB 2MG diazepam VALIUM TAB 5MG diazepam (anticonvulsant) DIASTAT ACUDIAL GEL 12.5-20 diazepam (anticonvulsant) DIASTAT ACUDIAL GEL 5-10MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 20 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description diazepam (anticonvulsant) DIASTAT PEDIATRIC GEL 2.5MG diazepam (anticonvulsant) DIAZEPAM GEL 10MG diazepam (anticonvulsant) DIAZEPAM GEL 2.5MG diazepam (anticonvulsant) DIAZEPAM GEL 20MG diazepam-dietary management product GABAVALE-5 PAK dichlorphenamide KEVEYIS TABS 50 MG dicloxacillin sodium dicloxacillin sodium cap 250mg dicloxacillin sodium dicloxacillin sodium cap 500mg dihydrocodeine compound SYNALGOS-DC CAP dihydrocodeine-guaifenesin J-MAX DHC LIQ dihydroergotamine mesylate dihydroergotamine mesylate inj 1mg/ml dihydroergotamine mesylate MIGRANAL SPR 4MG/ML dimethyl fumarate TECFIDERA CAP 120MG dimethyl fumarate TECFIDERA CAP 240MG dimethyl fumarate TECFIDERA STARTER PACK dimethyl sulfoxide RIMSO-50 SOL 50% diphenhydramine hcl DICOPANOL FUSEPAQ SUS 5MG/ML diphenhydramine hcl diphenhydramine hcl cap 25mg diphenhydramine hcl diphenhydramine hcl cap 50mg diphenhydramine hcl diphenhydramine hcl elx 12.5/5ml diphenhydramine hcl diphenhydramine hcl inj 50mg/ml diphenhydramine hcl dytuss syp 12.5/5ml diphenhydramine hcl-phenylephrine hcl tannate ALDEX-CT CHW 12.5-5MG diphenhydramine tannate ben-tann sus 25mg/5ml diphenhydramine tannate DYTAN CHW 25MG diphenhydramine tannate-carbetapentane tannate D-TANN AT SUS diphenhydramine tannate-phenylephrine tannate d-tann chw 25-10mg diphenhydramine tannate-phenylephrine tannate d-tann sus 25-7.5mg diphenhydramine-hydrocortisone-nystatin FIRST-DUKES MOUTHWASH SUS diphenhydramine-hydrocortisone-nystatin-tetracycline FIRST-MARYS MOUTHWASH SUS diphenhydramine-lidocaine-nystatin FIRST-BXN MOUTHWASH SUS diphenhydramine-phenylephrine zoden pd liq 25-7.5 diphenhydramine-pseudoephrineed TEKRAL TAB dornase alfa PULMOZYME SOL 1MG/ML doxycycline calcium VIBRAMYCIN SYP 50MG/5ML doxycycline hyclate w/ eyelid cleanser & spray OCUDOX KIT doxycycline hyclate w/ eyelid cleansers ALODOX CONVENIENCE KIT KIT 20MG doxylamine succinate DOXYTEX LIQ doxylamine succinate tannate ALDEX AN SUS droperidol droperidol inj 2.5mg/ml droxidopa NORTHERA CAP 100MG droxidopa NORTHERA CAP 200MG droxidopa NORTHERA CAP 300MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 21 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description efinaconazole JUBLIA SOL 10% elbasvir-grazoprevir ZEPATIER TABS 50-100 MG eletriptan hydrobromide RELPAX TAB 20MG eletriptan hydrobromide RELPAX TAB 40MG eliglustat CERDELGA 84MG eltrombopag olamine PROMACTA TAB 12.5MG eltrombopag olamine PROMACTA TAB 25MG eltrombopag olamine PROMACTA TAB 50MG eltrombopag olamine PROMACTA TAB 75MG eluxadoline VIBERZI TABS 100 MG eluxadoline VIBERZI TABS 75 MG enflurane ETHRANE INH enfuvirtide FUZEON INJ 90MG enfuvirtide FUZEON KIT enoxaparin sodium enoxaparin sodium inj 100mg/ml enoxaparin sodium enoxaparin sodium inj 120/0.7 enoxaparin sodium enoxaparin sodium inj 150mg/ml enoxaparin sodium enoxaparin sodium inj 30/0.3ml enoxaparin sodium enoxaparin sodium inj 300/3ml enoxaparin sodium enoxaparin sodium inj 40/0.4ml enoxaparin sodium ENOXAPARIN SODIUM INJ 60/0.6ML enoxaparin sodium enoxaparin sodium inj 80/0.8ml enoxaparin sodium LOVENOX INJ 100MG/ML enoxaparin sodium LOVENOX INJ 120/0.8 enoxaparin sodium LOVENOX INJ 150MG/ML enoxaparin sodium LOVENOX INJ 30/0.3ML enoxaparin sodium LOVENOX INJ 300/3ML enoxaparin sodium LOVENOX INJ 40/0.4ML enoxaparin sodium LOVENOX INJ 80/0.8ML enzalutamide XTANDI CAP 40MG ephedrine-guaifenesin BRONCHOLATE SYP 6.25-100 epinephrine epinephrine inj 0.15mg epinephrine EPIPEN 2-PAK INJ 0.3MG epinephrine EPIPEN-JR 2-PAK INJ 2-PAK epoetin alfa EPOGEN INJ 2000/ML epoetin alfa EPOGEN INJ 20000/ML epoetin alfa PROCRIT INJ 10000/ML epoetin alfa PROCRIT INJ 3000/ML epoetin alfa PROCRIT INJ 4000/ML epoetin alfa PROCRIT INJ 40000/ML ergotamine tartrate ERGOMAR SUB 2MG ergotamine-caffeine ergotamine tartrate-caffeine tab 1/100 ergotamine-caffeine MIGERGOT SUP 2/100
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 22 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description erlotinib TARCEVA TAB 100MG erlotinib TARCEVA TAB 150MG erlotinib TARCEVA TAB 25MG ertapenem sodium INVANZ INJ 1GM erythromycin (ophth) erythromycin oin op erythromycin (ophth) ILOTYCIN OIN OP erythromycin (ophth) ROMYCIN OIN OP estazolam estazolam tab 1mg estazolam estazolam tab 2mg estramustine phosphate sodium EMCYT CAP 140MG eszopiclone LUNESTA TAB 1MG eszopiclone LUNESTA TAB 2MG eszopiclone LUNESTA TAB 3MG etanercept ENBREL INJ 25/0.5ML etanercept ENBREL INJ 25MG etanercept ENBREL INJ 50MG/ML etanercept ENBREL SURECLICK INJ 50MG/ML ethambutol hcl ETHAMBUTOL HCL TAB 100MG ethambutol hcl ETHAMBUTOL HCL TAB 400MG ethambutol hcl MYAMBUTOL TAB 100MG ethambutol hcl MYAMBUTOL TAB 400MG etomidate AMIDATE INJ 2MG/ML etomidate etomidate inj 2mg/ml everolimus AFINITOR DISPERZ TAB 2MG everolimus AFINITOR DISPERZ TAB 3MG everolimus AFINITOR DISPERZ TAB 5MG everolimus AFINITOR TAB 10MG everolimus AFINITOR TAB 2.5MG everolimus AFINITOR TAB 5MG everolimus AFINITOR TAB 7.5MG evolocumab REPATHA INJ 140MG/ML evolocumab REPATHA SURECLICK INJ 140MG/ML factor ix complex PROFILNINE SD INJ factor ix complex PROFILNINE SD INJ 1000UNIT factor ix complex PROFILNINE SD INJ 1500UNIT factor ix complex PROFILNINE SD INJ 500UNIT fentanyl fentanyl dis 100mcg/hr fentanyl fentanyl dis 12mcg/hr fentanyl fentanyl dis 25mcg/hr fentanyl fentanyl dis 50mcg/hr fentanyl fentanyl dis 75mcg/hr fentanyl FENTANYL PT72 37.5 MCG/HR fentanyl FENTANYL PT72 62.5 MCG/HR
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 23 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description fentanyl FENTANYL PT72 87.5 MCG/HR fentanyl IONSYS PAD 40MCG/AC fentanyl SUBSYS SPR 100MCG fentanyl SUBSYS SPR 1200MCG fentanyl SUBSYS SPR 1600MCG fentanyl SUBSYS SPR 200MCG fentanyl SUBSYS SPR 400MCG fentanyl SUBSYS SPR 600MCG fentanyl SUBSYS SPR 800MCG fentanyl citrate ABSTRAL SUB 100MCG fentanyl citrate ABSTRAL SUB 200MCG fentanyl citrate ABSTRAL SUB 300MCG fentanyl citrate ABSTRAL SUB 400MCG fentanyl citrate ABSTRAL SUB 600MCG fentanyl citrate ABSTRAL SUB 800MCG fentanyl citrate fentanyl citrate inj 0.05mg/1ml fentanyl citrate fentanyl citrate oral transmucosal loz 1200mcg fentanyl citrate fentanyl citrate oral transmucosal loz 1600mcg fentanyl citrate fentanyl citrate oral transmucosal loz 200mcg fentanyl citrate fentanyl citrate oral transmucosal loz 400mcg fentanyl citrate fentanyl citrate oral transmucosal loz 600mcg fentanyl citrate fentanyl citrate oral transmucosal loz 800mcg fentanyl citrate FENTANYL CITRATE POWDER fentanyl citrate FENTORA TAB 100MCG fentanyl citrate FENTORA TAB 200MCG fentanyl citrate FENTORA TAB 300MCG fentanyl citrate FENTORA TAB 400MCG fentanyl citrate FENTORA TAB 600MCG fentanyl citrate FENTORA TAB 800MCG fentanyl citrate LAZANDA SPR 100MCG fentanyl citrate LAZANDA SPR 400MCG fentanyl citrate ONSOLIS MIS 1200MCG fentanyl citrate ONSOLIS MIS 200MCG fentanyl citrate ONSOLIS MIS 400MCG fentanyl citrate ONSOLIS MIS 600MCG fentanyl citrate ONSOLIS MIS 800MCG fentanyl citrate-sodium chloride FENTANYL CITRATE-NACL SOSY 500-0.9 MCG/50ML-% fexofenadine hcl ALLEGRA ALLERGY CHILDRENS SUS 30MG/5ML fexofenadine hcl ALLEGRA ALLERGY CHILDRENS TAB 30MG fexofenadine hcl ALLEGRA ALLERGY TAB 180MG fexofenadine hcl ALLEGRA ALLERGY TAB 60MG fexofenadine hcl ALLEGRA ODT TAB 30MG fexofenadine hcl ALLEGRA SUS 30MG/5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 24 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description fexofenadine hcl fexofenadine hcl tab 180mg fexofenadine hcl fexofenadine hcl tab 30mg fexofenadine hcl fexofenadine hcl tab 60mg fexofenadine-pseudoephedrine ALLEGRA-D 12 HOUR ALLERGY & CONGESTION TAB fexofenadine-pseudoephedrine ALLEGRA-D 24 HOUR ALLERGY & CONGESTION TAB fexofenadine-pseudoephedrine FEXOFENADINE/PSEUDOEPHEDRINE TAB 24 HOUR fexofenadine-pseudoephedrine FEXOFENADINE/PSEUDOEPHEDRINE TAB 60-120MG fidaxomicin DIFICID TAB 200MG filgrastim-sndz ZARXIO 300MCG/0.5 filgrastim-sndz ZARXIO 480MCG/0.5 fingolimod hcl GILENYA CAP 0.5MG flavocoxid LIMBREL CAP 250MG flavocoxid LIMBREL CAP 500MG flavocoxid-citrated zinc bisglycinate LIMBREL250 CAP 250-50MG flavocoxid-citrated zinc bisglycinate LIMBREL500 CAP 500-50MG fluconazole DIFLUCAN SUS 10MG/ML fluconazole DIFLUCAN SUS 40MG/ML fluconazole DIFLUCAN TAB 100MG fluconazole DIFLUCAN TAB 150MG fluconazole DIFLUCAN TAB 200MG fluconazole DIFLUCAN TAB 50MG fluconazole fluconazole sus 10mg/ml fluconazole fluconazole sus 40mg/ml fluconazole fluconazole tab 100mg fluconazole fluconazole tab 150mg fluconazole fluconazole tab 200mg fluconazole fluconazole tab 50mg fluconazole in dextrose FLUCONAZOLE IN DEXTROSE INJ 200 fluconazole in dextrose FLUCONAZOLE IN DEXTROSE INJ 400 fluconazole in nacl FLUCONAZOLE IN NACL INJ 100 fluconazole in nacl FLUCONAZOLE IN NACL INJ 200 fluconazole in nacl FLUCONAZOLE IN NACL INJ 400 fluorouracil (topical) CARAC CRE 0.5% fluorouracil (topical) EFUDEX CRE 5% fluorouracil (topical) EFUDEX OCCLUSION PACK KIT fluorouracil (topical) fluoroplex cre 1% fluorouracil (topical) fluorouracil cre 0.5% fluorouracil (topical) fluorouracil cre 5% fluorouracil (topical) fluorouracil sol 2% fluorouracil (topical) fluorouracil sol 5% flurazepam hcl flurazepam hcl cap 15mg flurazepam hcl flurazepam hcl cap 30mg follitropin alfa GONAL-F INJ 1050UNIT
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 25 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description follitropin alfa GONAL-F INJ 450UNIT follitropin alfa GONAL-F RFF INJ 75UNIT follitropin alfa GONAL-F RFF PEN INJ 300 follitropin alfa GONAL-F RFF PEN INJ 450 follitropin alfa GONAL-F RFF PEN INJ 900 follitropin beta FOLLISTIM AQ INJ 150UNIT follitropin beta FOLLISTIM AQ INJ 300UNIT follitropin beta FOLLISTIM AQ INJ 600UNIT follitropin beta FOLLISTIM AQ INJ 75UNIT follitropin beta FOLLISTIM AQ INJ 900UNIT fondaparinux sodium ARIXTRA SOL 10/0.8 fondaparinux sodium ARIXTRA SOL 2.5/0.5 fondaparinux sodium ARIXTRA SOL 5.0/0.4 fondaparinux sodium ARIXTRA SOL 7.5/0.6 fondaparinux sodium FONDAPARINUX SODIUM SOL 10/0.8 fondaparinux sodium FONDAPARINUX SODIUM SOL 2.5/0.5 fondaparinux sodium fondaparinux sodium sol 5.0/0.3 fondaparinux sodium fondaparinux sodium sol 7.5/0.5 foscarnet sodium FOSCARNET SODIUM INJ 24MG/ML fosfomycin tromethamine MONUROL PAK GRANULES frovatriptan succinate FROVA TAB 2.5MG fulvestrant FASLODEX INJ 250MG gabapentin (phn) GRALISE STARTER MIS 300/600 gabapentin (phn) GRALISE TAB 300MG gabapentin (phn) GRALISE TAB 600MG ganciclovir ophthalmic ZIRGAN GEL 0.15% ganciclovir sodium CYTOVENE INJ 500MG ganirelix acetate GANIRELIX ACETATE INJ gatifloxacin (ophth) ZYMAXID SOL 0.5% gefitinib IRESSA TAB 250MG gentamicin in saline gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml gentamicin sulfate (ophth) garamycin oin 0.3% op gentamicin sulfate (ophth) GARAMYCIN SOL 0.3% OP gentamicin sulfate (ophth) genoptic sol 0.3% op gentamicin sulfate (ophth) gentak oin 0.3% op gentamicin sulfate (ophth) gentamicin sulfate oin 0.3% op gentamicin sulfate (ophth) gentamicin sulfate sol 0.3% op gentamicin-prednisolone acetate PRED-G S.O.P. OIN OP gentamicin-prednisolone acetate PRED-G SUS OP glatiramer acetate COPAXONE INJ 40MG/ML glatiramer acetate COPAXONE KIT 20MG/ML glatiramer acetate GLATOPA INJ 40MG/ML glycerol phenylbutyrate RAVICTI LIQ 1.1GM/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 26 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description golimumab SIMPONI ARIA 50MG/4ML golimumab SIMPONI INJ 100MG golimumab SIMPONI INJ 50MG griseofulvin microsize GRIFULVIN V TAB 500MG griseofulvin microsize griseofulvin microsize sus 125/5ml griseofulvin microsize griseofulvin microsize tab micr 500 griseofulvin ultramicrosize griseofulvin ultramicrosi ze tab ultr 125 griseofulvin ultramicrosize griseofulvin ultramicrosi ze tab ultr 250 griseofulvin ultramicrosize GRIS-PEG TAB 125MG griseofulvin ultramicrosize GRIS-PEG TAB 250MG guaifenesin-chlorpheniramine maleate ALLFEN A TAB 400-4MG guaifenesin-codeine ALLFEN CD TAB 400-10MG guaifenesin-codeine ALLFEN CDX LIQ guaifenesin-codeine ALLFEN CDX TAB 400-20MG guaifenesin-codeine BRONTEX LIQ guaifenesin-codeine BRONTEX TAB guaifenesin-codeine dex-tuss liq guaifenesin-codeine guaifenesin ac syp ac guaifenesin-codeine MAR-COF CG EXPECTORANT LIQ guaifenesin-codeine m-clear wc liq guaifenesin-codeine PRO-CLEAR CAP 200-9MG guaifenesin-codeine TUSSO-C LIQ 200-10MG hydrocodone bitartrate HYSINGLA ER TAB 100 MG hydrocodone bitartrate HYSINGLA ER TAB 120 MG hydrocodone bitartrate HYSINGLA ER TAB 20 MG hydrocodone bitartrate HYSINGLA ER TAB 30 MG hydrocodone bitartrate HYSINGLA ER TAB 40 MG hydrocodone bitartrate HYSINGLA ER TAB 60 MG hydrocodone bitartrate HYSINGLA ER TAB 80 MG hydrocodone bitartrate ZOHYDRO ER C12A 10 MG hydrocodone bitartrate ZOHYDRO ER C12A 15 MG hydrocodone bitartrate ZOHYDRO ER C12A 20 MG hydrocodone bitartrate ZOHYDRO ER C12A 30 MG hydrocodone bitartrate ZOHYDRO ER C12A 40 MG hydrocodone bitartrate ZOHYDRO ER C12A 50 MG hydrocodone bitartrate ZOHYDRO ER CAP 10MG hydrocodone bitartrate ZOHYDRO ER CAP 15MG hydrocodone bitartrate ZOHYDRO ER CAP 20MG hydrocodone bitartrate ZOHYDRO ER CAP 30MG hydrocodone bitartrate ZOHYDRO ER CAP 40MG hydrocodone bitartrate ZOHYDRO ER CAP 50MG hydrocodone polistirex-chlorpheniramine polistirex hydrocodone polistirex and chlorpheniramine polistir liq hydrocodone polistirex-chlorpheniramine polistirex TUSSICAPS CAP 10-8MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 27 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description hydrocodone polistirex-chlorpheniramine polistirex TUSSICAPS CAP 5-4MG hydrocodone polistirex-chlorpheniramine polistirex TUSSIONEX PENNKINETIC EXTENDED RELEASE SUS hydrocodone polistirex-chlorpheniramine polistirex TUSSIONEX SUSP hydrocodone w/ homatropine hydrocodone bit/homatropine methylbrom syp 5-1.5/5 hydrocodone w/ homatropine HYDROMET SYP 5-1.5/5 hydrocodone w/ homatropine TUSSIGON TAB 5MG hydrocodone-acetaminophen HYCET SOL 7.5-325 hydrocodone-acetaminophen HYDROCODONE BITART-ACETAMINOPHEN TAB 2.5-325 hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen sol hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen sol 5-217/10mg hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen sol 7.5-325mg hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen tab 10-300mg hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen tab 10-750mg hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen tab 5-300mg hydrocodone-acetaminophen hydrocodone bitartrate-acetaminophen tab 7.5-300mg hydrocodone-acetaminophen hydrocodone-acetaminophen sol hydrocodone-acetaminophen HYDROCODONE-ACETAMINOPHEN SOL 10-325MG hydrocodone-acetaminophen hydrocodone-acetaminophen tab 10-325mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 10-500mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 10-650mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 10-660mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 2.5-500mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 5-325mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 5-500mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 7.5-325mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 7.5-500mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 7.5-650mg hydrocodone-acetaminophen hydrocodone-acetaminophen tab 7.5-750mg hydrocodone-acetaminophen stagesic cap 500-5mg hydrocodone-acetaminophen ZAMICET SOL 10-325MG hydrocodone-acetaminophen ZOLVIT SOL 10-300MG hydrocodone-acetaminophen ZYDONE TAB 10-400MG hydrocodone-acetaminophen ZYDONE TAB 5-400MG hydrocodone-acetaminophen ZYDONE TAB 7.5-400MG hydrocodone-acetaminophen-dietary management product THERACODOPHEN-325 PAK hydrocodone-acetaminophen-dietary management product THERACODOPHEN-650 PAK hydrocodone-acetaminophen-dietary management product THERACODOPHEN-LOW-90 PAK hydrocodone-chlorpheniramine VITUZ SOL 5-4MG hydrocodone-guaifenesin OBREDON SOL hydrocodone-homatropine hydromet syp 5-1.5/5 hydrocodone-homatropine tussigon tab 5mg hydrocodone-ibuprofen hydrocodone-ibuprofen tab 7.5-200 hydrocodone-ibuprofen IBUDONE TAB 10-200MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 28 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description hydrocodone-ibuprofen REPREXAIN TAB 2.5-200 hydrocodone-ibuprofen REPREXAIN TAB 5-200MG hydrocodone-ibuprofen VICOPROFEN TAB hydrocortisone w/acetic acid ACETASOL HC SOL OTIC hydrocortisone w/acetic acid HYDROCORTISONE/ACETIC ACID SOL OTIC hydrocortisone w/acetic acid VOSOL HC SOL OTIC hydromorphone hcl DILAUDID INJ 1MG/ML hydromorphone hcl DILAUDID INJ 2MG/ML hydromorphone hcl DILAUDID INJ 4MG/ML hydromorphone hcl DILAUDID LIQ 1MG/ML hydromorphone hcl DILAUDID TAB 2MG hydromorphone hcl DILAUDID TAB 4MG hydromorphone hcl DILAUDID TAB 8MG hydromorphone hcl DILAUDID-5 LIQ 1MG/ML hydromorphone hcl DILAUDID-HP INJ 10MG/ML hydromorphone hcl DILAUDID-HP INJ 10MG/ML hydromorphone hcl DILAUDID-HP INJ 250MG hydromorphone hcl DILAUDID-HP INJ 250MG hydromorphone hcl EXALGO TAB 12MG hydromorphone hcl EXALGO TAB 16MG hydromorphone hcl EXALGO TAB 32MG hydromorphone hcl EXALGO TAB 8MG hydromorphone hcl HYDROMORPHONE HCL DOSETTE INJ 2MG/ML hydromorphone hcl HYDROMORPHONE HCL ER TAB 32MG ER hydromorphone hcl HYDROMORPHONE HCL INJ 1MG/ML hydromorphone hcl hydromorphone hcl inj 2mg/ml hydromorphone hcl HYDROMORPHONE HCL INJ 2MG/ML hydromorphone hcl hydromorphone hcl inj 4mg/ml hydromorphone hcl HYDROMORPHONE HCL INJ 4MG/ML hydromorphone hcl hydromorphone hcl inj 500/50ml hydromorphone hcl HYDROMORPHONE HCL SUP 3MG hydromorphone hcl hydromorphone hcl tab 2mg hydromorphone hcl hydromorphone hcl tab 4mg hydromorphone hcl hydromorphone hcl tab 8mg hydromorphone hcl-sodium chloride HYDROMORPHONE HCL-NACL SOSY 10-0.9 MG/50ML-% hydromorphone hcl-sodium chloride HYDROMORPHONE-SODIUM CHLORIDE INJ /NACL hydroxyprogesterone caproate MAKENA INJ 250MG/ML ibrutinib IMBRUVICA CAP 140MG icatibant acetate FIRAZYR INJ 30MG/3ML idelalisib ZYDELIG TAB 100MG idelalisib ZYDELIG TAB 150MG iloprost VENTAVIS SOL 10MCG/ML iloprost VENTAVIS SOL 20MCG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 29 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description imatinib mesylate GLEEVEC TAB 100MG imatinib mesylate GLEEVEC TAB 400MG imiglucerase CEREZYME INJ 200UNIT imiglucerase CEREZYME INJ 400UNIT imiquimod ALDARA CRE 5% imiquimod imiquimod cre 5% imiquimod ZYCLARA CRE 3.75% imiquimod ZYCLARA PUMP CRE 2.5% infliximab REMICADE INJ 100MG interferon alfa-2b INTRON-A INJ 10MU PEN interferon alfa-2b INTRON-A INJ 18MU interferon alfa-2b INTRON-A INJ 25MU interferon alfa-2b INTRON-A INJ 3MU PEN interferon alfa-2b INTRON-A INJ 5MU PEN interferon alfa-2b INTRON-A W/DILUENT INJ 10MU interferon alfa-2b INTRON-A W/DILUENT INJ 18MU interferon alfa-2b INTRON-A W/DILUENT INJ 50MU interferon alfacon-1 INFERGEN INJ 15MCG interferon alfacon-1 INFERGEN INJ 9MCG interferon beta-1a AVONEX KIT 30MCG interferon beta-1a AVONEX PEN KIT 30MCG interferon beta-1a REBIF INJ 22/0.5 interferon beta-1a REBIF INJ 44/0.5 interferon beta-1a REBIF REBIDOSE INJ 22/0.5 interferon beta-1a REBIF REBIDOSE INJ 44/0.5 interferon beta-1a REBIF REBIDOSE TITRATION PACK SOL interferon beta-1a REBIF TITRATION PACK SOL PACK interferon beta-1b BETASERON INJ 0.3MG interferon beta-1b EXTAVIA INJ 0.3MG interferon gamma-1b ACTIMMUNE INJ 2MU/0.5 iodine strong (lugol's) IODINE STRONG SOL STRONG isavuconazonium sufate CRESEMBA CAP 186MG isavuconazonium sufate CRESEMBA INJ 372MG isoflurane FORANE SOL isoniazid ISONIAZID INJ 100MG/ML isoniazid ISONIAZID SYR 50MG/5ML isoniazid isoniazid tab 100mg isoniazid isoniazid tab 300mg isoniazid & rifampin RIFAMATE CAP isoniazid-rifampin w/ pyrazinamide RIFATER TAB itraconazole ONMEL TAB 200MG itraconazole SPORANOX SOL 10MG/ML ivacaftor KALYDECO PAK 50MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 30 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description ivacaftor KALYDECO PAK 75MG ivacaftor KALYDECO TAB 150MG ivermectin STROMECTOL TAB 3MG ixazomib citrate NINLARO CAPS 2.3 MG ixazomib citrate NINLARO CAPS 3 MG ixazomib citrate NINLARO CAPS 4 MG ketamine hcl KETALAR INJ 100MG/ML ketamine hcl KETALAR INJ 10MG/ML ketamine hcl KETALAR INJ 50MG/ML ketamine hcl ketamine hcl inj 100mg/ml ketamine hcl ketamine hcl inj 10mg/ml ketamine hcl ketamine hcl inj 50mg/ml ketoconazole KETOCONAZOLE TAB 200MG lanreotide acetate SOMATULINE DEPOT INJ 120/.5ML lanreotide acetate SOMATULINE DEPOT INJ 60/0.2ML lanreotide acetate SOMATULINE DEPOT INJ 90/0.3ML lapatinib ditosylate TYKERB TAB 250MG ledipasvir/sofosbuvir HARVONI TAB 90-400MG lenalidomide REVLIMID CAP 10MG lenalidomide REVLIMID CAP 15MG lenalidomide REVLIMID CAP 2.5MG lenalidomide REVLIMID CAP 20MG lenalidomide REVLIMID CAP 25MG lenalidomide REVLIMID CAP 5MG lenvatinib mesylate LENVIMA 10MG DAILY DOSE CAP 10MG lenvatinib mesylate LENVIMA 14MG DAILY DOSE CAP 14MG lenvatinib mesylate LENVIMA 20MG DAILY DOSE CAP 20MG lenvatinib mesylate LENVIMA 24MG DAILY DOSE CAP 24MG levocetirizine dihydrochloride levocetirizine dihydrochloride tab 5mg levocetirizine dihydrochloride XYZAL 5MG TAB levocetirizine dihydrochloride XYZAL SOL levofloxacin LEVAQUIN SOL 25MG/ML levofloxacin LEVAQUIN TAB 250MG levofloxacin LEVAQUIN TAB 500MG levofloxacin LEVAQUIN TAB 750MG levofloxacin LEVOFLOXACIN INJ 25MG/ML levofloxacin LEVOFLOXACIN SOL 25MG/ML levofloxacin levofloxacin tab 250mg levofloxacin levofloxacin tab 500mg levofloxacin levofloxacin tab 750mg levofloxacin (ophth) levofloxacin sol 0.5% levofloxacin (ophth) QUIXIN SOL 0.5% levofloxacin in d5w LEVAQUIN INJ 500/100ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 31 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description levofloxacin in d5w LEVAQUIN INJ 750/150ML levofloxacin in d5w LEVOFLOXACIN IN D5W INJ 250/50ML levofloxacin in d5w LEVOFLOXACIN IN D5W INJ 500/100ML levofloxacin in d5w LEVOFLOXACIN IN D5W INJ 750/150ML levorphanol tartrate LEVO DROMORAN INJ 2MG/ML levorphanol tartrate LEVORPHANOL TARTRATE TAB 2MG linezolid ZYVOX SOL 2MG/ML linezolid ZYVOX SUS 100MG/5M linezolid ZYVOX TAB 600MG liraglutide (weight management) SAXENDA SOPN 18 MG/3ML lisdexamfetamine dimesylate VYVANSE CAP 10MG lisdexamfetamine dimesylate VYVANSE CAP 20MG lisdexamfetamine dimesylate VYVANSE CAP 30MG lisdexamfetamine dimesylate VYVANSE CAP 40MG lisdexamfetamine dimesylate VYVANSE CAP 50MG lisdexamfetamine dimesylate VYVANSE CAP 60MG lisdexamfetamine dimesylate VYVANSE CAP 70MG l-methylfolate-algae DEPLIN 15 CAP l-methylfolate-algae L-METHYLFOLATE FORTE CAP FORTE lomitapide mesylate JUXTAPID CAP 10MG lomitapide mesylate JUXTAPID CAP 20MG lomitapide mesylate JUXTAPID CAP 30MG lomitapide mesylate JUXTAPID CAP 40MG lomitapide mesylate JUXTAPID CAP 5MG lomitapide mesylate JUXTAPID CAP 60MG lorazepam ATIVAN INJ 2MG/ML lorazepam ATIVAN INJ 4MG/ML lorazepam ATIVAN TAB 0.5MG lorazepam ATIVAN TAB 1MG lorazepam ATIVAN TAB 2MG lorazepam lorazepam inj 2mg/ml lorazepam lorazepam inj 4mg/ml lorazepam LORAZEPAM INTENSOL CON 2MG/ML lorazepam lorazepam tab 0.5mg lorazepam lorazepam tab 1mg lorazepam lorazepam tab 2mg lumacaftor-ivacaftor ORKAMBI TAB 200-125 lutropin alfa LUVERIS INJ 75UNIT macitentan OPSUMIT TAB 10MG mecamylamine hcl VECAMYL TAB 2.5MG mecasermin INCRELEX INJ 40MG/4ML mecasermin rinfabate (rdna) IPLEX INJ 36/0.6ML Mechlorethamine hcl (topical) VALCHLOR GEL 0.016%
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 32 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description mefloquine hcl mefloquine hcl tab 250mg menotropins MENOPUR INJ 75UNIT menotropins REPRONEX INJ 75UNIT meperidine hcl DEMEROL INJ 100/2ML meperidine hcl DEMEROL INJ 100MG/ML meperidine hcl DEMEROL INJ 25MG/0.5ML meperidine hcl DEMEROL INJ 25MG/ML meperidine hcl DEMEROL INJ 50MG/ML meperidine hcl DEMEROL INJ 75MG/1.5ML meperidine hcl DEMEROL INJ 75MG/ML meperidine hcl meperidine hcl inj 100mg/ml meperidine hcl meperidine hcl inj 10mg/ml meperidine hcl meperidine hcl inj 25mg/ml meperidine hcl meperidine hcl inj 50mg/ml meperidine hcl meperidine hcl inj 75mg/ml meperidine hcl MEPERIDINE HCL SOL 50MG/5ML meperidine hcl meperidine hcl tab 50mg meperidine hcl meperitab tab 100mg meperidine-promethazine meperidine/promethazine cap mephobarbital MEBARAL TAB 100MG mephobarbital MEBARAL TAB 32MG mephobarbital MEBARAL TAB 50MG mepolizumab NUCALA SOLR 100 MG meprobamate meprobamate tab 200mg meprobamate meprobamate tab 400mg meprobamate-aspirin EQUAGESIC TAB 200-325 methadone hcl DOLOPHINE HCL TAB 5MG methadone hcl DOLOPHINE TAB 10MG methadone hcl METHADONE HCL INJ 10MG/ML methadone hcl METHADONE HCL SOL 10MG/5ML methadone hcl METHADONE HCL SOL 5MG/5ML methadone hcl methadone hcl tab 10mg methadone hcl methadone hcl tab 5mg methadone hcl METHADOSE CON 10MG/ML methadone hcl METHADOSE SUGAR-FREE CON 10MG/ML methadone hcl METHADOSE TAB 40MG methamphetamine hcl DESOXYN TAB 5MG methohexital sodium BREVITAL SODIUM INJ 2.5GM methohexital sodium BREVITAL SODIUM INJ 200MG methohexital sodium BREVITAL SODIUM INJ 500MG methylphenidate DAYTRANA DIS 10MG/9HR methylphenidate DAYTRANA DIS 15MG/9HR methylphenidate DAYTRANA DIS 20MG/9HR
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 33 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description methylphenidate DAYTRANA DIS 30MG/9HR methylphenidate hcl APTENSIO XR CAP 10MG methylphenidate hcl APTENSIO XR CAP 15MG methylphenidate hcl APTENSIO XR CAP 20MG methylphenidate hcl APTENSIO XR CAP 30MG methylphenidate hcl APTENSIO XR CAP 40MG methylphenidate hcl APTENSIO XR CAP 50MG methylphenidate hcl APTENSIO XR CAP 60MG methylphenidate hcl CONCERTA TAB 18MG methylphenidate hcl CONCERTA TAB 27MG methylphenidate hcl CONCERTA TAB 36MG methylphenidate hcl CONCERTA TAB 54MG methylphenidate hcl METADATE CD CAP 10MG methylphenidate hcl METADATE CD CAP 20MG methylphenidate hcl METADATE CD CAP 30MG methylphenidate hcl METADATE CD CAP 40MG methylphenidate hcl METADATE CD CAP 50MG methylphenidate hcl METADATE CD CAP 60MG methylphenidate hcl METHYLIN CHW 10MG methylphenidate hcl METHYLIN CHW 2.5MG methylphenidate hcl METHYLIN CHW 5MG methylphenidate hcl METHYLIN SOL 10MG/5ML methylphenidate hcl METHYLIN SOL 5MG/5ML methylphenidate hcl methylphenidate hcl cd cap 10mg methylphenidate hcl methylphenidate hcl cd cap 20mg methylphenidate hcl methylphenidate hcl cd cap 30mg methylphenidate hcl methylphenidate hcl cd cap 40mg methylphenidate hcl methylphenidate hcl cd cap 50mg methylphenidate hcl methylphenidate hcl cd cap 60mg methylphenidate hcl METHYLPHENIDATE HCL ER TAB 10MG methylphenidate hcl methylphenidate hcl er tab 18mg methylphenidate hcl methylphenidate hcl er tab 20mg methylphenidate hcl methylphenidate hcl er tab 27mg methylphenidate hcl methylphenidate hcl er tab 36mg methylphenidate hcl methylphenidate hcl er tab 54mg methylphenidate hcl methylphenidate hcl tab 10mg methylphenidate hcl methylphenidate hcl tab 20mg methylphenidate hcl methylphenidate hcl tab 5mg methylphenidate hcl methylphenidate hydrochloride sol 10mg/5ml methylphenidate hcl methylphenidate hydrochloride sol 5mg/5ml methylphenidate hcl QUILLIVANT XR SUS XR methylphenidate hcl RITALIN LA CAP 10MG methylphenidate hcl RITALIN LA CAP 20MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 34 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description methylphenidate hcl RITALIN LA CAP 30MG methylphenidate hcl RITALIN LA CAP 40MG methylphenidate hcl RITALIN TAB 10MG methylphenidate hcl RITALIN TAB 20MG methylphenidate hcl RITALIN TAB 5MG methylprednisolone MEDROL DOSEPAK PAK 4MG methylprednisolone MEDROL TAB 16MG methylprednisolone MEDROL TAB 2MG methylprednisolone MEDROL TAB 32MG methylprednisolone MEDROL TAB 4MG methylprednisolone MEDROL TAB 8MG methylprednisolone methylprednisolone dose pack pak 4mg methylprednisolone methylprednisolone tab 16mg methylprednisolone methylprednisolone tab 32mg methylprednisolone methylprednisolone tab 4mg methylprednisolone methylprednisolone tab 8mg methylprednisolone acetate & bupivacaine hcl PHYSICIANS EZ USE M-PRED KIT metreleptin MYALEPT INJ 11.3MG metyrosine DEMSER CAP 250MG micafungin sodium MYCAMINE INJ 100MG micafungin sodium MYCAMINE INJ 50MG miconazole (mouth-throat) ORAVIG TAB 50MG midazolam hcl midazolam hcl inj 10mg/2ml midazolam hcl midazolam hcl inj 1mg/ml midazolam hcl midazolam hcl inj 25mg/5ml midazolam hcl midazolam hcl inj 2mg/2ml midazolam hcl midazolam hcl inj 50mg/10ml midazolam hcl midazolam hcl inj 5mg/1ml midazolam hcl midazolam hcl inj 5mg/5ml midazolam hcl midazolam hcl syp 2mg/ml mifepristone (hyperglycemia) KORLYM TAB 300MG miglustat ZAVESCA CAP 100MG mipomersen sodium KYNAMRO INJ 200MG/ML mitomycin (ophthalmic) MITOSOL KIT 0.2MG mitotane LYSODREN TAB 500MG modafanil MODAFINIL TAB 100MG modafanil MODAFINIL TAB 200MG modafinil PROVIGIL TAB 100MG modafinil PROVIGIL TAB 200MG morphine sulfate duramorph inj 0.5mg/ml morphine sulfate duramorph inj 1mg/ml morphine sulfate KADIAN CAP 100MG CR morphine sulfate KADIAN CAP 10MG CR
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 35 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description morphine sulfate KADIAN CAP 130MG CR morphine sulfate KADIAN CAP 150MG CR morphine sulfate KADIAN CAP 200MG CR morphine sulfate KADIAN CAP 20MG CR morphine sulfate KADIAN CAP 30MG CR morphine sulfate KADIAN CAP 40MG CR morphine sulfate KADIAN CAP 50MG CR morphine sulfate KADIAN CAP 60MG CR morphine sulfate KADIAN CAP 70MG CR morphine sulfate KADIAN CAP 80MG CR morphine sulfate MORPHINE SULFATE (PF) SOLN 10 MG/ML morphine sulfate MORPHINE SULFATE (PF) SOLN 4 MG/ML morphine sulfate MORPHINE SULFATE (PF) SOLN 8 MG/ML morphine sulfate morphine sulfate dilute-a-jet inj 25mg/ml morphine sulfate morphine sulfate er cap 100mg morphine sulfate morphine sulfate er cap 20mg morphine sulfate morphine sulfate er cap 30mg morphine sulfate morphine sulfate er cap 50mg morphine sulfate morphine sulfate er cap 60mg morphine sulfate morphine sulfate er cap 80mg morphine sulfate morphine sulfate er tab 100mg morphine sulfate morphine sulfate er tab 15mg morphine sulfate morphine sulfate er tab 200mg morphine sulfate morphine sulfate er tab 30mg morphine sulfate morphine sulfate er tab 60mg morphine sulfate morphine sulfate inj 0.5mg/ml morphine sulfate MORPHINE SULFATE INJ 10/0.7ML morphine sulfate morphine sulfate inj 10mg/ml morphine sulfate MORPHINE SULFATE INJ 10MG/ML morphine sulfate MORPHINE SULFATE INJ 150/30ML morphine sulfate morphine sulfate inj 15mg/ml morphine sulfate morphine sulfate inj 1mg/ml morphine sulfate morphine sulfate inj 25mg/ml morphine sulfate MORPHINE SULFATE INJ 25MG/ML morphine sulfate MORPHINE SULFATE INJ 2MG/ML morphine sulfate MORPHINE SULFATE INJ 2MG/ML morphine sulfate MORPHINE SULFATE INJ 4MG/ML morphine sulfate MORPHINE SULFATE INJ 4MG/ML morphine sulfate morphine sulfate inj 50mg/ml morphine sulfate MORPHINE SULFATE INJ 50MG/ML morphine sulfate MORPHINE SULFATE INJ 5MG/ML morphine sulfate MORPHINE SULFATE INJ 5MG/ML morphine sulfate morphine sulfate inj 8mg/ml
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 36 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description morphine sulfate MORPHINE SULFATE INJ 8MG/ML morphine sulfate morphine sulfate sol 10/0.5ml morphine sulfate MORPHINE SULFATE SOL 10MG/5ML morphine sulfate MORPHINE SULFATE SOL 20MG/5ML morphine sulfate morphine sulfate sol 20mg/ml morphine sulfate morphine sulfate sol 5/0.25ml morphine sulfate MORPHINE SULFATE SUP 10MG morphine sulfate MORPHINE SULFATE SUP 20MG morphine sulfate MORPHINE SULFATE SUP 30MG morphine sulfate MORPHINE SULFATE SUP 5MG morphine sulfate MORPHINE SULFATE TAB 10MG morphine sulfate morphine sulfate tab 15mg morphine sulfate MORPHINE SULFATE TAB 30MG morphine sulfate beads AVINZA CAP 120MG morphine sulfate beads AVINZA CAP 30MG morphine sulfate beads AVINZA CAP 45MG morphine sulfate beads AVINZA CAP 60MG morphine sulfate beads AVINZA CAP 75MG morphine sulfate beads AVINZA CAP 90MG morphine sulfate for continuous microinfusion INFUMORPH 200 INJ 10MG/ML morphine sulfate for continuous microinfusion INFUMORPH 500 INJ 25MG/ML morphine sulfate in dextrose MORPHINE SULF IN DEXTROSE 5% INJ 1MG/ML morphine sulfate liposome DEPODUR INJ 10MG/ML morphine sulfate liposome DEPODUR INJ 15/1.5ML morphine sulfate-sodium chloride MORPHINE SULFATE-NACL SOSY 50-0.9 MG/50ML-% morphine-naltrexone EMBEDA CAP 100-4MG morphine-naltrexone EMBEDA CAP 20-0.8MG morphine-naltrexone EMBEDA CAP 30-1.2MG morphine-naltrexone EMBEDA CAP 50-2MG morphine-naltrexone EMBEDA CAP 60-2.4MG morphine-naltrexone EMBEDA CAP 80-3.2MG morphine-naltrexone EMBEDA CPCR 100-4 MG morphine-naltrexone EMBEDA CPCR 20-0.8 MG morphine-naltrexone EMBEDA CPCR 30-1.2 MG morphine-naltrexone EMBEDA CPCR 50-2 MG morphine-naltrexone EMBEDA CPCR 60-2.4 MG morphine-naltrexone EMBEDA CPCR 80-3.2 MG moxifloxacin hcl AVELOX ABC PACK TAB 400MG moxifloxacin hcl AVELOX TAB 400MG moxifloxacin hcl moxifloxacin hcl tab 400mg moxifloxacin hcl (ophth) MOXEZA SOL 0.5% moxifloxacin hcl (ophth) VIGAMOX DRO 0.5% moxifloxacin hcl in sodium chloride AVELOX INJ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 37 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description nafarelin acetate SYNAREL SOL 2MG/ML nafcillin sodium NAFCILLIN SODIUM INJ 1GM nafcillin sodium NAFCILLIN SODIUM INJ 2GM nafcillin sodium in dextrose NALLPEN ISO-OSMOTIC IN DEXTROSE INJ 2GM/100 nafcillin sodium in dextrose NALLPEN/DEXTROSE INJ 1GM/50ML nalbuphine hcl nalbuphine hcl inj 10mg/ml nalbuphine hcl nalbuphine hcl inj 20mg/ml nalmefene hcl REVEX INJ 100MCG nalmefene hcl REVEX INJ 1MG/ML naloxone hcl DEPADE TAB 50MG naloxone hcl EVZIO INJ naloxone hcl NALOXONE HCL INJ 0.4MG/ML naloxone hcl naloxone hcl inj 1mg/ml naloxone hcl REVIA TAB 50MG naloxone hcl-bupropion hcl CONTRAVE TAB 8-90MG naltrexone VIVITROL INJ 380MG naltrexone hcl naltrexone hcl tab 50mg naproxen-esomeprazole magnesium VIMOVO TAB 375-20MG naproxen-esomeprazole magnesium VIMOVO TAB 500-20MG naratriptan hcl naratriptan hcl tab 1mg naratriptan hcl naratriptan hcl tab 2.5mg natamycin NATACYN SUS 5% OP neomycin-bacitracin zn-polymyxin neomycin/polymyxin/bacitracin zinc oin op neomycin-bacitracin zn-polymyxin NEO-POLYCIN OIN OP neomycin-colistin-hc-thonzonium COLY-MYCIN S SUS OTIC neomycin-colistin-hc-thonzonium CORTISPORIN-TC SUS -TC OTIC neomycin-polymy-dexameth DEXASPORIN SUS 0.1% OP neomycin-polymy-dexameth MAXITROL OIN 0.1% OP neomycin-polymy-dexameth MAXITROL SUS 0.1% OP neomycin-polymy-dexameth neomycin/polymyxin/dexamethasone oin 0.1% op neomycin-polymy-dexameth neomycin/polymyxin/dexamethasone sus 0.1% op neomycin-polymy-dexameth POLY-DEX OIN 0.1% OP neomycin-polymy-dexameth POLY-DEX SUS 0.1% OP neomycin-polymy-gramicid OCUTRICIN SOL OP neomycin-polymyxin-gramicidin NEOSPORIN SOL OP neomycin-polymyxin-hc OTIMAR SOL 1% OTIC neomycin-polymyxin-hc OTIMAR SUS 1% OTIC neomycin-polymyxin-hc (ophth) CORTISPORIN SUS 1% OP neomycin-polymyxin-hc (ophth) neomycin/polymyxin/hydrocortisone sus op neomycin-polymyxin-hc (otic) CORTISPORIN SOL 1% OTIC neomycin-polymyxin-hc (otic) CORTISPORIN SUS 1% OTIC neomycin-polymyxin-hc (otic) CORTOMYCIN SOL 1% OTIC neomycin-polymyxin-hc (otic) CORTOMYCIN SUS 1% OTIC
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 38 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description neomycin-polymyxin-hc (otic) neomycin/polymyxin/hc sol 1% otic neomycin-polymyxin-hc (otic) neomycin/polymyxin/hydrocortisone sus 1% otic neomycin-polymyxin-hc (otic) OTICIN HC SUS 1% OTIC neomycin-polymyxin-hc (otic) PEDIOTIC SUS 1% OTIC neomycin-polymyx-pred acetate POLY-PRED SUS OP netupitant-palonosetron AKYNZEO CAP nicotine nicotine transdermal system dis 14mg/24h nicotine nicotine transdermal system dis 21mg/24h nicotine nicotine transdermal system dis 7mg/24hr nicotine NICOTINE TRANSDERMAL SYSTEM KIT nicotine NICOTROL INHALER INH nicotine NICOTROL NS SPR 10MG/ML nicotine polacrilex COMMIT LOZ 4MG nicotine polacrilex NICORETTE LOZ 2MG nicotine polacrilex nicotine polacrilex gum 2mg orig nicotine polacrilex nicotine polacrilex gum 4mg nilotinib TASIGNA CAP 150MG nilotinib TASIGNA CAP 200MG nintedanib esylate OFEV CAP 100MG nintedanib esylate OFEV CAP 150MG nitisinone ORFADIN CAP 10MG nitisinone ORFADIN CAP 2MG nitisinone ORFADIN CAP 5MG nystatin BIO-STATIN CAP 1000000 nystatin BIO-STATIN CAP 500000 nystatin nystatin tab 500000 nystatin (mouth-throat) nystatin sus 100000 obinutuzumab GAZYVA INJ 25MG/ML octreotide acetate SANDOSTATIN LAR DEPOT KIT 10MG octreotide acetate SANDOSTATIN LAR DEPOT KIT 20MG octreotide acetate SANDOSTATIN LAR DEPOT KIT 30MG ofloxacin ofloxacin tab 400mg ofloxacin (ophth) OCUFLOX DRO 0.3% OP ofloxacin (ophth) ofloxacin dro 0.3% op ofloxacin (otic) FLOXIN OTIC DRO 0.3% ofloxacin (otic) FLOXIN OTIC SINGLES DRO SINGLES ofloxacin (otic) ofloxacin dro 0.3% otic olaparib LYNPARZA CAP 50MG omacetaxine mepesuccinate SYNRIBO INJ 3.5MG omalizumab XOLAIR SOL 150MG ombitasvir-paritaprevir-ritonavir TECHNIVIE TAB 12.5-75-50 MG ombitasvir-paritaprevir-ritonavir & dasabuvir VIEKIRA PAK TAB ondansetron ondansetron hcl sol 4mg/5ml
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 39 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description ondansetron ondansetron hcl tab 24mg ondansetron ondansetron hcl tab 4mg ondansetron ondansetron hcl tab 8mg ondansetron ondansetron odt tab 4mg odt ondansetron ondansetron odt tab 8mg odt ondansetron ZOFRAN ODT TAB 4MG ODT ondansetron ZOFRAN ODT TAB 8MG ODT ondansetron ZUPLENZ MIS 4MG ondansetron ZUPLENZ MIS 8MG ondansetron hcl ZOFRAN INJ 40/20ML ondansetron hcl ZOFRAN SOL 4MG/5ML ondansetron hcl ZOFRAN TAB 4MG ondansetron hcl ZOFRAN TAB 8MG orphenadrine-aspirin-caffeine ORPHENADRINE COMPOUND DS TAB orphenadrine-aspirin-caffeine orphenadrine/aspirin/caffeine tab oseltamivir phosphate TAMIFLU CAP 30MG oseltamivir phosphate TAMIFLU CAP 45MG oseltamivir phosphate TAMIFLU CAP 75MG oseltamivir phosphate TAMIFLU SUS 6MG/ML osimertinib mesylate TAGRISSO TABS 40 MG osimertinib mesylate TAGRISSO TABS 80 MG oxacillin sodium OXACILLIN SODIUM INJ 10GM oxacillin sodium OXACILLIN SODIUM INJ 1GM oxacillin sodium OXACILLIN SODIUM INJ 2GM oxacillin sodium in dextrose BACTOCILL IN DEXTROSE INJ 1GM oxacillin sodium in dextrose BACTOCILL IN DEXTROSE INJ 2GM oxazepam oxazepam cap 10mg oxazepam oxazepam cap 15mg oxazepam oxazepam cap 30mg oxazepam SERAX TAB 15MG oxycodone hcl DAZIDOX TAB 10MG oxycodone hcl eth-oxydose con 20mg/ml oxycodone hcl OXECTA TAB 5MG oxycodone hcl OXECTA TAB 7.5MG oxycodone hcl OXYCODONE HCL CAP 5MG oxycodone hcl oxycodone hcl con 20mg/ml oxycodone hcl oxycodone hcl sol 5mg/5ml oxycodone hcl oxycodone hcl tab 10mg oxycodone hcl oxycodone hcl tab 15mg oxycodone hcl OXYCODONE HCL TAB 20MG oxycodone hcl oxycodone hcl tab 30mg oxycodone hcl oxycodone hcl tab 5mg oxycodone hcl OXYCONTIN TAB 10MG CR
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 40 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description oxycodone hcl OXYCONTIN TAB 15MG CR oxycodone hcl OXYCONTIN TAB 20MG CR oxycodone hcl OXYCONTIN TAB 30MG CR oxycodone hcl OXYCONTIN TAB 40MG CR oxycodone hcl OXYCONTIN TAB 60MG CR oxycodone hcl OXYCONTIN TAB 80MG CR oxycodone-acetaminophen MAGNACET TAB 10-400MG oxycodone-acetaminophen MAGNACET TAB 2.5-400MG oxycodone-acetaminophen MAGNACET TAB 5-400MG oxycodone-acetaminophen MAGNACET TAB 7.5-400MG oxycodone-acetaminophen oxycodone-acetaminophen cap 5-500mg oxycodone-acetaminophen oxycodone-acetaminophen tab 10-325mg oxycodone-acetaminophen oxycodone-acetaminophen tab 10-650mg oxycodone-acetaminophen oxycodone-acetaminophen tab 2.5-325mg oxycodone-acetaminophen oxycodone-acetaminophen tab 5-325mg oxycodone-acetaminophen oxycodone-acetaminophen tab 7.5-325mg oxycodone-acetaminophen oxycodone-acetaminophen tab 7.5-500mg oxycodone-acetaminophen PRIMALEV TAB 2.5-300 oxycodone-acetaminophen PRIMLEV TAB 10-300MG oxycodone-acetaminophen PRIMLEV TAB 5-300MG oxycodone-acetaminophen PRIMLEV TAB 7.5-300 oxycodone-acetaminophen ROXICET SOL 5-325/5 oxycodone-acetaminophen ROXICET TAB 5-500MG oxycodone-acetaminophen XARTEMIS XR TAB 7.5-325 oxycodone-acetaminophen XOLOX TAB 10-500MG oxycodone-aspirin endodan tab oxycodone-aspirin oxycodone-aspirin tab oxycodone-ibuprofen oxycodone-ibuprofen tab 5-400mg oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 10MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 15MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 20MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 30MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 40MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 5MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 7.5MG oxymorphone hcl OPANA ER TAB 10MG oxymorphone hcl OPANA ER TAB 15MG oxymorphone hcl OPANA ER TAB 20MG oxymorphone hcl OPANA ER TAB 30MG oxymorphone hcl OPANA ER TAB 40MG oxymorphone hcl OPANA ER TAB 5MG oxymorphone hcl OPANA ER TAB 7.5MG oxymorphone hcl OPANA INJ 1MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 41 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description oxymorphone hcl oxymorphone hydrochloride ER tab 10mg oxymorphone hcl oxymorphone hydrochloride ER tab 15mg oxymorphone hcl oxymorphone hydrochloride ER tab 20mg oxymorphone hcl oxymorphone hydrochloride ER tab 30mg oxymorphone hcl oxymorphone hydrochloride ER tab 40mg oxymorphone hcl oxymorphone hydrochloride ER tab 5mg oxymorphone hcl oxymorphone hydrochloride ER tab 7.5mg oxymorphone hcl oxymorphone hydrochloride tab 10mg oxymorphone hcl oxymorphone hydrochloride tab 5mg palbociclib IBRANCE CAP 100MG palbociclib IBRANCE CAP 125MG palbociclib IBRANCE CAP 75MG palifermin KEPIVANCE INJ 6.25MG paliperidone palmitate INVEGA SUSTENNA INJ 117/0.75 paliperidone palmitate INVEGA SUSTENNA INJ 156MG/ML paliperidone palmitate INVEGA SUSTENNA INJ 234/1.5 paliperidone palmitate INVEGA SUSTENNA INJ 39/0.25 paliperidone palmitate INVEGA SUSTENNA INJ 78/0.5ML panobinostat FARYDAK CAP 10MG panobinostat FARYDAK CAP 15MG panobinostat FARYDAK CAP 20MG parathyroid hormone (recombinant) NATPARA INJ 100MCG parathyroid hormone (recombinant) NATPARA INJ 25MCG parathyroid hormone (recombinant) NATPARA INJ 50MCG parathyroid hormone (recombinant) NATPARA INJ 75MCG pasireotide diaspartate SIGNIFOR INJ 0.3MG/ML pasireotide diaspartate SIGNIFOR INJ 0.6MG/ML pasireotide diaspartate SIGNIFOR INJ 0.9MG/ML pasireotide diaspartate SIGNIFOR LAR INJ 20MG pasireotide diaspartate SIGNIFOR LAR INJ 40MG pasireotide diaspartate SIGNIFOR LAR INJ 60MG patiromer sorbitex calcium VELTASSA PACK 16.8 GM patiromer sorbitex calcium VELTASSA PACK 25.2 GM patiromer sorbitex calcium VELTASSA PACK 8.4 GM pazopanib hcl VOTRIENT TAB 200MG peg 3350-kcl-sod bicarb-sod chloride-sod sulfate COLYTE SOL peg 3350-kcl-sod bicarb-sod chloride-sod sulfate COLYTE-FLAVOR PACKS SOL PACKS peg 3350-kcl-sod bicarb-sod chloride-sod sulfate GAVILYTE-C SOL peg 3350-kcl-sod bicarb-sod chloride-sod sulfate peg 3350/electrolytes sol electrol peginterferon alfa-2a PEGASYS INJ peginterferon alfa-2a PEGASYS INJ 180MCG/M peginterferon alfa-2a PEGASYS KIT peginterferon alfa-2a PEGASYS PROCLICK INJ
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 42 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description peginterferon alfa-2a PEGASYS PROCLICK INJ PROCLICK peginterferon alfa-2b PEG-INTRON KIT 120MCG peginterferon alfa-2b PEG-INTRON KIT 150MCG peginterferon alfa-2b PEG-INTRON KIT 50MCG peginterferon alfa-2b PEG-INTRON KIT 80MCG peginterferon alfa-2b PEG-INTRON REDIPEN KIT 120 RP peginterferon alfa-2b PEG-INTRON REDIPEN KIT 150 RP peginterferon alfa-2b PEG-INTRON REDIPEN KIT 50MCG RP peginterferon alfa-2b PEG-INTRON REDIPEN KIT 80MCG RP peginterferon alfa-2b (antineoplastic) SYLATRON KIT 296MCG peginterferon alfa-2b (antineoplastic) SYLATRON KIT 444MCG peginterferon alfa-2b (antineoplastic) SYLATRON KIT 888MCG peginterferon beta-1a PLEGRIDY INJ peginterferon beta-1a PLEGRIDY INJ PEN peginterferon beta-1a PLEGRIDY STARTER PACK INJ pegvisomant SOMAVERT INJ 10MG pegvisomant SOMAVERT INJ 15MG pegvisomant SOMAVERT INJ 20MG pegvisomant SOMAVERT INJ 25MG pegvisomant SOMAVERT INJ 30MG penicillamine CUPRIMINE CAP 250MG penicillamine DEPEN TITRATABS TAB 250MG penicillin g benzathine BICILLIN L-A INJ 1200000 penicillin g benzathine BICILLIN L-A INJ 2400000 penicillin g benzathine BICILLIN L-A INJ 600000 penicillin g benzathine & procaine BICILLIN C-R INJ 1200000 penicillin g benzathine & procaine BICILLIN C-R INJ 900/300 penicillin g pot in dextrose PENICILLIN G POT IN ISO-OSMOTIC DEXT INJ 1MU penicillin g pot in dextrose PENICILLIN G POT IN ISO-OSMOTIC DEXT INJ 2MU penicillin g pot in dextrose PENICILLIN G POT IN ISO-OSMOTIC DEXT INJ 3MU penicillin g potassium PENICILLIN G POTASSIUM INJ 20MU penicillin g potassium PENICILLIN G POTASSIUM INJ 5MU penicillin g potassium PFIZERPEN-G INJ 20MU penicillin g potassium PFIZERPEN-G INJ 5MU penicillin g procaine PENICILLIN G PROCAINE INJ 600000 penicillin g sodium PENICILLIN G SODIUM INJ 5000000 penicillin v potassium penicillin v potassium sol 125/5ml penicillin v potassium penicillin v potassium sol 250/5ml penicillin v potassium penicillin v potassium tab 250mg penicillin v potassium penicillin v potassium tab 500mg pentamidine isethionate NEBUPENT INH 300MG pentamidine isethionate PENTAM 300 INJ 300MG pentazocine lactate TALWIN INJ 30MG/ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 43 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description pentazocine-acetaminophen PENTAZOCINE-ACETAMINOPHEN TAB 25-650MG pentazocine-naloxone pentazocine-naloxone hcl tab pentobarbital sodium NEMBUTAL INJ 50MG/ML pentosan polysulfate sodium ELMIRON CAP 100MG phenylephrine hcl-dextrometh hbr-guaifenesin tannate TUSSO-XR SUS phenylephrine hcl-diphenhyd hcl-dextrometh hbr tannate DURATUSS AC 12 SUS AC phenylephrine hcl-pyrilamine mal-dm hbr tannate DECONSAL DM CHW phenylephrine tan-carbetapentane tan-homeopathic prod ZINX COLD KIT phenylephrine tan-dexchlorphenir tan-dextromethorphan tan DONATUSSIN DM SUS DM phenylephrine tan-dm tan-pyrilamine maleate-dm tan POLY TAN DM SUS phenylephrine tannate-bromphen tan-dextromethorphan tan bromatan-dm sus phenylephrine tannate-bromphen tan-dextromethorphan tan NEO DM SUS phenylephrine tannate-carbetapentane tannate carb/phenyl-12 sus phenylephrine tannate-carbetapentane tannate DYNEX 12 SUS phenylephrine tannate-carbetapentane tannate l-all 12 nf sus 25-30mg phenylephrine tannate-chlorphen tan-carbetapentane tan CARBAPHEN 12 PED SUS PED phenylephrine tannate-chlorphen tan-carbetapentane tan CARBAPHEN 12 SUS phenylephrine tannate-chlorphen tan-dextromethorphan tan MAXIPHEN ADT TAB phenylephrine tannate-diphenhyd tan-carbetapentane tan d-tann ct sus phenylephrine tannate-diphenhyd tan-carbetapentane tan d-tann ct tab phenylephrine tannate-diphenhyd tan-carbetapentane tan DYTAN-CD SUS phenylephrine tannate-diphenhyd tan-dextromethorphan tan livetan dm sus phenylephrine tannate-guaifenesin SINA-12X SUS phenylephrine tannate-guaifenesin SINA-12X TAB 25-200MG phenylephrine tannate-pyrilamine tan-carbetapentane tan TUSSI-12D S SUS phenylephrine tannate-pyrilamine tan-carbetapentane tan TUSSI-12D TAB 10-40-60 phenylephrine tannate-pyrilamine tan-dextromethorphan tan SINADEX 12 SUS phenylephrine tannate-pyrilamine tan-dextromethorphan tan VIRATAN-DM CHW 25-30-25 phenylephrine tannate-pyrilamine tannate-guaifenesin RYNA-12X SUS 5-30-100 phenylephrine tannate-pyrilamine tannate-guaifenesin RYNA-12X TAB phenylephrine tannate-pyrilamine tann-dextromethorphan tan allanvan-dm sus phenylephrine-brompheniramine-carbetapentane trexbrom liq phenylephrine-brompheniramine-carbetapentane VAZOTAN SUS phenylephrine-brompheniramine-carbetapentane v-cof sus phenylephrine-brompheniramine-codeine BROVEX PB C TAB 10-4-10 phenylephrine-brompheniramine-codeine BROVEX PB CX TAB 10-4-20 phenylephrine-brompheniramine-codeine M-END PE LIQ phenylephrine-brompheniramine-codeine POLY-TUSSIN AC LIQ AC phenylephrine-brompheniramine-dihydrocodeine POLY-TUSSIN DHC LIQ DHC phenylephrine-brompheniramine-dm ALACOL DM DROP phenylephrine-brompheniramine-dm ALAHIST DM LIQ 7.5-4-15 phenylephrine-brompheniramine-dm bpm pe dm syp 5-2-10mg phenylephrine-brompheniramine-dm brompheniramine-phenylephrine-dm liq 4-10-20
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 44 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description phenylephrine-brompheniramine-dm-guaifenesin BROMHIST-PDX SYP phenylephrine-brompheniramine-guaifenesin DECON-G DRO 2-1-40MG phenylephrine-carbetapentane-guaifenesin albatussin nn liq phenylephrine-carbetapentane-guaifenesin AQUATAB C TAB phenylephrine-carbetapentane-guaifenesin carbetaplex syp phenylephrine-carbetapentane-guaifenesin extendryl gcp sol phenylephrine-carbetapentane-guaifenesin phencarb guaifenesin syp phenylephrine-carbetapentane-guaifen-homeopathic prod ZINX COUGH KIT phenylephrine-carbetapentane-potassium guaiacolsulfonate CARBATUSS-CL LIQ phenylephrine-chlorphen-dm ACCUHIST PDX DROP PDX phenylephrine-chlorphen-dm centergy dm drop phenylephrine-chlorphen-dm c-phen dm drop phenylephrine-chlorphen-dm de-chlor dm syp liquid phenylephrine-chlorphen-dm de-chlor dr syp liquid phenylephrine-chlorphen-dm ed-a-hist dm liq phenylephrine-chlorphen-dm NEO DM DROP phenylephrine-chlorphen-dm NEOTUSS PLUS LIQ phenylephrine-chlorphen-dm pe-hist dm syp 5-2-15mg phenylephrine-chlorphen-dm sildec pe-dm syp phenylephrine-chlorphen-dm zoden dm drop phenylephrine-chlorphen-dm zotex-12d tab phenylephrine-chlorphen-guaifenesin p chlor gg sol drop phenylephrine-chlorpheniramine-carbetapentane CARBAPHEN 12 LIQ phenylephrine-chlorpheniramine-codeine CAPCOF SYP phenylephrine-chlorpheniramine-codeine ENDAL CD SYP phenylephrine-chlorpheniramine-dihydrocodeine BALTUSSIN SYP 20-5-3 phenylephrine-chlorpheniramine-dihydrocodeine DESPEC-PDC LIQ phenylephrine-chlorpheniramine-dihydrocodeine DIHYDRO-PE SYP phenylephrine-chlorpheniramine-dihydrocodeine DUOHIST DH LIQ 5-2-7.25 phenylephrine-chlorpheniramine-dihydrocodeine NOVAHISTINE DH LIQ phenylephrine-chlorpheniramine-dm-gg-methscopolamine SYMPAK DM MIS phenylephrine-chlorpheniramine-dm-guaifenesin chlordex gp syp phenylephrine-chlorpheniramine-dm-guaifenesin DONATUSSIN SYP phenylephrine-chlorpheniramine-dm-guaifenesin ZOTEX-DM SYP phenylephrine-codeine ALAHIST AC LIQ 7.5-10 phenylephrine-codeine NOTUSS-PE LIQ phenylephrine-codeine-guaifenesin GILTUSS PED-C LIQ PED-C phenylephrine-codeine-guaifenesin MAXIPHEN CD TAB phenylephrine-codeine-guaifenesin MAXIPHEN CDX TAB phenylephrine-codeine-guaifenesin-acetaminophen PHENFLU CD TAB phenylephrine-codeine-guaifenesin-acetaminophen PHENFLU CDX TAB phenylephrine-dexbrompheniramine-dextromethorphan DEXALL SYP 10-2-20 phenylephrine-dexbrompheniramine-dextromethorphan TUSSALL-ER TAB 20-6-30
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 45 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description phenylephrine-dexbrompheniramine-dm-guaifenesin PANATUSS DXP PEDIATRIC LIQ phenylephrine-dexchlorpheniramine-carbetapentane CORZALL-PE LIQ phenylephrine-dexchlorpheniramine-codeine VANACOF CD LIQ phenylephrine-dexchlorpheniramine-pyrilamine-dm coryza-dm syp phenylephrine-dihydrocodeine ALAHIST DHC LIQ 7.5-3 phenylephrine-dihydrocodeine-guaifenesin DONATUSS DC SYP phenylephrine-dihydrocodeine-guaifenesin POLY-TUSSIN EX SYP EX phenylephrine-diphenhydramine-codeine AIRACOF SYP phenylephrine-diphenhydramine-dm-acetaminophen RESPA C&C IR TAB phenylephrine-diphenhydramine-dm-acetaminophen RESPA C&C TAB phenylephrine-dm-guaifenesin biotuss liq phenylephrine-dm-guaifenesin biotuss pediatric liq phenylephrine-dm-guaifenesin BRONCOTRON-D SUS phenylephrine-dm-guaifenesin DESPEC DM SYP phenylephrine-dm-guaifenesin GILTUSS LIQ phenylephrine-dm-guaifenesin GILTUSS PEDIATRIC LIQ phenylephrine-dm-guaifenesin GILTUSS TR CAP 7-14-288 phenylephrine-dm-guaifenesin GILTUSS TR TAB phenylephrine-dm-guaifenesin MAXIPHEN DM TAB phenylephrine-dm-guaifenesin nortuss-de drop phenylephrine-dm-guaifenesin PDM GG SYP 10-30-20 phenylephrine-dm-guaifenesin SINUTUSS DM TAB phenylephrine-dm-guaifenesin TRITUSS SYP phenylephrine-dm-guaifenesin TUSSAFED EX LIQ phenylephrine-dm-guaifenesin TUSSI-PRES PEDIATRIC LIQ phenylephrine-dm-guaifenesin z-dex syp phenylephrine-dm-guaifenesin ZOTEX PEDIATRIC DROP phenylephrine-dm-guaifenesin ZOTEX-EX TAB phenylephrine-dm-guaifenesin ZOTEX-G SYP phenylephrine-dm-guaifenesin-acetaminophen PHENFLU DM TAB phenylephrine-dm-guaifenesin-acetaminophen PHENFLU G TAB phenylephrine-dm-pyril-pot guai-sod cit-citric acid GENTEX 30 LIQ phenylephrine-ephedrine-chlorphenir-carbetapentane RYNATUSS TAB phenylephrine-ephedrine-chlorphenirw-carbetapentane quad-tuss tannate pediatric sus phenylephrine-guaifenesin GILPHEX TR TAB 10-388MG phenylephrine-guaifenesin guaifenesin-phenylephrine hcl syp phenylephrine-guaifenesin maxiphen tab 10-400mg phenylephrine-guaifenesin nazarin liq phenylephrine-guaifenesin phenavent ped cap 7.5-200 phenylephrine-guaifenesin phenylephrine-guaifenesin drop 1.5-20mg phenylephrine-guaifenesin quintex syp 7.5-100 phenylephrine-guaifenesin SINUVENT PE TAB 15-600MG phenylephrine-guaifenesin SITREX PD LIQ 7.5-75MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 46 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description phenylephrine-guaifenesin ZOTEX-GP TAB phenylephrine-guaifenesin-chlorphenir-methscopolamine SYMPAK MIS phenylephrine-hydrocodone-guaifenesin GILTUSS HC LIQ phenylephrine-methscopolamine EXTENDRYL PEM TAB PEM phenylephrine-promethazine-cod promethazine vc-codeine syp phenylephrine-pyrilamine-codeine PRO-RED AC SYP phenylephrine-pyrilamine-codeine ZOTEX-C SYP phenylephrine-pyrilamine-dihydrocodeine POLY HIST DHC LIQ DHC phenylephrine-pyrilamine-dm POLY HIST DM LIQ phenylephrine-pyrilamine-dm pyril dm sus phenylephrine-triprolidine-chlophedianol PROHIST CD LIQ phenylephrine-triprolidine-codeine HISTEX-AC SYP phenylephrine-triprolidine-dextromethorphan HISTEX-DM SYP phenyltoloxamine-acetaminophen ACUFLEX TAB phenyltoloxamine-acetaminophen biogesic tab 30-500mg phenyltoloxamine-acetaminophen bp poly-650 tab phenyltoloxamine-acetaminophen DOLOGESIC LIQ 30-500MG phenyltoloxamine-acetaminophen RELAGESIC LIQ 5-160MG phenyltoloxamine-acetaminophen RELAGESIC TAB 50-650MG phenyltoloxamine-acetaminophen rhinoflex tab 50-500mg phenyltoloxamine-acetaminophen STAFLEX TAB 55-500MG phenyltoloxamine-acetaminophen zgesic tab 66-600mg piperacillin sodium-tazobactam sodium PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM INJ 36-4.5GM piperacillin sodium-tazobactam sodium PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INJ 2-0.25GM piperacillin sodium-tazobactam sodium PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INJ 3-0.375G piperacillin sodium-tazobactam sodium PIPERACILLIN SODIUM/TAZOBACTAM SODIUM INJ 4-0.5GM piperacillin sodium-tazobactam sodium ZOSYN INJ 2-0.25GM piperacillin sodium-tazobactam sodium ZOSYN INJ 3-0.375G piperacillin sodium-tazobactam sodium ZOSYN INJ 36-4.5GM piperacillin sodium-tazobactam sodium ZOSYN INJ 4-0.5GM piperacillin sodium-tazobactam sodium in dextrose ZOSYN SOL 2-0.25GM piperacillin sodium-tazobactam sodium in dextrose ZOSYN SOL 3-0.375G piperacillin sodium-tazobactam sodium in dextrose ZOSYN SOL 4-0.50GM pirfenidone ESBRIET CAP 267MG piroxicam FELDENE CAP 10MG piroxicam piroxicam cap 20mg polymyxin b-trimethoprim polymyxin b sulfate/trimethoprim sulfate sol polymyxin b-trimethoprim POLYTRIM SOL OP polymyxin b-trimethoprim trimethoprim sulfate/polymyxin b sulfate sol pomalidomide POMALYST CAP 1MG pomalidomide POMALYST CAP 2MG pomalidomide POMALYST CAP 3MG pomalidomide POMALYST CAP 4MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 47 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description ponatinib hcl ICLUSIG TAB 15MG ponatinib hcl ICLUSIG TAB 45MG posaconazole NOXAFIL INJ 300/16.7 posaconazole NOXAFIL SUS 40MG/ML posaconazole NOXAFIL TAB 100MG potassium guaiacolsulfonate YODEFAN-NF LIQ 300MG/5ML povidone-iodine (ophth) BETADINE OPHTHALMIC PREP SOL 5% OP praziquantel BILTRICIDE TAB 600MG prednisolone MILLIPRED DP PAK 5MG prednisolone MILLIPRED TAB 5MG prednisolone PREDNISOLONE SOL 15MG/5ML prednisolone prednisolone syp 5mg/5ml prednisolone PRELONE SYP 15MG/5ML prednisolone sodium phosphate ASMALPRED PLUS SOL prednisolone sodium phosphate ASMALPRED SOL 15MG/5ML prednisolone sodium phosphate MILLIPRED SOL 10MG/5ML prednisolone sodium phosphate ORAPRED ODT TAB 10MG prednisolone sodium phosphate ORAPRED ODT TAB 15MG prednisolone sodium phosphate ORAPRED ODT TAB 30MG prednisolone sodium phosphate ORAPRED SOL 15MG/5ML prednisolone sodium phosphate PEDIAPRED SOL 6.7/5ML prednisolone sodium phosphate prednisolone sodium phosphate odt tab 10mg prednisolone sodium phosphate prednisolone sodium phosphate odt tab 15mg prednisolone sodium phosphate prednisolone sodium phosphate odt tab 30mg prednisolone sodium phosphate prednisolone sodium phosphate sol 15mg/5ml prednisolone sodium phosphate prednisolone sodium phosphate sol 25mg/5ml prednisolone sodium phosphate prednisolone sodium phosphate sol 5mg/5ml prednisolone sodium phosphate VERIPRED 20 SOL 20MG/5ML prednisone DELTASONE TAB 10MG prednisone PREDNISONE INTENSOL CON 5MG/ML prednisone PREDNISONE PAK 10MG prednisone PREDNISONE PAK 5MG prednisone PREDNISONE SOL 5MG/5ML prednisone prednisone tab 10mg prednisone prednisone tab 1mg prednisone prednisone tab 2.5mg prednisone prednisone tab 20mg prednisone prednisone tab 50mg prednisone prednisone tab 5mg prednisone RAYOS TAB 1MG prednisone RAYOS TAB 2MG prednisone RAYOS TAB 5MG prednisone STERAPRED DS PAK 10MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 48 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description prednisone STERAPRED PAK 5MG primaquine phosphate primaquine phosphate tab 26.3mg procarbazine hcl MATULANE CAP 50MG progesterone (vaginal) ENDOMETRIN SUP 100MG progesterone (vaginal) FIRST-PROGESTERONE VGS 100 COMPD KIT SUP progesterone (vaginal) FIRST-PROGESTERONE VGS 200 COMPD KIT SUP progesterone (vaginal) FIRST-PROGESTERONE VGS 25 COMPD KIT SUP progesterone (vaginal) FIRST-PROGESTERONE VGS 400 COMPD KIT SUP progesterone (vaginal) FIRST-PROGESTERONE VGS 50 CCOMPD KIT SUP promethazine & phenylephrine promethazine vc plain syp plain promethazine hcl PHENERGAN INJ 25MG/ML promethazine hcl PHENERGAN INJ 50MG/ML promethazine hcl promethazine hcl inj 25mg/ml promethazine hcl promethazine hcl inj 50mg/ml promethazine hcl promethazine hcl syp 6.25/5ml promethazine hcl promethazine hcl tab 12.5mg promethazine hcl promethazine hcl tab 25mg promethazine hcl promethazine hcl tab 50mg promethazine hcl promethegan sup 12.5mg promethazine hcl promethegan sup 25mg promethazine hcl promethegan sup 50mg promethazine w/codeine promethazine-codeine syp 6.25-10 promethazine-dm promethazine-dextromethorphan syp propofol fresenius propoven inj 10mg/ml propofol propofol inj 10mg/ml propoxyphene compound DARVON CAP CPD 65 propoxyphene hcl DARVON CAP 65MG propoxyphene hcl propoxyphene hcl cap 65mg propoxyphene hcl-acetaminophen DARVOCET A500 TAB propoxyphene hcl-acetaminophen DARVOCET-N 100 TAB propoxyphene hcl-acetaminophen DARVOCET-N 50 TAB propoxyphene hcl-acetaminophen propoxyphene/acetaminophen tab 65-650mg propoxyphene napsylate DARVON-N TAB 100MG propoxyphene-n-acetaminophen propoxyphene napsylate-acetaminophen tab 100-325 propoxyphene-n-acetaminophen propoxyphene-n-acetaminophen tab 100-500 propoxyphene-n-acetaminophen propoxyphene-n-acetaminophen tab 100-650 propoxyphene-n-acetaminophen propoxyphene-n-acetaminophen tab 50/325 pseudoeph w/hydrocodone-gg HYCOFENIX SOL pseudoephedrine hcl-chlorphen mal-dm hbr tannate chlorpheniramine-pseudoephedrine-dm tannate sus pseudoephedrine hcl-dm hbr-guaifenesin tannate Z-COF 12DM SUS pseudoephedrine tan-bromphen tan-dm tan ANAPLEX DMX SUS pseudoephedrine tan-chlorphen tan-dm tan DICEL DM SUS pseudoephedrine tan-dexchlorphen tan-dm tan dur-tann forte sus forte
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 49 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description pseudoephedrine tan-dexchlorphen tan-dm tan sutan-dm sus pseudoephedrine tan-dexchlorphen tan-dm tan TANAFED DMX SUS pseudoephedrine tannate-carbetapentane tannate PSEUDACARB CHW 75-25MG pseudoephedrine-bromphen-dm allanhist pdx drop pdx pseudoephedrine-bromphen-dm andehist dm nr syp nr pseudoephedrine-bromphen-dm bromfed dm syp pseudoephedrine-bromphen-dm BROVEX PSB DM LIQ DM pseudoephedrine-bromphen-dm BROVEX PSE DM TAB DM pseudoephedrine-bromphen-dm DELTUSS DMX LIQ pseudoephedrine-bromphen-dm pbm allergy syp pseudoephedrine-bromphen-dm PEDIAHIST DM DROP 15-1-4MG pseudoephedrine-bromphen-dm pse brom dm syp pseudoephedrine-bromphen-dm RESPERAL-DM DROP 12-1-5MG pseudoephedrine-bromphen-dm tgq 50pse-3brm-30dm syp brm-30dm pseudoephedrine-brompheniramine-codeine CPB WC LIQ pseudoephedrine-brompheniramine-codeine MAR-COF BP LIQ pseudoephedrine-brompheniramine-codeine mesehist wc liq pseudoephedrine-brompheniramine-dihydrocodeine J-COF DHC LIQ pseudoephedrine-brompheniramine-dm-guaifenesin bromhist-dm pediatric syp ped pseudoephedrine-carbetapentane-guaifenesin EXALL-D LIQ pseudoephedrine-chlorphen-dm ACCUHIST PDX DROP pseudoephedrine-chlorphen-dm HDC DM SYP pseudoephedrine-chlorphen-dm mesehist dm liq pseudoephedrine-chlorphen-dm TUSSAFED LIQ pseudoephedrine-chlorpheniramine-dihydrocodeine DIHYDRO-CP SYP pseudoephedrine-chlorpheniramine-dm-guaifenesin NEOTUSS-D LIQ pseudoephedrine-codeine endacof-dc liq pseudoephedrine-codeine NUCOFED CAP pseudoephedrine-codeine-guaifenesin AMBIFED CD TAB pseudoephedrine-codeine-guaifenesin AMBIFED CDX TAB pseudoephedrine-codeine-guaifenesin AMBIFED-G CD TAB pseudoephedrine-codeine-guaifenesin AMBIFED-G CDX TAB CDX pseudoephedrine-codeine-guaifenesin cheratussin dac sol dac pseudoephedrine-codeine-guaifenesin LORTUSS EX LIQ pseudoephedrine-codeine-guaifenesin MAXIFED CD TAB pseudoephedrine-codeine-guaifenesin MAXIFED CDX TAB pseudoephedrine-codeine-guaifenesin MAXIFED-G CD TAB pseudoephedrine-codeine-guaifenesin MAXIFED-G CDX TAB CDX pseudoephedrine-codeine-guaifenesin TUSNEL C SYP pseudoephedrine-codeine-guaifenesin TUSNEL PED-C SYP pseudoephedrine-codeine-guaifenesin ZODRYL DEC 50 SUS pseudoephedrine-codeine-guaifenesin ZODRYL DEC 60 SUS pseudoephedrine-codeine-guaifenesin ZODRYL DEC 80 SUS
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 50 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description pseudoephedrine-codeine-guaifenesin Z-TUSS E LIQ pseudoephedrine-codeine-guaifenesin-acetaminophen MAXIFLU CD TAB pseudoephedrine-codeine-guaifenesin-acetaminophen MAXIFLU CDX TAB pseudoephedrine-cpm-hydrocod ZUTRIPRO LIQ pseudoephedrine-dexbrompheniramine-dm-guaifenesin DEKA LIQ pseudoephedrine-dihydrocodeine-guaifenesin DESPEC-EXP SYP pseudoephedrine-dm-guaifenesin ALDEX GS DM TAB pseudoephedrine-dm-guaifenesin ambi 60pse-400gfn-20dm tab pseudoephedrine-dm-guaifenesin DONATUSS XP SUS pseudoephedrine-dm-guaifenesin DONATUSSIN DM SYP DM pseudoephedrine-dm-guaifenesin pseudo cough liq pseudoephedrine-dm-guaifenesin PSEUDOEPHEDRINE-DM-GUAIFENESIN SYP 40-15-10 pseudoephedrine-dm-guaifenesin RU-TUSS DM SYP pseudoephedrine-dm-guaifenesin sudatex-dm tab pseudoephedrine-dm-guaifenesin tl-dex dm liq pseudoephedrine-dm-guaifenesin TRISPEC PSE LIQ pseudoephedrine-dm-guaifenesin TUSNEL LIQ pseudoephedrine-dm-guaifenesin TUSNEL PEDIATRIC LIQ pseudoephedrine-dm-guaifenesin TUSNEL-DM PEDIATRIC LIQ PEDI DROP pseudoephedrine-dm-guaifenesin Z-COF 8DM SUS pseudoephedrine-dm-guaifenesin Z-COF I SUS pseudoephedrine-dm-guaifenesin-acetaminophen DURAFLU TAB pseudoephedrine-dm-guaifenesin-acetaminophen MAXIFLU DM TAB pseudoephedrine-dm-guaifenesin-acetaminophen MAXIFLU-G TAB pseudoephedrine-guaifenesin ALDEX GS TAB 30-190MG pseudoephedrine-guaifenesin ambi 40pse-400gfn tab 400gfn pseudoephedrine-guaifenesin ambi 60-580 tab pseudoephedrine-guaifenesin maxifed tab 60-400mg pseudoephedrine-guaifenesin PSEUDOEPHEDRINE-GUAIFENESIN SYP 40-200MG pseudoephedrine-guaifenesin PSEUDOVENT 400 CAP 400 pseudoephedrine-guaifenesin PSEUDOVENT CAP CR pseudoephedrine-guaifenesin pseudovent ped cap ped cr pseudoephedrine-guaifenesin RESPAIRE-30 CAP pseudoephedrine-guaifenesin TENAR PSE LIQ pseudoephedrine-guaifenesin TUSNEL PEDIATRIC DROP 5-10MG/ML pseudoephedrine-hydrocodone REZIRA SOL 60-5/5ML pseudoephedrine-methscop-chlorphen-phenyleph-methscop ALLERX DOSE PACK MIS pseudoephedrine-methscopolamine respivent-d tab pseudoephedrine-pyrilamine-carbetapentane CORZALL PLUS LIQ pseudoephedrine-pyrilamine-carbetapentane ZOTEX-D SYP pseudoephedrine-pyrilamine-codeine NEO AC SYP pseudoephedrine-pyrilamine-dextromethorphan VIRAVAN-PDM LIQ pseudoephrine hcl-pyrilamine mal-dextromethorphan hbr tan VIRAVAN-PDM SUS 15-15-15
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 51 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description pseudoephrine-chlorphen-codeine PHENYLHISTINE DH LIQ DH pseudoephrine-chlorphen-codeine ZODRYL DAC 50 SUS pseudoephrine-chlorphen-codeine ZODRYL DAC 60 SUS pseudoephrine-chlorphen-codeine ZODRYL DAC 80 SUS pseudoephrine-triprolidine-codeine POLY HIST NC LIQ pseudoephrine-triprolidine-dm PEDIATEX TDM SUS pyrazinamide pyrazinamide tab 500mg pyrilamine maleate-phenylephrine hcl tannate DECONSAL CT CHW 16-10MG pyrilamine maleate-phenylephrine hcl tannate pyril d sus 16-5mg/5ml pyrilamine maleate-pseudoephedrine hcl tannate VIRAVAN-P SUS 15-15MG pyrilamine tannate PYRLEX SUS 12MG/5ML pyrilamine tannate-phenylephrine tannate allanvan-s sus 30-12.5 pyrilamine tannate-phenylephrine tannate PYRLEX PD SUS 12-9MG pyrilamine tannate-phenylephrine tannate RYNA-12 TAB 60-25MG pyrilamine tannate-phenylephrine tannate rynesa 12s sus pyrilamine-pseudoephedrine VIRAVAN-P LIQ pyrimethamine DARAPRIM TAB 25MG quazepam DORAL TAB 15MG quinine sulfate QUININE SULFATE CAP 324MG quinupristin-dalfopristin SYNERCID INJ 500MG ramelteon ROZEREM TAB 8MG regorafenib STIVARGA TAB 40MG remifentanil hcl ULTIVA INJ 1MG remifentanil hcl ULTIVA INJ 2MG remifentanil hcl ULTIVA INJ 5MG rifabutin MYCOBUTIN CAP 150MG rifampin RIFADIN CAP 150MG rifampin RIFADIN CAP 300MG rifampin RIFADIN INJ 600 MG rifampin rifampin cap 150mg rifampin rifampin cap 300mg rifampin RIFAMPIN INJ 600 MG rifapentine PRIFTIN TAB 150MG rifaximin XIFAXAN TAB 200MG rifaximin XIFAXAN TAB 550MG rilonacept ARCALYST INJ 220MG rimantadine hydrochloride rimantadine hcl tab 100mg riociguat ADEMPAS TAB 0.5MG riociguat ADEMPAS TAB 1.5MG riociguat ADEMPAS TAB 1MG riociguat ADEMPAS TAB 2.5MG riociguat ADEMPAS TAB 2MG risperidone microspheres RISPERDAL CONSTA INJ 12.5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 52 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description risperidone microspheres RISPERDAL CONSTA INJ 25MG risperidone microspheres RISPERDAL CONSTA INJ 37.5MG risperidone microspheres RISPERDAL CONSTA INJ 50MG rizatriptan benzoate MAXALT TAB 10MG rizatriptan benzoate MAXALT TAB 5MG rizatriptan benzoate MAXALT-MLT TAB 10MG rizatriptan benzoate MAXALT-MLT TAB 5MG ruxolitinib phosphate JAKAFI TAB 10MG ruxolitinib phosphate JAKAFI TAB 15MG ruxolitinib phosphate JAKAFI TAB 20MG ruxolitinib phosphate JAKAFI TAB 25MG ruxolitinib phosphate JAKAFI TAB 5MG sapropterin dihydrochloride KUVAN POW 100MG sapropterin dihydrochloride KUVAN POW 500MG sapropterin dihydrochloride KUVAN TAB 100MG sargramostim LEUKINE INJ 250MCG sargramostim LEUKINE INJ 500 MCG secobarbital sodium SECONAL CAP 100MG secukinumab COSENTYX INJ selexipag UPTRAVI TABS 200MCG selexipag UPTRAVI TABS 400MCG selexipag UPTRAVI TABS 600MCG selexipag UPTRAVI TABS 800MCG selexipag UPTRAVI TABS 1000MCG selexipag UPTRAVI TABS 1200MCG selexipag UPTRAVI TABS 1400MCG selexipag UPTRAVI TABS 1600MCG selexipag UPTRAVI TPK 200 & 800MCG sevoflurane ULTANE SOL sildenafil citrate VIAGRA TAB 100MG sildenafil citrate VIAGRA TAB 25MG sildenafil citrate VIAGRA TAB 50MG simeprevir sodium OLYSIO CAP 150MG sodium oxybate XYREM SOL 500MG/ML sofosbuvir SOVALDI TAB 400MG somatropin GENOTROPIN INJ 12MG somatropin GENOTROPIN INJ 5MG somatropin GENOTROPIN MINIQUICK INJ 0.2MG somatropin GENOTROPIN MINIQUICK INJ 0.4MG somatropin GENOTROPIN MINIQUICK INJ 0.6MG somatropin GENOTROPIN MINIQUICK INJ 0.8MG somatropin GENOTROPIN MINIQUICK INJ 1.2MG somatropin GENOTROPIN MINIQUICK INJ 1.4MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 53 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description somatropin GENOTROPIN MINIQUICK INJ 1.6MG somatropin GENOTROPIN MINIQUICK INJ 1.8MG somatropin GENOTROPIN MINIQUICK INJ 1MG somatropin GENOTROPIN MINIQUICK INJ 2MG somatropin HUMATROPE COMBO PACK INJ 5MG somatropin HUMATROPE INJ 12MG somatropin HUMATROPE INJ 24MG somatropin HUMATROPE INJ 6MG somatropin NORDITROPIN CARTRIDGE INJ 15/1.5ML somatropin NORDITROPIN FLEXPRO INJ 10/1.5ML somatropin NORDITROPIN FLEXPRO INJ 5/1.5ML somatropin NORDITROPIN NORDIFLEX PEN INJ 15/1.5ML somatropin NORDITROPIN NORDIFLEX PEN INJ 30/3ML somatropin NUTROPIN AQ INJ 10MG/2ML somatropin NUTROPIN AQ NUSPIN 5 INJ somatropin NUTROPIN AQ PEN INJ 10MG/2ML somatropin NUTROPIN AQ PEN INJ 20MG/2ML somatropin NUTROPIN INJ 10MG somatropin NUTROPIN INJ 5MG somatropin OMNITROPE INJ 10/1.5ML somatropin OMNITROPE INJ 5.8MG somatropin OMNITROPE INJ 5/1.5ML somatropin ZOMACTON SOLR 10 MG somatropin ZOMACTON SOLR 5 MG somatropin ZORBTIVE INJ somatropin (non-refrigerated) SAIZEN CLICK.EASY INJ 8.8MG somatropin (non-refrigerated) SAIZEN INJ 5MG somatropin (non-refrigerated) SAIZEN INJ 8.8MG somatropin (non-refrigerated) SEROSTIM INJ 4MG somatropin (non-refrigerated) SEROSTIM INJ 5MG somatropin (non-refrigerated) SEROSTIM INJ 6MG somatropin (non-refrigerated) ZORBTIVE INJ 8.8MG sonedgib ODOZMO sorafenib tosylate NEXAVAR TAB 200MG sufentanil citrate sufentanil citrate inj 50mcg/ml sulfacetamide sodium (ophth) BLEPH-10 SOL 10% OP sulfacetamide sodium (ophth) sodium sulfacetamide sol 10% op sulfacetamide sodium (ophth) SULFACET SOD OIN 10% OP sulfacetamide sodium (ophth) sulfacetamide sodium oin 10% op sulfacetamide sod-prednisolone BLEPHAMIDE S.O.P. OIN S.O.P. sulfacetamide sod-prednisolone BLEPHAMIDE SUS OP sulfacetamide sod-prednisolone sulfacetamide sod/prednisolone sodium phosphate sol op sumatriptan SUMATRIPTAN SPR 20MG/ACT
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 54 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description sumatriptan SUMATRIPTAN SPR 5MG/ACT sumatriptan succinate ALSUMA KIT 6MG/0.5ml sumatriptan succinate IMITREX INJ 6MG/0.5ML sumatriptan succinate IMITREX STATDOSE REFILL INJ 4MG/0.5ML sumatriptan succinate IMITREX STATDOSE REFILL INJ 6MG/0.5ML sumatriptan succinate IMITREX STATDOSE SYSTEM KIT 4MG/0.5ML sumatriptan succinate IMITREX TAB 100MG sumatriptan succinate IMITREX TAB 25MG sumatriptan succinate IMITREX TAB 50MG sumatriptan succinate sumatriptan succinate inj 4mg/0.5ml sumatriptan succinate sumatriptan succinate inj 6mg/0.5ml sumatriptan succinate sumatriptan succinate inj kit 6mg/0.5ml sumatriptan succinate sumatriptan succinate inj refill kit 4mg/0.5ml sumatriptan succinate sumatriptan succinate inj refill kit 6mg/0.5ml sumatriptan succinate sumatriptan succinate tab 100mg sumatriptan succinate sumatriptan succinate tab 25mg sumatriptan succinate sumatriptan succinate tab 50mg sumatriptan succinate SUMAVEL DOSEPRO INJ 4MG/0.5ML sumatriptan succinate SUMAVEL DOSEPRO INJ 6MG/0.5ML sumatriptan-naproxen sodium TREXIMET TAB 85-500MG sunitinib malate SUTENT CAP 12.5MG sunitinib malate SUTENT CAP 25MG sunitinib malate SUTENT CAP 50MG tadalafil CIALIS TAB 10MG tadalafil CIALIS TAB 2.5MG tadalafil CIALIS TAB 20MG tadalafil CIALIS TAB 5MG taliglucerase alfa ELELYSO INJ 200UNIT talimogene laherparepvec IMLYGIC SUSP 1000000 UNIT/ML talimogene laherparepvec IMLYGIC SUSP 100000000 UNIT/ML tapentadol hcl NUCYNTA ER TAB 100MG tapentadol hcl NUCYNTA ER TAB 150MG tapentadol hcl NUCYNTA ER TAB 200MG tapentadol hcl NUCYNTA ER TAB 250MG tapentadol hcl NUCYNTA ER TAB 50MG tapentadol hcl NUCYNTA TAB 100MG tapentadol hcl NUCYNTA TAB 50MG tapentadol hcl NUCYNTA TAB 75MG tasimelteon HETLIOZ CAP 20MG tavaborole KERYDIN SOL 5% tedizolid phosphate SIVEXTRO INJ 200MG tedizolid phosphate SIVEXTRO TAB 200MG teduglutide (rdna) GATTEX KIT 5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 55 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description telaprevir INCIVEK TAB 375MG telbivudine TYZEKA TAB 600MG temazepam RESTORIL CAP 15MG temazepam RESTORIL CAP 22.5MG temazepam RESTORIL CAP 30MG temazepam RESTORIL CAP 7.5MG temazepam temazepam cap 15mg temazepam temazepam cap 22.5mg temazepam temazepam cap 30mg temazepam temazepam cap 7.5mg temazepam-dietary management product STRAZEPAM PAK temozolomide TEMODAR CAP 100MG temozolomide TEMODAR CAP 140MG temozolomide TEMODAR CAP 180MG temozolomide TEMODAR CAP 20MG temozolomide TEMODAR CAP 250MG temozolomide TEMODAR CAP 5MG temozolomide TEMODAR INJ 100MG temozolomide temozolomide cap 180mg temozolomide temozolomide cap 20mg temozolomide temozolomide cap 250mg temozolomide temozolomide cap 5mg terbinafine hcl LAMISIL GRA 125MG terbinafine hcl LAMISIL GRA 187.5MG terbinafine hcl LAMISIL TAB 250MG terbinafine hcl terbinafine hcl tab 250mg terbinafine-hydroxypropyl chitosan TERBINEX KIT teriflunomide AUBAGIO TAB 14MG teriflunomide AUBAGIO TAB 7MG teriparatide (recombinant) FORTEO SOL 600/2.4 tesamorelin acetate EGRIFTA INJ 1MG tesamorelin acetate EGRIFTA SOL 2MG tetrabenazine tetrabenazine tab 12.5mg tetrabenazine tetrabenazine tab 25mg tetrabenazine XENAZINE TAB 12.5MG tetrabenazine XENAZINE TAB 25MG thalidomide THALOMID CAP 100MG thalidomide THALOMID CAP 150MG thalidomide THALOMID CAP 200MG thalidomide THALOMID CAP 50MG tiopronin THIOLA TAB 100MG tobramycin BETHKIS NEB 300/4ML tobramycin KITABIS PAK NEB 300/5ML
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 56 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description tobramycin TOBI PODHALER CAP 28MG tobramycin tobramycin neb 300/5ml tobramycin (ophth) TOBRAMYCIN SULFATE SOL 0.3% OP tobramycin (ophth) TOBREX OIN 0.3% OP tobramycin (ophth) TOBREX SOL 0.3% OP tocilizumab ACTEMRA INJ 162/0.9 tocilizumab ACTEMRA INJ 200/10ML tocilizumab ACTEMRA INJ 400/20ML tocilizumab ACTEMRA INJ 80MG/4ML tofacitinib citrate XELJANZ TAB 5MG tolvaptan SAMSCA TABS 15 MG tolvaptan SAMSCA TABS 30 MG tramadol hcl CONZIP CAP 100MG tramadol hcl CONZIP CAP 200MG tramadol hcl CONZIP CAP 300MG tramadol hcl RYBIX ODT TAB 50MG tramadol hcl RYZOLT TAB 100MG tramadol hcl RYZOLT TAB 200MG tramadol hcl RYZOLT TAB 300MG tramadol hcl SYNAPRYN FUSEPAQ SUS 10MG/ML tramadol hcl TRAMADOL HCL ER CAP 150MG tramadol hcl tramadol hcl er tab 100mg tramadol hcl tramadol hcl er tab 200mg tramadol hcl tramadol hcl er tab 300mg tramadol hcl tramadol hcl tab 50mg tramadol hcl ULTRAM ER TAB 100MG tramadol hcl ULTRAM ER TAB 200MG tramadol hcl ULTRAM ER TAB 300MG tramadol hcl ULTRAM TAB 50MG tramadol hcl-dietary management product THERATRAMADOL-60 PAK -60 tramadol-acetaminophen tramadol hydrochloride-acetaminophen tab 37.5-325 tramadol-acetaminophen ULTRACET TAB 37.5-325MG trametinib dimethyl sulfoxide MEKINIST TAB 0.5MG trametinib dimethyl sulfoxide MEKINIST TAB 2MG treprostinil diolamine ORENITRAM TAB 0.125MG treprostinil diolamine ORENITRAM TAB 0.25MG treprostinil diolamine ORENITRAM TAB 1MG treprostinil diolamine ORENITRAM TAB 2.5MG tretinoin (chemotherapy) VESANOID CAP 10MG triazolam HALCION TAB 0.25MG triazolam triazolam tab 0.125mg triazolam triazolam tab 0.25mg trientine hcl SYPRINE CAP 250MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 57 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description trifluridine trifluridine sol 1% op trifluridine VIROPTIC SOL 1% OP trifluridine-tipitacil LONSURF TABS 15-6.14 MG trifluridine-tipitacil LONSURF TABS 20-8.19 MG triprolidine hcl HISTEX PD DRO 0.938MG triprolidine hcl HISTEX SYP 2.5MG/5 triprolidine hcl tripohist liq 1.25/5ml triprolidine tannate ZYMINE XR SUS 2.5MG triprolidine tannate-pseudoephedrine tannate ZYMINE DXR SUS 2.5-45MG triprolidine-phenylephrine HISTEX-PE SYP 2.5-10/5 triprolidine-phenylephrine PROHIST LQ LIQ triprolidine-pseudoephedrine PEDIATEX TD LIQ triprolidine-pseudoephedrine ZYMINE-D LIQ 1.25-45 uridine triacetate VISTOGARD uridine triacetate XURIDEN PACK 2 GM urofollitropin purified BRAVELLE INJ 75UNIT ustekinumab STELARA INJ 45MG/0.5 ustekinumab STELARA INJ 90MG/ML valganciclovir hcl* VALCYTE SOL 50MG/ML valganciclovir hcl* VALCYTE TAB 450MG vancomycin hcl FIRST-VANCOMYCIN 25 SOL 25MG/ML vancomycin hcl FIRST-VANCOMYCIN 50 SOL 50MG/ML vancomycin hcl VANCOCIN HCL CAP 125MG vancomycin hcl VANCOCIN HCL CAP 250MG vancomycin hcl vancomycin hcl cap 125mg vancomycin hcl vancomycin hcl cap 250mg vancomycin hcl VANCOMYCIN HCL INJ 1000MG vancomycin hcl VANCOMYCIN HCL INJ 10GM vancomycin hcl VANCOMYCIN HCL INJ 500MG vancomycin hcl VANCOMYCIN HCL INJ 5GM vancomycin hcl VANCOMYCIN HCL INJ 750MG vancomycin hcl in dextrose VANCOMYCIN HCL IN DEXTROS E INJ 1GM vancomycin hcl in dextrose VANCOMYCIN HCL IN DEXTROS E INJ 500MG vandetanib CAPRELSA TAB 100MG vandetanib VANDETANIB TAB 300MG vardenafil hcl LEVITRA TAB 10MG vardenafil hcl LEVITRA TAB 2.5MG vardenafil hcl LEVITRA TAB 20MG vardenafil hcl LEVITRA TAB 5MG vardenafil hcl STAXYN TAB 10MG varenicline tartrate CHANTIX PAK 0.5& 1MG varenicline tartrate CHANTIX PAK 1MG varenicline tartrate CHANTIX TAB 0.5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 58 of 59 Revision date: February 26, 2016 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Generic Name Product Description velaglucerase alfa VPRIV INJ 400UNIT vemurafenib ZELBORAF TAB 240MG vigabatrin SABRIL POW 500MG vigabatrin SABRIL TAB 500MG vismodegib ERIVEDGE CAP 150MG voriconazole VFEND IV INJ 200MG voriconazole VFEND SUS 40MG/ML voriconazole VFEND TAB 200MG voriconazole VFEND TAB 50MG voriconazole voriconazole sus 40mg/ml voriconazole voriconazole tab 200mg voriconazole voriconazole tab 50mg vorinostat ZOLINZA CAP 100MG zaleplon SONATA CAP 10MG zaleplon SONATA CAP 5MG zaleplon zaleplon cap 10mg zaleplon zaleplon cap 5mg zanamivir RELENZA DISKHALER MIS DISKHALE ziconotide acetate PRIALT INJ 100MCG ziconotide acetate PRIALT INJ 25MCG/ML zileuton ZYFLO CR TAB 600MG zileuton ZYFLO TAB 600MG zolmitriptan ZOMIG SPR 5MG zolmitriptan ZOMIG TAB 2.5MG zolmitriptan ZOMIG TAB 5MG zolmitriptan ZOMIG ZMT TAB 2.5 MG zolmitriptan ZOMIG ZMT TAB 5MG zolpidem tartrate AMBIEN CR TAB 12.5MG zolpidem tartrate AMBIEN CR TAB 6.25MG zolpidem tartrate AMBIEN TAB 10MG zolpidem tartrate AMBIEN TAB 5MG zolpidem tartrate EDLUAR SUB 10MG zolpidem tartrate EDLUAR SUB 5MG zolpidem tartrate EDLUAR SUB 5MG zolpidem tartrate INTERMEZZO SUB 1.75MG zolpidem tartrate INTERMEZZO SUB 3.5MG zolpidem tartrate zolpidem tartrate er tab 12.5mg zolpidem tartrate zolpidem tartrate er tab 6.25mg zolpidem tartrate zolpidem tartrate tab 10mg zolpidem tartrate zolpidem tartrate tab 5mg zolpidem tartrate ZOLPIMIST SPR 5MG
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive.
Page 59 of 59 Revision date: February 26, 2016