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Maintenance Medication Exclusion List

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 acetaminophen OFIRMEV INJ 10MG/ML acetaminophen (bulk) ACETAMINOPHEN POW acetaminophen w/ acetaminophen/codeine #2 tab 300-15mg acetaminophen w/ codeine acetaminophen/codeine #3 tab 300-30mg acetaminophen w/ codeine acetaminophen/codeine #4 tab 300-60mg acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine acetaminophen/codeine sol 120-12/5 acetaminophen w/ codeine CAPITAL/CODEINE SUS 120-12/5 acetaminophen w/ codeine COCET PLUS TAB 650-60MG acetaminophen w/ codeine COCET TAB 650-30MG acetaminophen-caff-dihydrocod acetaminophen/caffeine/ bitart tab acetaminophen-caff-dihydrocod TREZIX CAP acetaminophen-isometheptene-caffeine MIGRALAM CAP acetaminophen-isometheptene-caffeine PRODRIN TAB acetaminophen-isometheptene-dichloralphenazone MIDRIN CAP acetaminophen-mag salicylate-phenyltolox-caffeine cafgesic forte tab acetaminophen--caffeine FLEXTRA CAP acetaminophen- FRENADOL TAB acetaminophen-salicylamide-phenyltoloxamine ANABAR TAB acetaminophen-salicylamide-phenyltoloxamine dolorex cap acetaminophen-salicylamide-phenyltoloxamine duraxin cap acetaminophen-salicylamide-phenyltoloxamine-caffeine cafgesic cap ACETANILIDE POW & pseudoephedrine SEMPREX-D CAP 8-60MG adalimumab HUMIRA KIT 20MG/0.4 adalimumab HUMIRA KIT 40MG/0.8 adalimumab HUMIRA PEN KIT 40MG/0.8 alfentanil inj 500/ml almotriptan malate AXERT TAB 12.5MG almotriptan malate AXERT TAB 6.25MG alprazolam alprazolam er tab 0.5mg er alprazolam alprazolam er tab 1mg er alprazolam alprazolam er tab 2mg er alprazolam alprazolam er tab 3mg er alprazolam ALPRAZOLAM INTENSOL CON 1 MG/ML alprazolam alprazolam odt tab 0.25mg alprazolam alprazolam odt tab 0.5mg od alprazolam alprazolam odt tab 1mg odt alprazolam alprazolam odt tab 2mg odt alprazolam alprazolam tab 0.25mg alprazolam alprazolam tab 0.5mg alprazolam alprazolam tab 1mg alprazolam alprazolam tab 2mg alprazolam-dietary management product GABAZOLAMINE PAK amobarbital sodium AMYTAL SODIUM INJ 500MG -dextroamphetamine ADDERALL TAB 12.5MG amphetamine-dextroamphetamine ADDERALL TAB 15MG amphetamine-dextroamphetamine ADDERALL TAB 7.5MG amphetamine-dextroamphetamine ADDERALL XR CAP 10MG amphetamine-dextroamphetamine ADDERALL XR CAP 15MG

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 2 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description amphetamine-dextroamphetamine ADDERALL XR CAP 20MG amphetamine-dextroamphetamine ADDERALL XR CAP 25MG amphetamine-dextroamphetamine ADDERALL XR CAP 30MG amphetamine-dextroamphetamine ADDERALL XR CAP 5MG amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 10mg amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 20mg amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 30mg amphetamine-dextroamphetamine amphetamine/dextroamphetamine tab 5mg anakinra KINERET INJ armodafinil NUVIGIL TAB 150MG armodafinil NUVIGIL TAB 250MG armodafinil NUVIGIL TAB 50MG w/ codeine aspirin/codeine tab 325-30mg aspirin w/ codeine aspirin/codeine tab 325-60mg aspirin-apap-salicyl-caff LEVACET TAB benzonatate benzonatate cap 100mg benzonatate benzonatate cap 200mg benzonatate ZONATUSS CAP 150MG & phenyleph ALACOL DRO 0.4-1MG brompheniramine & phenyleph ALACOL SYP 2-5MG brompheniramine & phenyleph bpm pe liq brompheniramine & phenyleph bromax d tab brompheniramine & phenyleph BROVEX PEB LIQ brompheniramine & phenyleph DECON-A ELX 2-5MG/5M brompheniramine & phenyleph entre-b sus 6-10mg/5 brompheniramine & phenyleph phenylephrine hcl/bromphenir mal cap 15-12mg brompheniramine & phenyleph phenylephrine hcl/bromphenir mal cap 7.5-6mg brompheniramine & phenyleph tanabid sr tab 6-30mg brompheniramine & phenyleph vazotab chw brompheniramine & phenyleph ZOTEX PE TAB brompheniramine & pseudoeph andehist nr syp 4-45mg/m brompheniramine & pseudoeph bpm pseudo tab 6-45mg brompheniramine & pseudoeph bromfenex cap 12-120cr brompheniramine & pseudoeph bromhist pediatric dro ped brompheniramine & pseudoeph bromhist-nr dro brompheniramine & pseudoeph brompheniramine/pse cap 9-90mg brompheniramine & pseudoeph BROVEX PSB LIQ brompheniramine & pseudoeph BROVEX PSE TAB 4-40MG brompheniramine & pseudoeph HISTEX SR TAB 10-120MG brompheniramine & pseudoeph J-TAN D PD DRO 1-7.5MG brompheniramine & pseudoeph LODRANE 24D CAP 12-90MG brompheniramine & pseudoeph pse bpm liq brompheniramine & pseudoeph respahist cap 6-60mgcr brompheniramine maleate BROMPHENIRAMINE MALEATE POW MALEATE brompheniramine maleate bromspiro liq 2mg/5ml brompheniramine maleate J-TAN PD DRO 1MG/ML brompheniramine maleate LODRANE 24 CAP brompheniramine maleate lohist-12 tab 12 hour brompheniramine maleate RESPA-BR TAB 11MG brompheniramine maleate-phenylephrine hcl tannate VAZOTAB CHW brompheniramine tannate BROVEX CT CHW 12MG brompheniramine tannate BROVEX SUS 12MG/5ML brompheniramine tannate J-TAN SUS brompheniramine tannate P-TEX SUS 10MG/5ML brompheniramine tannate TANACOF-XR SUS 8MG/5ML

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 3 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description brompheniramine tannate-phenylephrine tannate brompheniramine tann/phenylephrine tann sus 4-5mg brompheniramine tannate-phenylephrine tannate brompheniramine/phenylephrine tannate sus tann brompheniramine tannate-phenylephrine tannate BROVEX ADT SUS 12-10 brompheniramine tannate-phenylephrine tannate C-TAN D PLUS SUS brompheniramine tannate-phenylephrine tannate J-TAN D SUS brompheniramine tannate-phenylephrine tannate RELHIST CHW brompheniramine tannate-phenylephrine tannate tanabid chw 2.2-1.58 brompheniramine tannate-pseudoephedrine tannate BROVEX PD SUS brompheniramine tannate-pseudoephedrine tannate LODRANE D SUS brompheniramine w/ dm-gg TRISPEC SFX LIQ brompheniramine w/ dm-gg TUSNEL CAP brompheniramine- ALA-HIST TAB 6-25MG brompheniramine-diphenhydramine-phenylephrine ALA-HIST D TAB 6-25-20 bromphen-pseudoephed-chlorphen-phenyleph-methscopol SYMPAK II MIS BUTRANS DIS 10MCG/HR buprenorphine BUTRANS DIS 15MCG/HR buprenorphine BUTRANS DIS 20MCG/HR buprenorphine BUTRANS DIS 5MCG/HR buprenorphine hcl BUPRENEX INJ 0.3MG/ML buprenorphine hcl buprenorphine hcl inj 0.3mg/ml buprenorphine hcl buprenorphine hcl inj 0.3mg/ml buprenorphine hcl buprenorphine hcl sub 2mg buprenorphine hcl buprenorphine hcl sub 8mg buprenorphine hcl (bulk) BUPRENORPHINE HCL POW HCL buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 12-3MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 2-0.5MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 4-1MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 8-2MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE SUB 2-0.5MG buprenorphine hcl-naloxone hcl dihydrate SUBOXONE SUB 8-2MG buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUB 1.4-0.36 buprenorphine hcl-naloxone hcl dihydrate ZUBSOLV SUB 5.7-1.4 butabarbital sodium BUTISOL SODIUM ELX 30MG/5ML butabarbital sodium BUTISOL SODIUM TAB 30MG butabarbital sodium BUTISOL SODIUM TAB 50MG butalbital-acetaminophen butalbital/acetaminophen tab 50-325 butalbital-acetaminophen 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 tab butalbital-acetaminophen-caffeine butalbital/acetaminophen/caffeine tab butalbital-acetaminophen-caffeine butalbital/apap/caffeine cap butalbital-acetaminophen-caffeine DOLGIC PLUS TAB butalbital-acetaminophen-caffeine ORBIVAN CAP butalbital-acetaminophen-caffeine zebutal cap butalbital-acetaminophen-caffeine w/ codeine butalbital/acetaminophen/caffeine/codeine cap butalbital-acetaminophen-caffeine w/ codeine FIORICET/CODEINE CAP CODEINE butalbital-aspirin-caffeine butalbital/asa/caffeine cap butalbital-aspirin-caffeine butalbital/aspirin/caffeine tab butalbital-aspirin-caffeine w/cod ascomp/codeine cap 30mg tartrate butorphanol tartrate inj 1mg/ml butorphanol tartrate butorphanol tartrate inj 2mg/ml butorphanol tartrate butorphanol tartrate sol 10mg/ml butorphanol tartrate (bulk) BUTORPHANOL TARTRATE POW

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 4 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description canakinumab ILARIS INJ 180MG carbetapentane citrate-carbetapentane tannate-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 PD 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/ carbetapentane-guaifenesin TUSSO-ZMR CAP 8-200MG carbetapentane-guaifenesin TUSSO-ZR SYP 7.5-150 carbetapentane-pseudoephedrine CORZALL LIQ 20-30MG maleate carbinoxamine maleate liq 4mg/5ml carbinoxamine maleate carbinoxamine maleate tab 4mg certolizumab pegol CIMZIA KIT certolizumab pegol CIMZIA KIT 200MG/ML hcl cetirizine hcl syp 1mg/ml cetrorelix acetate CETROTIDE KIT 0.25MG cetrorelix acetate CETROTIDE KIT 3MG chlophedianol- 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 chlorphen tan & pseudoeph tan DICEL SUS chlorpheniramine & phenylephrine ACCUHIST DRO 1-2.5MG chlorpheniramine & phenylephrine centergy drop 1-2mg/ml 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 RESCON-JR TAB chlorpheniramine & phenylephrine sildec-pe syp chlorpheniramine & pseudoeph chlorpheniramine/pseudoephedrine cr cap 8-120 cr chlorpheniramine & pseudoeph CHLORPHENIRAMINE/PSEUDOEPHEDRINE SYP chlorpheniramine & pseudoeph DECONAMINE TAB 4-60MG chlorpheniramine & pseudoeph duratuss da cap 12-100mg chlorpheniramine & pseudoeph LOHIST-D LIQ chlorpheniramine & pseudoeph neutrahist dro 0.8-9mg chlorpheniramine & pseudoeph SUDAHIST TAB 12-120MG chlorpheniramine maleate CHLORPHENIRAMINE MALEATE ER CAP 12MG ER chlorpheniramine maleate chlorpheniramine maleate er cap 8mg er chlorpheniramine maleate CHLORPHENIRAMINE MALEATE POW MALEATE 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 5 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description 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/5 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 pedi chlorpheniramine tannate-phenylephrine tannate r-tanna tab 9-25mg chlorpheniramine tannate-phenylephrine tannate RYNATAN PEDIATRIC CHW 4.5-5MG chlorpheniramine tan-phenylephrine tan-methscopol AH-CHEW ULTRA CHW ULTRA chlorpheniramine tan-phenylephrine tan-methscopol redur-pcm sus chlorpheniramine tan-phenylephrine tan-methscopol SYMPAK PDX MIS chlorpheniramine tan-pyrilamine tan-phenylephrine tan conal sus chlorpheniramine tan-pyrilamine tan-phenylephrine tan nalex-a 12 sus chlorpheniramine w/ codeine CODAR AR LIQ chlorpheniramine w/ codeine COTAB A TAB 4-10MG chlorpheniramine w/ codeine COTAB AX TAB 4-20MG chlorpheniramine w/ codeine endacof-c liq 2-10mg/5 chlorpheniramine w/ codeine ZODRYL AC 25 SUS chlorpheniramine w/ codeine ZODRYL AC 30 SUS chlorpheniramine w/ codeine ZODRYL AC 35 SUS chlorpheniramine w/ codeine ZODRYL AC 40 SUS chlorpheniramine w/ codeine ZODRYL AC 50 SUS chlorpheniramine w/ codeine ZODRYL AC 60 SUS chlorpheniramine w/ codeine ZODRYL AC 80 SUS chlorpheniramine w/ codeine Z-TUSS AC LIQ 2-9/5ML chlorpheniramine w/ dm-gg 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-acetaminophen PROTID TAB CR chlorpheniramine-phenylephrine-methscopolamine AEROKID SYP chlorpheniramine-phenylephrine-methscopolamine AH-CHEW II CHW chlorpheniramine-phenylephrine-methscopolamine ALLERX PE MIS chlorpheniramine-phenylephrine-methscopolamine chlor-mes d syp liquid chlorpheniramine-phenylephrine-methscopolamine cpm 8/pe 20/msc 1.25 tab chlorpheniramine-phenylephrine-methscopolamine DALLERGY CHW chlorpheniramine-phenylephrine-methscopolamine DALLERGY PE SYP chlorpheniramine-phenylephrine-methscopolamine DALLERGY PE TAB chlorpheniramine-phenylephrine-methscopolamine DALLERGY SYP chlorpheniramine-phenylephrine-methscopolamine DALLERGY TAB chlorpheniramine-phenylephrine-methscopolamine DALLERGY TAB ER chlorpheniramine-phenylephrine-methscopolamine DEHISTINE SYP chlorpheniramine-phenylephrine-methscopolamine OMNIHIST II LA TAB LA chlorpheniramine-phenylephrine-methscopolamine phenylephrine cm tab chlorpheniramine-phenylephrine-methscopolamine re-drylex jr tab chlorpheniramine-phenylephrine-methscopolamine RELCOF DN PE MIS chlorpheniramine-phenylephrine-methscopolamine RESCON TAB chlorpheniramine-phenylephrine-methscopolamine RESCON TAB

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 6 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description 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-pyrilamine & phenylephrine myhist-pd liq chlorpheniramine-pyrilamine & phenylephrine PHENA-PLUS TAB chlorpheniramine-pyrilamine & phenylephrine PHENA-S LIQ chlorpheniramine-pyrilamine & phenylephrine RU-HIST FORTE TAB FORTE chlorphenir-phenylephrine-methscopol & homeopathic ZINX KIDS SNEEZE KIT SNEEZE chlorphenir-phenyltoloxamine-phenylephrine-apap 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-pe chlorpheniramine/phenyltoloxamine/phenylephrine liq chlorphen-phenyltolox-pe rhinacon a tab chlorphen-pse--- ru-tuss tab choriogonadotropin alfa OVIDREL INJ chorionic gonadotropin chorionic gonadotropin inj 10000unt fumarate CLEMASTINE FUMARATE POW FUMARATE clemastine fumarate clemastine fumarate syp 0.5/5ml clemastine fumarate clemastine fumarate tab 2.68mg clemastine fumarate TAVIST ALLERGY TAB 1.34MG hcl (bulk) CLEMIZOLE HCL POW HCL clomiphene citrate clomiphene citrate tab 50mg 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 codeine phosphate CODEINE PHOSPHATE INJ 30MG/2ML codeine phosphate CODEINE PHOSPHATE INJ 60MG/2ML codeine phosphate CODEINE PHOSPHATE POW PHOSPHAT codeine phosphate CODEINE PHOSPHATE TAB SOL 30MG codeine sulfate CODEINE SULFATE SOL 30MG/5ML codeine sulfate CODEINE SULFATE TAB 15MG codeine sulfate CODEINE SULFATE TAB 30MG codeine sulfate CODEINE SULFATE TAB 60MG codeine-brompheniramine BROVEX CB TAB 10-4MG codeine-brompheniramine BROVEX CBX TAB 20-4MG codeine-brompheniramine NALEX AC SYP codeine- 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 hcl cyproheptadine hcl syp 2mg/5ml cyproheptadine hcl cyproheptadine hcl syp 2mg/5ml cyproheptadine hcl cyproheptadine hcl tab 4mg cyproheptadine hcl (bulk) CYPROHEPTADINE HCL POW dalfampridine AMPYRA TAB 10MG desflurane SUPRANE INH

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 7 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description CLARINEX REDITABS TAB 2.5MG desloratadine CLARINEX REDITABS TAB 5MG desloratadine CLARINEX SYP 0.5MG/ML desloratadine CLARINEX TAB 5MG desloratadine-pseudoephedrine CLARINEX-D 12 HOUR TAB 2.5-120 desloratadine-pseudoephedrine CLARINEX-D 24 HOUR TAB 5-240MG tannate-pyrilamine maleate POLY TAN SUS dexbrompheniramine tan-pyrilamine mal-phenylephrine tan POLY TAN D SUS 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 FOCALIN TAB 10MG dexmethylphenidate hcl FOCALIN TAB 2.5MG dexmethylphenidate hcl FOCALIN TAB 5MG dexmethylphenidate hcl FOCALIN XR CAP 10MG dexmethylphenidate hcl FOCALIN XR CAP 15MG dexmethylphenidate hcl FOCALIN XR CAP 20MG dexmethylphenidate hcl FOCALIN XR CAP 25MG dexmethylphenidate hcl FOCALIN XR CAP 30MG dexmethylphenidate hcl FOCALIN XR CAP 35MG dexmethylphenidate hcl FOCALIN XR CAP 40MG dexmethylphenidate hcl FOCALIN XR CAP 5MG dextroamphetamine sulfate dextroamphetamine sulfate er cap 10mg er dextroamphetamine sulfate dextroamphetamine sulfate er cap 15mg er dextroamphetamine sulfate dextroamphetamine sulfate er cap 5mg er dextroamphetamine sulfate dextroamphetamine sulfate tab 10mg dextroamphetamine sulfate ZENZEDI TAB 2.5MG dextroamphetamine sulfate zenzedi tab 5mg dextroamphetamine sulfate ZENZEDI TAB 7.5MG hbr-guaifenesin tannate DURATUSS DM 12 SUS DM 12 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 5MG/ML diazepam DIAZEPAM INJ 5MG/ML diazepam DIAZEPAM INTENSOL CON 5MG/ML diazepam DIAZEPAM SOL 1MG/ML diazepam diazepam tab 10mg diazepam diazepam tab 2mg diazepam diazepam 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. Revision date: December 2013 (ver 4_20131211) Page 8 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description diazepam (anticonvulsant) DIASTAT PEDIATRIC GEL 2.5M GEL dihydrocodeine compound SYNALGOS-DC CAP dihydrocodeine-guaifenesin J-MAX DHC LIQ dihydroergotamine mesylate dihydroergotamine mesylate inj 1mg/ml dihydroergotamine mesylate dihydroergotamine mesylate inj 1mg/ml dihydroergotamine mesylate MIGRANAL SPR 4MG/ML diphenhydramine & pseudoephed TEKRAL TAB 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 diphenhydramine hcl inj 50mg/ml diphenhydramine hcl DIPHENHYDRAMINE HCL POW HCL 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-phenylephrine zoden pd liq 25-7.5 succinate DOXYLAMINE SUCCINATE POW SUCCINAT doxylamine succinate DOXYTEX LIQ doxylamine succinate tannate ALDEX AN SUS droperidol inj 2.5mg/ml droperidol droperidol inj 2.5mg/ml eletriptan hydrobromide RELPAX TAB 20MG eletriptan hydrobromide RELPAX TAB 40MG ETHRANE INH ephedrine-guaifenesin BRONCHOLATE SYP 6.25-100 ergoloid mesylates ergoloid mesylates tab 1mg oral ergotamine tartrate ERGOMAR SUB 2MG ergotamine w/ caffeine ergotamine tartrate/caffeine tab 1/100 ergotamine w/ caffeine MIGERGOT SUP 2/100 estazolam estazolam tab 1mg estazolam estazolam tab 2mg 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 etomidate AMIDATE INJ 2MG/ML etomidate AMIDATE INJ 2MG/ML etomidate etomidate inj 2mg/ml etomidate (bulk) ETOMIDATE POW fentanyl dis 100mcg/h fentanyl fentanyl dis 12mcg/hr fentanyl fentanyl dis 25mcg/hr fentanyl fentanyl dis 50mcg/hr fentanyl fentanyl dis 75mcg/hr fentanyl SUBSYS SPR 100MCG fentanyl SUBSYS SPR 1200MCG fentanyl SUBSYS SPR 1600MCG

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 9 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description 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/1 fentanyl citrate fentanyl citrate inj 0.05mg/1 fentanyl citrate fentanyl citrate inj 0.05mg/1 fentanyl citrate fentanyl citrate inj 0.05mg/1 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 POW CITRATE fentanyl citrate FENTANYL CITRATE POW CITRATE 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 hcl ALLEGRA ODT TAB 30MG fexofenadine hcl ALLEGRA SUS 30MG/5ML fexofenadine hcl fexofenadine hcl tab 180mg fexofenadine hcl fexofenadine hcl tab 30mg fexofenadine hcl fexofenadine hcl tab 60mg fexofenadine-pseudoephedrine FEXOFENADINE/PSEUDOEPHEDRINE TAB 24 HOUR fexofenadine-pseudoephedrine FEXOFENADINE/PSEUDOEPHEDRINE TAB 60-120MG flurazepam hcl flurazepam hcl cap 15mg flurazepam hcl flurazepam hcl cap 30mg follitropin alfa GONAL-F INJ 1050UNIT follitropin alfa GONAL-F INJ 450UNIT follitropin alfa GONAL-F RFF INJ 75UNIT follitropin alfa GONAL-F RFF PEN INJ 300 follitropin alfa GONAL-F RFF PEN INJ 450 follitropin alfa GONAL-F RFF PEN INJ 900 follitropin beta FOLLISTIM AQ INJ 150UNIT follitropin beta FOLLISTIM AQ INJ 300UNIT follitropin beta FOLLISTIM AQ INJ 600UNIT follitropin beta FOLLISTIM AQ INJ 75UNIT follitropin beta FOLLISTIM AQ INJ 900UNIT

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 10 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description frovatriptan succinate FROVA TAB 2.5MG (phn) GRALISE STARTER MIS 300/600 gabapentin (phn) GRALISE TAB 300MG gabapentin (phn) GRALISE TAB 600MG ganirelix acetate GANIRELIX ACETATE INJ golimumab SIMPONI INJ 50MG golimumab SIMPONI INJ 50MG 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 EXPECT guaifenesin-codeine m-clear wc liq guaifenesin-codeine PRO-CLEAR CAP 200-9MG guaifenesin-codeine TUSSO-C LIQ 200-10MG bitartrate (antitussive) HYDROCODONE BITARTRATE CRY BITARTRA hydrocodone bitartrate (antitussive) HYDROCODONE BITARTRATE POW BITARTRA hydrocodone polistirex-chlorpheniramine polistirex hydrocodone polistirex and chlorpheniramine polistirex liq hydrocodone polistirex-chlorpheniramine polistirex TUSSICAPS CAP 10-8MG hydrocodone polistirex-chlorpheniramine polistirex TUSSICAPS CAP 5-4MG hydrocodone w/ hydromet syp 5-1.5/5 hydrocodone w/ homatropine tussigon tab 5mg hydrocodone-acetaminophen HYCET SOL 7.5-325 hydrocodone-acetaminophen HYDROCODONE BITARTRATE/ACETAMIN TAB 2.5-325 hydrocodone-acetaminophen hydrocodone bitartrate/acetaminophen sol hydrocodone-acetaminophen hydrocodone bitartrate/acetaminophen sol 5-217/10 hydrocodone-acetaminophen hydrocodone bitartrate/acetaminophen sol 7.5-325 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 7.5-300 hydrocodone-acetaminophen HYDROCODONE/ACETAMINOPHEN SOL 10-325MG hydrocodone-acetaminophen HYDROCODONE/ACETAMINOPHEN SOL 10-325MG hydrocodone-acetaminophen hydrocodone/acetaminophen sol apap hydrocodone-acetaminophen hydrocodone/acetaminophen sol apap hydrocodone-acetaminophen hydrocodone/acetaminophen sol apap hydrocodone-acetaminophen hydrocodone/acetaminophen sol apap 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 2.5-500 hydrocodone-acetaminophen hydrocodone/acetaminophen tab 5-325mg hydrocodone-acetaminophen hydrocodone/acetaminophen tab 5-500mg hydrocodone-acetaminophen hydrocodone/acetaminophen tab 7.5-325 hydrocodone-acetaminophen hydrocodone/acetaminophen tab 7.5-500 hydrocodone-acetaminophen hydrocodone/acetaminophen tab 7.5-650 hydrocodone-acetaminophen hydrocodone/acetaminophen tab 7.5-750 hydrocodone-acetaminophen stagesic cap 500-5mg hydrocodone-acetaminophen ZAMICET SOL 10-325MG hydrocodone-acetaminophen ZOLVIT SOL 10-300MG

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 11 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description hydrocodone-acetaminophen ZYDONE TAB 10-400MG hydrocodone-acetaminophen ZYDONE TAB 5-400MG hydrocodone-acetaminophen ZYDONE TAB 7.5-400 hydrocodone-acetaminophen-dietary management product THERACODOPHEN-325 PAK -325 hydrocodone-acetaminophen-dietary management product THERACODOPHEN-650 PAK -650 hydrocodone-acetaminophen-dietary management product THERACODOPHEN-LOW-90 PAK -LOW-90 hydrocodone-chlorpheniramine VITUZ SOL 5-4MG hydrocodone- IBUDONE TAB 10-200MG hydrocodone-ibuprofen REPREXAIN TAB 2.5-200 hydrocodone-ibuprofen REPREXAIN TAB 5-200MG hydrocodone-ibuprofen VICOPROFEN TAB hcl DILAUDID-5 LIQ 1MG/ML hydromorphone hcl DILAUDID-HP INJ 10MG/ML hydromorphone hcl DILAUDID-HP INJ 250MG hydromorphone hcl EXALGO TAB 12MG hydromorphone hcl EXALGO TAB 16MG hydromorphone hcl EXALGO TAB 16MG hydromorphone hcl EXALGO TAB 32MG hydromorphone hcl EXALGO TAB 8MG hydromorphone hcl EXALGO TAB 8MG hydromorphone hcl hydromorphone hcl dosette inj 2mg/ml hydromorphone hcl hydromorphone hcl inj 1mg/ml hydromorphone hcl hydromorphone hcl inj 1mg/ml 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 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 POW HCL hydromorphone hcl HYDROMORPHONE HCL SUP 3MG hydromorphone hcl hydromorphone hcl tab 2mg hydromorphone hcl hydromorphone hcl tab 4mg hydromorphone hcl hydromorphone hcl tab 8mg hydromorphone hcl-sodium chloride HYDROMORPHONE/SODIUM CHLORIDE INJ /NACL icatibant acetate FIRAZYR INJ 30MG/3ML infliximab REMICADE INJ 100MG iodine strong (lugol's) IODINE STRONG SOL STRONG isoflurane FORANE SOL hcl ketamine hcl inj 100mg/ml ketamine hcl ketamine hcl inj 10mg/ml ketamine hcl ketamine hcl inj 50mg/ml ketamine hcl (bulk) KETAMINE HCL POW dihydrochloride levocetirizine dihydrochl oride tab dhcl 5mg levocetirizine dihydrochloride XYZAL SOL tartrate LEVO DROMORAN INJ 2MG/ML levorphanol tartrate LEVO DROMORAN INJ 2MG/ML levorphanol tartrate LEVORPHANOL TARTRATE TAB 2MG levorphanol tartrate (bulk) LEVORPHANOL TARTRATE POW TARTRATE lisdexamfetamine dimesylate VYVANSE CAP 20MG lisdexamfetamine dimesylate VYVANSE CAP 30MG lisdexamfetamine dimesylate VYVANSE CAP 40MG lisdexamfetamine dimesylate VYVANSE CAP 50MG lisdexamfetamine dimesylate VYVANSE CAP 60MG

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 12 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description lisdexamfetamine dimesylate VYVANSE CAP 70MG lorazepam lorazepam inj 2mg/ml lorazepam lorazepam inj 2mg/ml lorazepam lorazepam inj 4mg/ml lorazepam lorazepam inj 4mg/ml lorazepam LORAZEPAM INTENSOL CON 2MG/ML lorazepam lorazepam tab 0.5mg lorazepam lorazepam tab 1mg lorazepam lorazepam tab 2mg lutropin alfa LUVERIS INJ 75UNIT mecasermin INCRELEX INJ 40MG/4ML mecasermin rinfabate (rdna) IPLEX INJ 36/0.6ML menotropins MENOPUR INJ 75UNIT menotropins REPRONEX INJ 75UNIT meperidine hcl DEMEROL INJ 100/2ML meperidine hcl DEMEROL INJ 100MG/ML meperidine hcl DEMEROL INJ 100MG/ML meperidine hcl DEMEROL INJ 100MG/ML meperidine hcl DEMEROL INJ 25MG/0.5 meperidine hcl DEMEROL INJ 25MG/ML meperidine hcl DEMEROL INJ 50MG/ML meperidine hcl DEMEROL INJ 50MG/ML meperidine hcl DEMEROL INJ 50MG/ML meperidine hcl DEMEROL INJ 75MG/1.5 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 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 POW meperidine hcl MEPERIDINE HCL SOL 50MG/5ML meperidine hcl meperidine hcl tab 50mg meperidine hcl meperitab tab 100mg meperidine w/ meperidine/promethazine cap prometh mephobarbital MEBARAL TAB 100MG mephobarbital MEBARAL TAB 32MG mephobarbital MEBARAL TAB 50MG meprobamate meprobamate tab 200mg meprobamate meprobamate tab 400mg meprobamate-aspirin EQUAGESIC TAB 200-325 hcl METHADONE HCL INJ 10MG/ML methadone hcl METHADONE HCL POW 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 sugar-free con 10mg/ml methadone hcl methadose tab 40mg hcl DESOXYN TAB 5MG methohexital sodium BREVITAL SODIUM INJ 2.5GM methohexital sodium BREVITAL SODIUM INJ 200MG methohexital sodium BREVITAL SODIUM INJ 500MG DAYTRANA DIS 10MG/9HR

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 13 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description methylphenidate DAYTRANA DIS 15MG/9HR methylphenidate DAYTRANA DIS 20MG/9HR methylphenidate DAYTRANA DIS 30MG/9HR methylphenidate hcl METHYLIN CHW 10MG methylphenidate hcl METHYLIN CHW 2.5MG methylphenidate hcl METHYLIN CHW 5MG 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 ER methylphenidate hcl methylphenidate hcl er tab 18mg methylphenidate hcl methylphenidate hcl er tab 20mg methylphenidate hcl methylphenidate hcl er tab 27mg methylphenidate hcl methylphenidate hcl er tab 36mg methylphenidate hcl methylphenidate hcl er tab 54mg methylphenidate hcl methylphenidate hcl tab 10mg methylphenidate hcl methylphenidate hcl tab 20mg methylphenidate hcl methylphenidate hcl tab 5mg methylphenidate hcl methylphenidate hydrochloride sol 10mg/5ml methylphenidate hcl methylphenidate hydrochloride sol 5mg/5ml methylphenidate hcl QUILLIVANT XR SUS XR methylphenidate hcl RITALIN LA CAP 10MG methylphenidate hcl RITALIN LA CAP 20MG methylphenidate hcl RITALIN LA CAP 30MG methylphenidate hcl RITALIN LA CAP 40MG midazolam hcl midazolam hcl inj 1mg/ml midazolam hcl midazolam hcl inj 2mg/2ml midazolam hcl midazolam hcl inj 2mg/2ml midazolam hcl midazolam hcl inj 5mg/5ml midazolam hcl midazolam hcl inj 5mg/ml midazolam hcl midazolam hcl inj 5mg/ml midazolam hcl midazolam hcl inj 5mg/ml midazolam hcl midazolam hcl inj 5mg/ml midazolam hcl midazolam hcl inj 5mg/ml midazolam hcl midazolam hcl syp 2mg/ml miglustat ZAVESCA CAP 100MG modafinil PROVIGIL TAB 100MG modafinil PROVIGIL TAB 200MG sulfate duramorph inj 0.5mg/ml morphine sulfate duramorph inj 1mg/ml morphine sulfate KADIAN CAP 100MG CR morphine sulfate KADIAN CAP 10MG CR morphine sulfate KADIAN CAP 130MG CR morphine sulfate KADIAN CAP 150MG CR morphine sulfate KADIAN CAP 200MG CR morphine sulfate KADIAN CAP 20MG CR morphine sulfate KADIAN CAP 30MG CR morphine sulfate KADIAN CAP 40MG CR morphine sulfate KADIAN CAP 50MG CR morphine sulfate KADIAN CAP 60MG CR morphine sulfate KADIAN CAP 70MG CR morphine sulfate KADIAN CAP 80MG CR

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 14 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description morphine sulfate morphine sulfate dilute-a-jet inj 25mg/ml morphine sulfate morphine sulfate er tab 100mg er morphine sulfate morphine sulfate er tab 15mg er morphine sulfate morphine sulfate er tab 200mg er morphine sulfate morphine sulfate er tab 30mg er morphine sulfate morphine sulfate er tab 60mg er 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 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 15mg/ml morphine sulfate MORPHINE SULFATE INJ 15MG/ML morphine sulfate morphine sulfate inj 1mg/ml morphine sulfate morphine sulfate inj 1mg/ml morphine sulfate morphine sulfate inj 1mg/ml morphine sulfate morphine sulfate inj 1mg/ml morphine sulfate morphine sulfate inj 1mg/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 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 5MG/ML morphine sulfate morphine sulfate inj 8mg/ml morphine sulfate morphine sulfate inj 8mg/ml morphine sulfate morphine sulfate inj 8mg/ml morphine sulfate MORPHINE SULFATE INJ 8MG/ML morphine sulfate MORPHINE SULFATE POW SULFATE 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 15MG morphine sulfate MORPHINE SULFATE TAB 30MG 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 15 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description 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 in dextrose MORPHINE SULF IN DEXTROSE 5% INJ 1MG/ML morphine sulfate liposome DEPODUR INJ 10MG/ML morphine sulfate liposome DEPODUR INJ 15/1.5ML morphine-naltrexone EMBEDA CAP 100-4MG morphine-naltrexone EMBEDA CAP 20-0.8MG morphine-naltrexone EMBEDA CAP 30-1.2MG morphine-naltrexone EMBEDA CAP 50-2MG morphine-naltrexone EMBEDA CAP 60-2.4MG morphine-naltrexone EMBEDA CAP 80-3.2MG nafarelin acetate SYNAREL SOL 2MG/ML hcl nalbuphine hcl inj 10mg/ml nalbuphine hcl nalbuphine hcl inj 10mg/ml nalbuphine hcl nalbuphine hcl inj 20mg/ml nalbuphine hcl nalbuphine hcl inj 20mg/ml nalbuphine hcl (bulk) NALBUPHINE HCL POW HCL hcl REVEX INJ 100MCG nalmefene hcl REVEX INJ 1MG/ML naloxone hcl NALOXONE HCL INJ 0.4MG/ML naloxone hcl NALOXONE HCL INJ 0.4MG/ML naloxone hcl NALOXONE HCL INJ 0.4MG/ML naloxone hcl naloxone hcl inj 1mg/ml naltrexone VIVITROL INJ 380MG naltrexone hcl naltrexone hcl tab 50mg naratriptan hcl naratriptan hcl tab 1mg naratriptan hcl naratriptan hcl tab 2.5mg 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 nitisinone ORFADIN CAP 10MG nitisinone ORFADIN CAP 2MG nitisinone ORFADIN CAP 5MG octreotide acetate SANDOSTATIN LAR DEPOT KIT LAR 10MG octreotide acetate SANDOSTATIN LAR DEPOT KIT LAR 20MG octreotide acetate SANDOSTATIN LAR DEPOT KIT LAR 30MG w/ aspirin & caff ORPHENADRINE COMPOUND DS TAB DS orphenadrine w/ aspirin & caff orphenadrine/asa/caffeine tab oxazepam oxazepam cap 10mg oxazepam oxazepam cap 15mg oxazepam oxazepam cap 30mg 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 16 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description oxycodone hcl oxycodone hcl con 20mg/ml oxycodone hcl OXYCODONE HCL POW HCL oxycodone hcl oxycodone hcl sol 5mg/5ml 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 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 w/ acetaminophen MAGNACET TAB 10-400MG oxycodone w/ acetaminophen MAGNACET TAB 2.5-400 oxycodone w/ acetaminophen MAGNACET TAB 5-400MG oxycodone w/ acetaminophen MAGNACET TAB 7.5-400 oxycodone w/ acetaminophen oxycodone/acetaminophen cap 5-500mg oxycodone w/ acetaminophen oxycodone/acetaminophen tab 10-325mg oxycodone w/ acetaminophen oxycodone/acetaminophen tab 10-650mg oxycodone w/ acetaminophen oxycodone/acetaminophen tab 2.5-325 oxycodone w/ acetaminophen oxycodone/acetaminophen tab 5-325mg oxycodone w/ acetaminophen oxycodone/acetaminophen tab 7.5-325 oxycodone w/ acetaminophen oxycodone/acetaminophen tab 7.5-500 oxycodone w/ acetaminophen PRIMALEV TAB 2.5-300 oxycodone w/ acetaminophen PRIMLEV TAB 10-300MG oxycodone w/ acetaminophen PRIMLEV TAB 5-300MG oxycodone w/ acetaminophen PRIMLEV TAB 7.5-300 oxycodone w/ acetaminophen ROXICET SOL 5-325/5 oxycodone w/ acetaminophen ROXICET TAB 5-500MG oxycodone w/ acetaminophen XOLOX TAB 10-500MG oxycodone w/ aspirin endodan tab oxycodone w/ aspirin oxycodone/aspirin tab oxycodone-ibuprofen oxycodone/ibuprofen tab 5-400mg hcl OPANA ER (CRUSH RESISTANT) TAB 10MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 15MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 20MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 30MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 40MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 5MG oxymorphone hcl OPANA ER (CRUSH RESISTANT) TAB 7.5MG oxymorphone hcl OPANA ER TAB 10MG oxymorphone hcl OPANA ER TAB 15MG oxymorphone hcl OPANA ER TAB 20MG oxymorphone hcl OPANA ER TAB 30MG oxymorphone hcl OPANA ER TAB 40MG oxymorphone hcl OPANA ER TAB 5MG oxymorphone hcl OPANA ER TAB 7.5MG oxymorphone hcl OPANA INJ 1MG/ML oxymorphone hcl oxymorphone hydrochloride tab hcl 10mg oxymorphone hcl oxymorphone hydrochloride tab hcl 5mg palifermin KEPIVANCE INJ 6.25MG pasireotide diaspartate SIGNIFOR INJ 0.3MG/ML pasireotide diaspartate SIGNIFOR INJ 0.6MG/ML

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 17 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description pasireotide diaspartate SIGNIFOR INJ 0.9MG/ML pegvisomant SOMAVERT INJ 10MG pegvisomant SOMAVERT INJ 15MG pegvisomant SOMAVERT INJ 20MG lactate TALWIN INJ 30MG/ML pentazocine lactate TALWIN INJ 30MG/ML pentazocine w/ naloxone pentazocine/naloxone hcl tab naloxone pentazocine-acetaminophen PENTAZOCINE/ACETAMINOPHEN TAB 25-650MG pentobarbital sodium NEMBUTAL INJ 50MG/ML phenyleph hcl-diphenhyd hcl-dextromethorphan hbr tannate DURATUSS AC 12 SUS AC 12 phenyleph hcl-pyrilamine mal-dextromethorphan hbr tannate DECONSAL DM CHW phenyleph tan-dexbromphen tan-pyrilamine maleate-dm tan POLY TAN DM SUS phenyleph tannate-bromphen tan-dextromethorphan tan bromatan-dm sus phenyleph tannate-bromphen tan-dextromethorphan tan NEO DM SUS phenyleph tannate-chlorphen tan-carbetapentane tan CARBAPHEN 12 PED SUS PED phenyleph tannate-chlorphen tan-carbetapentane tan CARBAPHEN 12 SUS phenyleph tannate-chlorphen tan-dextromethorphan tan MAXIPHEN ADT TAB phenyleph tannate-diphenhyd tan-carbetapentane tan d-tann ct sus phenyleph tannate-diphenhyd tan-carbetapentane tan d-tann ct tab phenyleph tannate-diphenhyd tan-carbetapentane tan DYTAN-CD SUS phenyleph tannate-diphenhyd tan-dextromethorphan tan livetan dm sus phenyleph tannate-pyrilamine tan-carbetapentane tan TUSSI-12D S SUS phenyleph tannate-pyrilamine tan-carbetapentane tan TUSSI-12D TAB 10-40-60 phenyleph tannate-pyrilamine tan-dextromethorphan tan SINADEX 12 SUS phenyleph tannate-pyrilamine tan-dextromethorphan tan VIRATAN-DM CHW 25-30-25 phenyleph tannate-pyrilamine tann-dextromethorphan tan allanvan-dm sus phenyleph-dm-pyril-pot guai-sod cit-citric acid ALBATUSSIN NN LIQ NN phenyleph-promethazine w/ cod promethazine vc/codeine syp codeine phenylephrine hcl-dextromethorphan hbr-guaifenesin tannate TUSSO-XR SUS phenylephrine tan-carbetapentane tan & homeopathic prod ZINX COLD KIT phenylephrine tan-dexchlorphenir tan-dextromethorphan tan DONATUSSIN DM SUS DM phenylephrine tannate-carbetapentane tannate carb/phenyl-12 sus 12 phenylephrine tannate-carbetapentane tannate DYNEX 12 SUS phenylephrine tannate-carbetapentane tannate l-all 12 nf sus 25-30mg phenylephrine tannate-guaifenesin SINA-12X SUS phenylephrine tannate-guaifenesin SINA-12X TAB 25-200MG phenylephrine tannate-pyrilamine tannate-guaifenesin RYNA-12X SUS 5-30-100 phenylephrine tannate-pyrilamine tannate-guaifenesin RYNA-12X TAB phenylephrine w/ codeine ALAHIST AC LIQ 7.5-10 phenylephrine w/ codeine NOTUSS-PE LIQ phenylephrine w/ codeine-gg GILTUSS PED-C LIQ PED-C phenylephrine w/ codeine-gg MAXIPHEN CD TAB phenylephrine w/ codeine-gg MAXIPHEN CDX TAB phenylephrine w/ dm-gg biotuss liq phenylephrine w/ dm-gg biotuss pediatric liq pediatrc phenylephrine w/ dm-gg BRONCOTRON-D SUS phenylephrine w/ dm-gg DESPEC DM SYP phenylephrine w/ dm-gg GILTUSS LIQ phenylephrine w/ dm-gg GILTUSS PEDIATRIC LIQ phenylephrine w/ dm-gg GILTUSS TR CAP 7-14-288 phenylephrine w/ dm-gg GILTUSS TR TAB phenylephrine w/ dm-gg MAXIPHEN DM TAB phenylephrine w/ dm-gg nortuss-de dro phenylephrine w/ dm-gg PDM GG SYP 10-30-20 phenylephrine w/ dm-gg SINUTUSS DM TAB

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 18 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description phenylephrine w/ dm-gg TRITUSS SYP phenylephrine w/ dm-gg TUSSAFED EX LIQ phenylephrine w/ dm-gg TUSSI-PRES PEDIATRIC LIQ PEDIATRC phenylephrine w/ dm-gg z-dex syp phenylephrine w/ dm-gg ZOTEX PEDIATRIC DRO phenylephrine w/ dm-gg ZOTEX-D SYP phenylephrine w/ dm-gg ZOTEX-EX TAB phenylephrine w/ dm-gg ZOTEX-EX TAB phenylephrine w/ dm-gg ZOTEX-G SYP phenylephrine w/hydrocodone-gg GILTUSS HC LIQ phenylephrine-brompheniramine w/ codeine BROVEX PB C TAB 10-4-10 phenylephrine-brompheniramine w/ codeine BROVEX PB CX TAB 10-4-20 phenylephrine-brompheniramine w/ codeine M-END PE LIQ phenylephrine-brompheniramine w/ codeine POLY-TUSSIN AC LIQ AC phenylephrine-brompheniramine-carbetapentane trexbrom liq phenylephrine-brompheniramine-carbetapentane VAZOTAN SUS phenylephrine-brompheniramine-carbetapentane v-cof sus phenylephrine-brompheniramine-dihydrocodeine POLY-TUSSIN DHC LIQ DHC phenylephrine-brompheniramine-dm ALACOL DM DRO phenylephrine-brompheniramine-dm ALAHIST DM LIQ 7.5-4-15 phenylephrine-brompheniramine-dm bpm pe dm syp 5-2-10mg phenylephrine-brompheniramine-dm brompheniramine/phenylephrine/dm liq 4-10-20 phenylephrine-brompheniramine-dm-guaifenesin BROMHIST-PDX SYP phenylephrine-brompheniramine-guaifenesin DECON-G DRO 2-1-40MG phenylephrine-carbetapentane-guaifen& homeopathic prod ZINX COUGH KIT phenylephrine-carbetapentane-guaifenesin albatussin nn liq nn phenylephrine-carbetapentane-guaifenesin AQUATAB C TAB phenylephrine-carbetapentane-guaifenesin carbetaplex syp phenylephrine-carbetapentane-guaifenesin extendryl gcp sol gcp phenylephrine-carbetapentane-guaifenesin phencarb gg syp phenylephrine-carbetapentane-potassium guaiacolsulfonate CARBATUSS-CL LIQ phenylephrine-chlorphen-dm ACCUHIST PDX DRO PDX phenylephrine-chlorphen-dm centergy dm dro phenylephrine-chlorphen-dm c-phen dm dro 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 DRO 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 dro phenylephrine-chlorphen-dm zotex-12d tab phenylephrine-chlorphen-gg p chlor gg sol drops phenylephrine-chlorpheniramine w/ codeine CAPCOF SYP phenylephrine-chlorpheniramine w/ codeine ENDAL CD SYP phenylephrine-chlorpheniramine w/ dm-gg chlordex gp syp phenylephrine-chlorpheniramine w/ dm-gg DONATUSSIN SYP phenylephrine-chlorpheniramine w/ dm-gg ZOTEX-DM SYP phenylephrine-chlorpheniramine-carbetapentane CARBAPHEN 12 LIQ phenylephrine-chlorpheniramine-carbetapentane CARBAPHEN 12 PED SUS PED 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 19 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description phenylephrine-chlorpheniramine-dihydrocodeine NOVAHISTINE DH LIQ DH phenylephrine-chlorpheniramine-dm-gg-methscopolamine SYMPAK DM MIS phenylephrine-codeine-guaifenesin-acetaminophen PHENFLU CD TAB phenylephrine-codeine-guaifenesin-acetaminophen PHENFLU CDX TAB phenylephrine-dexbrompheniramine-dextromethorphan DEXALL SYP 10-2-20 phenylephrine-dexbrompheniramine-dextromethorphan TUSSALL-ER TAB 20-6-30 phenylephrine-dexbrompheniramine-dm-guaifenesin PANATUSS DXP PEDIATRIC LIQ phenylephrine-dexchlorpheniramine-carbetapentane CORZALL-PE LIQ phenylephrine-dexchlorpheniramine-codeine VANACOF CD LIQ phenylephrine-dexchlorpheniramine-pyrilamine-dm coryza-dm syp phenylephrine-dihydrocodeine ALAHIST DHC LIQ 7.5-3 phenylephrine-dihydrocodeine-guaifenesin DONATUSS DC SYP phenylephrine-dihydrocodeine-guaifenesin POLY-TUSSIN EX SYP EX phenylephrine-diphenhydramine-codeine AIRACOF SYP phenylephrine-diphenhydramine-codeine ENDAL CD SYP phenylephrine-diphenhydramine-dm w/ apap RESPA C&C IR TAB phenylephrine-diphenhydramine-dm w/ apap RESPA C&C TAB phenylephrine-dm-gg w/ apap PHENFLU DM TAB phenylephrine-dm-gg w/ apap PHENFLU G TAB phenylephrine-ephedrine-chlorphenir w/ carbetapentane RYNATUSS TAB phenylephrine-ephedrine-chlorphenirw/ carbetapentane quad-tuss tannate pediatric sus tann/ped phenylephrine-guaifenesin GILPHEX TR TAB 10-388MG phenylephrine-guaifenesin guaifenesin/phenylephrine hcl syp phenylephrine-guaifenesin maxiphen tab 10-400mg phenylephrine-guaifenesin nazarin liq phenylephrine-guaifenesin phenavent ped cap 7.5-200 phenylephrine-guaifenesin phenylephrine/guaifenesin drop 1.5-20mg phenylephrine-guaifenesin quintex syp 7.5-100 phenylephrine-guaifenesin SINUVENT PE TAB 15-600MG phenylephrine-guaifenesin SITREX PD LIQ 7.5-75MG phenylephrine-guaifenesin ZOTEX -GP TAB phenylephrine-guaifenesin-chlorphenir-methscopolamine SYMPAK MIS phenylephrine-methscopolamine EXTENDRYL PEM TAB PEM phenylephrine-pyrilamine w/cod PRO-RED AC SYP phenylephrine-pyrilamine w/cod ZOTEX-C SYP phenylephrine-pyrilamine-dihydrocodeine POLY HIST DHC LIQ DHC phenylephrine-pyrilamine-dm POLY HIST DM LIQ phenylephrine-pyrilamine-dm pyril dm sus phenylephrine-triprolidine-chlophedianol PROHIST CD LIQ phenyltoloxamine-acetaminophen ACUFLEX TAB phenyltoloxamine-acetaminophen biogesic tab 30-500mg 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 potassium guaiacolsulfonate YODEFAN-NF LIQ 300MG/5 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 20 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description promethazine & phenylephrine promethazine vc plain syp plain promethazine hcl promethazine hcl inj 25mg/ml promethazine hcl promethazine hcl inj 25mg/ml promethazine hcl promethazine hcl inj 25mg/ml promethazine hcl promethazine hcl inj 50mg/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 hcl (bulk) PROMETHAZINE HCL POW HCL promethazine w/codeine promethazine/codeine syp 6.25-10 promethazine-dm promethazine/dextromethorphan syp dm propofol fresenius propoven inj 10mg/ml propofol fresenius propoven inj 10mg/ml propofol fresenius propoven inj 10mg/ml propofol fresenius propoven inj 10mg/ml propofol propofol inj 10mg/ml propoxyphene hcl propoxyphene hcl cap 65mg propoxyphene hcl w/ acetaminophen propoxyphene/acetaminophen tab 65-650mg propoxyphene napsylate DARVON-N TAB 100MG propoxyphene napsylate (bulk) PROPOXYPHENE NAPSYLATE POW NAPSYLAT propoxyphene-n w/ acetaminophen propoxyphene napsylate/acetaminophen tab 100-325 propoxyphene-n w/ acetaminophen propoxyphene-n/acetaminophen tab 100-500 propoxyphene-n w/ acetaminophen propoxyphene-n/acetaminophen tab 100-650 propoxyphene-n w/ acetaminophen propoxyphene-n/acetaminophen tab 50/325 pseudoeph hcl-pyrilamine mal-dextromethorphan hbr tannate VIRAVAN-PDM SUS 15-15-15 pseudoeph-chlorphen w/ cod PHENYLHISTINE DH LIQ DH pseudoeph-chlorphen w/ cod ZODRYL DAC 50 SUS 50 pseudoeph-chlorphen w/ cod ZODRYL DAC 60 SUS 60 pseudoeph-chlorphen w/ cod ZODRYL DAC 80 SUS 80 pseudoephed hcl-chlorphen mal-dm hbr tannate chlorpheniramine/pseudo/dm tannate sus pseudoephed-bromphen-dm allanhist pdx dro pdx pseudoephed-bromphen-dm andehist dm nr syp nr pseudoephed-bromphen-dm bromfed dm syp pseudoephed-bromphen-dm BROVEX PSB DM LIQ DM pseudoephed-bromphen-dm BROVEX PSE DM TAB DM pseudoephed-bromphen-dm DELTUSS DMX LIQ pseudoephed-bromphen-dm pbm allergy syp pseudoephed-bromphen-dm PEDIAHIST DM DRO 15-1-4MG pseudoephed-bromphen-dm pse brom dm syp pseudoephed-bromphen-dm RESPERAL-DM DRO 12-1-5MG pseudoephed-bromphen-dm tgq 50pse/3brm/30dm syp brm/30dm pseudoephed-cpm w/ hydrocod ZUTRIPRO LIQ pseudoephed-methscop & chlorphen-phenyleph-methscop ALLERX DOSE PACK MIS pseudoephedrine hcl-dm hbr-guaifenesin tannate Z-COF 12DM SUS pseudoephedrine tan-bromphen tan-dm tan ANAPLEX DMX SUS pseudoephedrine tan-chlorphen tan-dm tan DICEL DM SUS pseudoephedrine tan-dexchlorphen tan-dm tan dur-tann forte sus forte pseudoephedrine tan-dexchlorphen tan-dm tan sutan-dm sus pseudoephedrine tan-dexchlorphen tan-dm tan TANAFED DMX SUS pseudoephedrine tannate-carbetapentane tannate PSEUDACARB CHW 75-25MG

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 21 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description pseudoephedrine w/ codeine endacof-dc liq pseudoephedrine w/ codeine NUCOFED CAP pseudoephedrine w/ codeine-gg AMBIFED CD TAB pseudoephedrine w/ codeine-gg AMBIFED CDX TAB pseudoephedrine w/ codeine-gg AMBIFED-G CD TAB pseudoephedrine w/ codeine-gg AMBIFED-G CDX TAB CDX pseudoephedrine w/ codeine-gg cheratussin dac sol dac pseudoephedrine w/ codeine-gg LORTUSS EX LIQ pseudoephedrine w/ codeine-gg MAXIFED CD TAB pseudoephedrine w/ codeine-gg MAXIFED CDX TAB pseudoephedrine w/ codeine-gg MAXIFED-G CD TAB pseudoephedrine w/ codeine-gg MAXIFED-G CDX TAB CDX pseudoephedrine w/ codeine-gg TUSNEL PED-C SYP pseudoephedrine w/ codeine-gg ZODRYL DEC 50 SUS pseudoephedrine w/ codeine-gg ZODRYL DEC 60 SUS pseudoephedrine w/ codeine-gg ZODRYL DEC 80 SUS pseudoephedrine w/ codeine-gg Z-TUSS E LIQ pseudoephedrine w/ dm-gg ALDEX GS DM TAB pseudoephedrine w/ dm-gg ambi 60pse/400gfn/20dm tab /20dm pseudoephedrine w/ dm-gg DONATUSS XP SUS pseudoephedrine w/ dm-gg DONATUSSIN DM SYP DM pseudoephedrine w/ dm-gg pseudo cough liq pseudoephedrine w/ dm-gg PSEUDOEPHEDRINE/DM/GUAIFENESIN SYP 40-15-10 pseudoephedrine w/ dm-gg RU-TUSS DM SYP pseudoephedrine w/ dm-gg sudatex-dm tab pseudoephedrine w/ dm-gg tl-dex dm liq pseudoephedrine w/ dm-gg TRISPEC PSE LIQ pseudoephedrine w/ dm-gg TUSNEL LIQ pseudoephedrine w/ dm-gg TUSNEL PEDIATRIC LIQ pseudoephedrine w/ dm-gg TUSNEL-DM PEDIATRIC LIQ PEDI DRO pseudoephedrine w/ dm-gg TUSNEL-DM PEDIATRIC LIQ PEDI DRO pseudoephedrine w/ dm-gg Z-COF 8DM SUS pseudoephedrine w/ dm-gg Z-COF I SUS pseudoephedrine w/ hydrocodone REZIRA SOL 60-5/5ML 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-gg bromhist-dm pediatric syp ped pseudoephedrine-carbetapentane-guaifenesin EXALL-D LIQ pseudoephedrine-chlorphen-dm ACCUHIST PDX DRO pseudoephedrine-chlorphen-dm HDC DM SYP pseudoephedrine-chlorphen-dm mesehist dm liq pseudoephedrine-chlorphen-dm TUSSAFED LIQ pseudoephedrine-chlorpheniramine w/ dm-gg NEOTUSS-D LIQ pseudoephedrine-chlorpheniramine-dihydrocodeine DIHYDRO-CP SYP pseudoephedrine-codeine-guaifenesin-acetaminophen MAXIFLU CD TAB pseudoephedrine-codeine-guaifenesin-acetaminophen MAXIFLU CDX TAB pseudoephedrine-dexbrompheniramine w/ dm-gg DEKA LIQ pseudoephedrine-dihydrocodeine-guaifenesin DESPEC-EXP SYP pseudoephedrine-dm-gg w/ apap DURAFLU TAB pseudoephedrine-dm-gg w/ apap MAXIFLU DM TAB pseudoephedrine-dm-gg w/ apap MAXIFLU-G TAB pseudoephedrine-guaifenesin ALDEX GS TAB 30-190MG pseudoephedrine-guaifenesin ambi 40pse/400gfn tab 400gfn

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 22 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description pseudoephedrine-guaifenesin ambi 60/580 tab pseudoephedrine-guaifenesin maxifed tab 60-400mg pseudoephedrine-guaifenesin PSEUDOEPHEDRINE/GUAIFENES IN 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 DRO 5-10MG/M 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 pseudoeph-triprolidine w/ cod POLY HIST NC LIQ pseudoeph-triprolidine-dm PEDIATEX TDM SUS pyrilamine maleate PYRILAMINE MALEATE POW MALEATE pyrilamine maleate-phenylephrine hcl tannate DECONSAL CT CHW 16-10MG pyrilamine maleate-phenylephrine hcl tannate pyril d sus 16-5mg/5 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 quazepam DORAL TAB 15MG ROZEREM TAB 8MG hcl ULTIVA INJ 1MG remifentanil hcl ULTIVA INJ 2MG remifentanil hcl ULTIVA INJ 5MG rilonacept ARCALYST INJ 220MG rizatriptan benzoate MAXALT TAB 10MG rizatriptan benzoate MAXALT TAB 5MG rizatriptan benzoate MAXALT-MLT TAB 10MG rizatriptan benzoate MAXALT-MLT TAB 5MG salicylamide (bulk) SALICYLAMIDE POW sapropterin dihydrochloride KUVAN TAB 100MG secobarbital sodium SECONAL CAP 100MG sevoflurane ULTANE SOL sildenafil citrate VIAGRA TAB 100MG sildenafil citrate VIAGRA TAB 25MG sildenafil citrate VIAGRA TAB 50MG somatropin GENOTROPIN INJ 12MG somatropin GENOTROPIN INJ 5MG somatropin GENOTROPIN MINIQUICK INJ 0.2MG somatropin GENOTROPIN MINIQUICK INJ 0.4MG somatropin GENOTROPIN MINIQUICK INJ 0.6MG somatropin GENOTROPIN MINIQUICK INJ 0.8MG somatropin GENOTROPIN MINIQUICK INJ 1.2MG somatropin GENOTROPIN MINIQUICK INJ 1.4MG somatropin GENOTROPIN MINIQUICK INJ 1.6MG somatropin GENOTROPIN MINIQUICK INJ 1.8MG somatropin GENOTROPIN MINIQUICK INJ 1MG somatropin GENOTROPIN MINIQUICK INJ 2MG

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 23 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description 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 NUSPIN 5 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 (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 citrate sufentanil citrate inj 50mcg/ml sufentanil citrate sufentanil citrate inj 50mcg/ml sufentanil citrate (bulk) SUFENTANIL CITRATE POW CITRATE sumatriptan SUMATRIPTAN SPR 20MG/ACT sumatriptan SUMATRIPTAN SPR 5MG/ACT sumatriptan succinate ALSUMA KIT 6MG/0.5 sumatriptan succinate IMITREX STATDOSE SYSTEM KIT 4MG/0.5 sumatriptan succinate SUMATRIPTAN SUCCINATE INJ 4MG/0.5 sumatriptan succinate sumatriptan succinate inj 4mg/0.5 sumatriptan succinate sumatriptan succinate inj 6mg/0.5 sumatriptan succinate sumatriptan succinate inj 6mg/0.5 sumatriptan succinate SUMATRIPTAN SUCCINATE KIT 6MG/0.5 sumatriptan succinate SUMATRIPTAN SUCCINATE REFILL KIT 4MG/0.5 sumatriptan succinate SUMATRIPTAN SUCCINATE REFILL KIT 6MG/0.5 sumatriptan succinate sumatriptan succinate tab 100mg sumatriptan succinate sumatriptan succinate tab 25mg sumatriptan succinate sumatriptan succinate tab 50mg sumatriptan succinate SUMAVEL DOSEPRO INJ 6MG/0.5 sumatriptan- sodium TREXIMET TAB 85-500MG tadalafil CIALIS TAB 10MG tadalafil CIALIS TAB 2.5MG tadalafil CIALIS TAB 20MG tadalafil CIALIS TAB 5MG 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 24 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description tapentadol hcl NUCYNTA TAB 75MG temazepam temazepam cap 15mg temazepam temazepam cap 22.5mg temazepam temazepam cap 30mg temazepam temazepam cap 7.5mg temazepam-dietary management product STRAZEPAM PAK tesamorelin acetate EGRIFTA INJ 1MG tocilizumab ACTEMRA INJ 162/0.9 tocilizumab ACTEMRA INJ 200/10ML tocilizumab ACTEMRA INJ 400/20ML tocilizumab ACTEMRA INJ 80MG/4ML 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 TRAMADOL HCL ER CAP 150MG ER tramadol hcl tramadol hcl er tab 100mg er tramadol hcl tramadol hcl er tab 200mg er tramadol hcl tramadol hcl tab 50mg tramadol hcl ULTRAM ER TAB 300MG tramadol hcl (bulk) TRAMADOL HCL POW tramadol hcl-dietary management product THERATRAMADOL-60 PAK -60 tramadol-acetaminophen tramadol hydrochloride/acetaminophen tab 37.5-325 triazolam triazolam tab 0.125mg triazolam triazolam tab 0.25mg trimeprazine tartrate (bulk) TRIMEPRAZINE TARTRATE POW TARTRATE hcl TRIPELENNAMINE HCL POW triprolidine & pseudoephedrine PEDIATEX TD LIQ triprolidine & pseudoephedrine ZYMINE-D LIQ 1.25-45 triprolidine hcl tripohist liq 1.25/5ml triprolidine hcl (bulk) TRIPROLIDINE HCL CRY triprolidine tannate ZYMINE XR SUS 2.5MG triprolidine tannate-pseudoephedrine tannate ZYMINE DXR SUS 2.5-45MG triprolidine-phenylephrine PROHIST LQ LIQ urofollitropin purified BRAVELLE INJ 75UNIT 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 zaleplon cap 10mg zaleplon zaleplon cap 5mg acetate PRIALT INJ 100MCG ziconotide acetate PRIALT INJ 25MCG/ML 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

Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2013 (ver 4_20131211) Page 25 of 26 Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List

Generic Name Product Description tartrate EDLUAR SUB 10MG zolpidem tartrate EDLUAR SUB 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. Revision date: December 2013 (ver 4_20131211) Page 26 of 26

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