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Kaiser Permanente
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
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 2 of 26
Generic Name Product Description
acetaminophen w/ codeine 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 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/dihydrocodeine bitartrate tab
hydrocod
acetaminophen-caff-dihydrocod TREZIX CAP
acetaminophen-isometheptene-caffeine MIGRALAM CAP
acetaminophen-isometheptene-caffeine PRODRIN TAB
acetaminophen-isometheptene-dichloralphenazone MIDRIN CAP
acetaminophen-magnesium salicylate-
phenyltoloxamine-caffeine CAFGESIC FORTE TAB
acetaminophen-phenyltoloxamine-caffeine FLEXTRA CAP
acetaminophen-salicylamide-phenyltoloxamine DOLOREX CAP
acetaminophen-salicylamide-phenyltoloxamine-
caffeine CAFGESIC CAP
acrivastine & pseudoephedrine SEMPREX-D CAP 8-60MG
alfentanil alfentanil inj 500/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 1 mg/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-dietary management product GABAZOLAMINE PAK
amobarbital sodium AMYTAL SODIUM INJ 500MG
armodafinil NUVIGIL TAB 150MG
armodafinil NUVIGIL TAB 250MG
armodafinil NUVIGIL TAB 50MG
aspirin 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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 3 of 26
Generic Name Product Description
benzonatate benzonatate cap 200mg
benzonatate ZONATUSS CAP 150MG
brompheniramine & 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 ENTRE-B SUS 6-10MG/5
brompheniramine & phenyleph phenylephrine hydrochlori de/brompheniramine
maleate cap 15-12mg
brompheniramine & phenyleph phenylephrine hydrochlori de/brompheniramine
maleate cap 7.5-6mg
brompheniramine & phenyleph VAZOTAB CHW
brompheniramine & pseudoeph ANDEHIST NR SYP 4-45MG/M
brompheniramine & pseudoeph bpm pseudo tab 6-45mg
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 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 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 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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 4 of 26
Generic Name Product Description
brompheniramine-diphenhydramine ALA-HIST TAB 6-25MG
brompheniramine-diphenhydramine-phenylephrine ALA-HIST D TAB 6-25-20
bromphen-pseudoephed-chlorphen-phenyleph-
methscopolamine SYMPAK II MIS
buprenorphine BUTRANS DIS 10MCG/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 sub 2mg
buprenorphine hcl buprenorphine hcl sub 8mg
buprenorphine hcl-naloxone hcl dihydrate SUBOXONE MIS 2-0.5MG
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
buspirone hcl buspirone hcl tab 10mg
buspirone hcl buspirone hcl tab 15mg
buspirone hcl buspirone hcl tab 30mg
buspirone hcl buspirone hcl tab 5mg
buspirone hcl buspirone hcl tab 7.5mg
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 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/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
codeine
butalbital-aspirin-caffeine butalbital/asa/caffeine cap
butalbital-aspirin-caffeine butalbital/aspirin/caffeine tab
butalbital-aspirin-caffeine w/cod 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
carbetapentane citrate-carbetapentane tannate-pe hcl-
pe tan CARBATUSS-12 SUS
carbetapentane citrate-guaifenesin tannate RESPI-TANN G SUS
carbetapentane citrate-pseudoephedrine hcl tannate ALLRES PD SUS
carbetapentane citrate-pseudoephedrine hcl tannate RESPI-TANN CHW
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 5 of 26
Generic Name Product Description
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
carbinoxamine maleate carbinoxamine maleate liq 4mg/5ml
carbinoxamine maleate carbinoxamine maleate tab 4mg
cetirizine hcl cetirizine hcl syp 1mg/ml
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
chlorphen tan & pseudoeph tan DICEL SUS
chlorpheniramine & phenylephrine ACCUHIST DRO 1-2.5MG
chlorpheniramine & phenylephrine CENTERGY DRO 1-2MG/ML
chlorpheniramine & phenylephrine C-PHEN DRO
chlorpheniramine & phenylephrine DALLERGY JR CAP 4-20MG
chlorpheniramine & phenylephrine HISTEX SR TAB 6-15MG
chlorpheniramine & phenylephrine NOHIST TAB 8-20MG
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 cap 12mg ER
chlorpheniramine maleate chlorpheniramine maleate cap 8mg ER
chlorpheniramine maleate CPM CAP 12MG CR
chlorpheniramine maleate tannate PEDIOX-S SUS 4MG/5ML
chlorpheniramine maleate-pseudoephedrine hcl
tannate SUDAL 12 TANNATE CHW 4-30MG
chlorpheniramine mal-phenylephrine hcl-methscop AH-CHEW ULTRA SUS ULTRA
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 6 of 26
Generic Name Product Description
nit tannate
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-carbetapentane tannate TUSTAN 12S SUS
chlorpheniramine tannate-methscopolamine DEXODRYL CHW 2-1.5MG
chlorpheniramine tannate-methscopolamine DEXODRYL SUS
chlorpheniramine tannate-phenylephrine tan-
methscopolamine AH-CHEW ULTRA CHW ULTRA
chlorpheniramine tannate-phenylephrine tan-
methscopolamine REDUR-PCM SUS
chlorpheniramine tannate-phenylephrine tan-
methscopolamine SYMPAK PDX MIS
chlorpheniramine tannate-phenylephrine tannate ALLERX SUS
chlorpheniramine tannate-phenylephrine tannate DALLERGY-JR SUS
chlorpheniramine tannate-phenylephrine tannate ED CHLORPED D SUS D
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-pyrilamine tan-phenylephrine
tan CONAL SUS
chlorpheniramine tan-pyrilamine tan-phenylephrine
tan NALEX-A 12 SUS
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 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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 7 of 26
Generic Name Product Description
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
chlorpheniramine-phenylephrine-methscopolamine phenylephrine cm tab
chlorpheniramine-phenylephrine-methscopolamine RE-DRYLEX JR TAB
chlorpheniramine-phenylephrine-methscopolamine RELCOF DN PE MIS
chlorpheniramine-phenylephrine-methscopolamine RELCOF PE TAB
chlorpheniramine-phenylephrine-methscopolamine RESCON TAB
chlorpheniramine-phenylephrine-methscopolamine &
homeopathic ZINX KIDS SNEEZE KIT
chlorpheniramine-phenyltoloxamine-phenylephrine-
apap NOREL SR TAB
chlorpheniramine-pseudoephedrine & belladonna
alkaloids RESPA-A.R. TAB
chlorpheniramine-pseudoephedrine & homeopathic
product ZINX ALLERGY KIT
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
chlorpheniramine-pseudoephedrine &
methscopolamine RELCOF PSE TAB
chlorpheniramine-pseudoephedrine &
methscopolamine TIME-HIST QD TAB
chlorpheniramine-pseudoephedrine &
methscopolamine VISRX DOSE PACK TAB
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
chlorpheniramine-pyrilamine tan-phenyleph hcl-
phenyleph tan PHENA-S 12 SUS
chlorphen-phenyltolox-pe chlorpheniramine/phenylto loxamine/phenylephrine
liq pe
chlorphen-phenyltolox-pe RHINACON A TAB
chlorphen-pse-atropine-hyoscyamine-scopolamine RU-TUSS TAB
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 8 of 26
Generic Name Product Description
choriogonadotropin alfa OVIDREL INJ
chorionic gonadotropin chorionic gonadotropin inj 10000unt
clemastine fumarate clemastine fumarate syp 0.5/5ml
clemastine fumarate clemastine fumarate tab 2.68mg
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 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
cyproheptadine hcl cyproheptadine hcl syp 2mg/5ml
cyproheptadine hcl cyproheptadine hcl tab 4mg
desloratadine 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
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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 9 of 26
Generic Name Product Description
dextromethorphan 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 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
diazepam (anticonvulsant) DIASTAT PEDIATRIC GEL 2.5M
dihydrocodeine compound SYNALGOS-DC CAP
dihydrocodeine-guaifenesin J-MAX DHC LIQ
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 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
doxylamine succinate DOXYTEX LIQ
doxylamine succinate tannate ALDEX AN SUS
droperidol droperidol inj 2.5mg/ml
eletriptan hydrobromide RELPAX TAB 20MG
eletriptan hydrobromide RELPAX TAB 40MG
ephedrine-guaifenesin BRONCHOLATE SYP 6.25-100
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 10 of 26
Generic Name Product Description
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
eszopiclone LUNESTA TAB 1MG
eszopiclone LUNESTA TAB 2MG
eszopiclone LUNESTA TAB 3MG
fentanyl 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 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 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 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 ONSOLIS MIS 1200MCG
fentanyl citrate ONSOLIS MIS 200MCG
fentanyl citrate ONSOLIS MIS 400MCG
fentanyl citrate ONSOLIS MIS 600MCG
fentanyl citrate ONSOLIS MIS 800MCG
fexofenadine hcl ALLEGRA 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/pseudoephedr ine tab 24 hour
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 11 of 26
Generic Name Product Description
fexofenadine-pseudoephedrine fexofenadine/pseudoephedr ine 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
frovatriptan succinate FROVA TAB 2.5MG
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
hydrocodone polistirex-chlorpheniramine polistirex hydrocodone polistirex/chlorpheniramine polistirex
liq
hydrocodone polistirex-chlorpheniramine polistirex TUSSICAPS CAP 10-8MG
hydrocodone polistirex-chlorpheniramine polistirex TUSSICAPS CAP 5-4MG
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 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 apap
hydrocodone-acetaminophen hydrocodone/acetaminophen tab 10-325mg
hydrocodone-acetaminophen hydrocodone/acetaminophen tab 10-500mg
hydrocodone-acetaminophen hydrocodone/acetaminophen tab 10-650mg
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 12 of 26
Generic Name Product Description
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
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-ibuprofen IBUDONE TAB 10-200MG
hydrocodone-ibuprofen REPREXAIN TAB 2.5-200
hydrocodone-ibuprofen REPREXAIN TAB 5-200MG
hydrocodone-ibuprofen VICOPROFEN TAB
hydromorphone 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 8MG
hydromorphone hcl hydromorphone hcl dosette inj 2mg/ml
hydromorphone hcl hydromorphone hcl inj 1mg/ml
hydromorphone hcl hydromorphone hcl inj 2mg/ml
hydromorphone hcl hydromorphone hcl inj 4mg/ml
hydromorphone hcl hydromorphone hcl inj 500/50ml
hydromorphone hcl hydromorphone hcl sup 3mg
hydromorphone hcl hydromorphone hcl tab 2mg
hydromorphone hcl hydromorphone hcl tab 4mg
hydromorphone hcl hydromorphone hcl tab 8mg
hydromorphone hcl-sodium chloride hydromorphone/sodium chloride inj /nacl
hydroxyzine hcl hydroxyzine hcl inj 25mg/ml
hydroxyzine hcl hydroxyzine hcl inj 50mg/ml
hydroxyzine hcl hydroxyzine hcl syp 10mg/5ml
hydroxyzine hcl hydroxyzine hcl tab 10mg
hydroxyzine hcl hydroxyzine hcl tab 25mg
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 13 of 26
Generic Name Product Description
hydroxyzine hcl hydroxyzine hcl tab 50mg
hydroxyzine pamoate hydroxyzine pamoate cap 100mg
hydroxyzine pamoate hydroxyzine pamoate cap 25mg
hydroxyzine pamoate hydroxyzine pamoate cap 50mg
iodine strong (lugol's) IODINE STRONG SOL STRONG
levocetirizine dihydrochloride levocetirizine dihydrochl oride tab dhcl 5mg
levocetirizine dihydrochloride XYZAL SOL
levorphanol tartrate LEVO DROMORAN INJ 2MG/ML
levorphanol tartrate LEVORPHANOL TARTRATE TAB 2MG
lorazepam lorazepam inj 2mg/ml
lorazepam lorazepam inj 4mg/ml
lorazepam lorazepam intensol con 2mg/ml
lorazepam lorazepam tab 0.5mg
lorazepam lorazepam tab 1mg
lorazepam lorazepam tab 2mg
lutropin alfa LUVERIS INJ 75UNIT
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 25MG/0.5
meperidine hcl DEMEROL INJ 25MG/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 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 w/ promethazine 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
methadone hcl methadone hcl inj 10mg/ml
methadone hcl methadone hcl sol 10mg/5ml
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 14 of 26
Generic Name Product Description
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
midazolam hcl midazolam hcl inj 1mg/ml
midazolam hcl midazolam hcl inj 2mg/2ml
midazolam hcl midazolam hcl inj 5mg/ml
midazolam hcl midazolam hcl syp 2mg/ml
modafinil PROVIGIL TAB 100MG
modafinil PROVIGIL TAB 200MG
morphine sulfate DURAMORPH INJ 0.5MG/ML
morphine sulfate DURAMORPH INJ 1MG/ML
morphine sulfate KADIAN CAP 100MG CR
morphine sulfate KADIAN CAP 10MG CR
morphine sulfate KADIAN CAP 200MG CR
morphine sulfate KADIAN CAP 20MG CR
morphine sulfate KADIAN CAP 30MG CR
morphine sulfate KADIAN CAP 50MG CR
morphine sulfate KADIAN CAP 60MG CR
morphine sulfate KADIAN CAP 80MG CR
morphine sulfate morphine sulfate dilute-a-jet inj 25mg/ml
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 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 2mg/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 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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 15 of 26
Generic Name Product Description
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 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 sulfate 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
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 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 NICOTROL INHALER INH
nicotine NICOTROL NS SPR 10MG/ML
orphenadrine 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
oxycodone hcl DAZIDOX TAB 10MG
oxycodone hcl ETH-OXYDOSE CON 20MG/ML
oxycodone hcl oxycodone hcl cap 5mg
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 16 of 26
Generic Name Product Description
oxycodone hcl oxycodone hcl con 20mg/ml
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
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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 17 of 26
Generic Name Product Description
palifermin KEPIVANCE INJ 6.25MG
pegvisomant SOMAVERT INJ 10MG
pegvisomant SOMAVERT INJ 15MG
pegvisomant SOMAVERT INJ 20MG
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 tannate-
dextromethorphan tannate BROMATAN-DM SUS
phenyleph tannate-bromphen tannate-
dextromethorphan tannate NEO DM SUS
phenyleph tannate-chlorphen tannate-carbetapentane
tannate CARBAPHEN 12 PED SUS
phenyleph tannate-chlorphen tannate-carbetapentane
tannate CARBAPHEN 12 PED SUS
phenyleph tannate-chlorphen tannate-carbetapentane
tannate CARBAPHEN 12 SUS
phenyleph tannate-chlorphen tannate-
dextromethorphan tannate MAXIPHEN ADT TAB
phenyleph tannate-diphenhyd tannate-carbetapentane
tannate D-TANN CT SUS
phenyleph tannate-diphenhyd tannate-carbetapentane
tannate D-TANN CT TAB
phenyleph tannate-diphenhyd tannate-carbetapentane
tannate DYTAN-CD SUS
phenyleph tannate-diphenhyd tannate-
dextromethorphan tannate LIVETAN DM SUS
phenyleph tannate-pyrilamine tannate-carbetapentane
tannate TUSSI-12D S SUS
phenyleph tannate-pyrilamine tannate-carbetapentane
tannate TUSSI-12D TAB 10-40-60
phenyleph tannate-pyrilamine tannate-
dextromethorphan tan ALLANVAN-DM SUS
phenyleph tannate-pyrilamine tannate-
dextromethorphan tan SINADEX 12 SUS
phenyleph tannate-pyrilamine tannate-
dextromethorphan tan VIRATAN-DM CHW 25-30-25
phenyleph-dm-pyril-pot guai-sod cit-citric acid ALBATUSSIN NN LIQ NN
phenyleph-promethazine w/ cod promethazine vc/codeine syp codeine
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 18 of 26
Generic Name Product Description
phenylephrine hcl-dextromethorphan hbr-guaifenesin
tannate TUSSO-XR SUS
phenylephrine tan-carbetapentane tan & homeopathic
product ZINX COLD KIT
phenylephrine tan-dexchlorphenir tan-
dextromethorphan tan DONATUSSIN DM SUS DM
phenylephrine tannate-carbetapentane tannate carb/phenyl-12 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-carbetapentane tannate LEVALL-12 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 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
phenylephrine w/ dm-gg TRITUSS SYP
phenylephrine w/ dm-gg TUSSAFED EX LIQ
phenylephrine w/ dm-gg TUSSI-PRES PEDIATRIC LIQ
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-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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 19 of 26
Generic Name Product Description
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-dextromethorphan-
guaifenesin BROMHIST-PDX SYP
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/phenyleph rine/dm liq 4-10-20
phenylephrine-brompheniramine-guaifenesin DECON-G DRO 2-1-40MG
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-guaifenesin &
homeopathic prod ZINX COUGH KIT
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
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 DH
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 20 of 26
Generic Name Product Description
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 PEDIATRI
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 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-chlorpheniramine w/
carbetapentane
QUAD-TUSS TANNATE PEDIATR IC SUS
TANN/PED
phenylephrine-ephedrine-chlorpheniramine w/
carbetapentane RYNATUSS TAB
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 dro 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-chlorpheniramine-
methscopolamine SYMPAK MIS
phenylephrine-methscopolamine EXTENDRYL PEM TAB
phenylephrine-pyrilamine w/cod PRO-RED AC SYP
phenylephrine-pyrilamine w/cod ZOTEX-C SYP
phenylephrine-pyrilamine-dihydrocodeine POLY HIST DHC LIQ
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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 21 of 26
Generic Name Product Description
phenyltoloxamine-acetaminophen BP POLY-650 TAB
phenyltoloxamine-acetaminophen DOLOGESIC LIQ 30-500MG
phenyltoloxamine-acetaminophen RELAGESIC LIQ 5-160MG
phenyltoloxamine-acetaminophen RELAGESIC TAB 50-650MG
phenyltoloxamine-acetaminophen RHINOFLEX TAB 50-500MG
phenyltoloxamine-acetaminophen STAFLEX TAB 55-500MG
phenyltoloxamine-acetaminophen ZGESIC TAB 66-600MG
potassium guaiacolsulfonate YODEFAN-NF LIQ 300MG/5
promethazine & phenylephrine promethazine vc plain syp plain
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/dextromethor phan syp dm
propoxyphene hcl propoxyphene hcl cap 65mg
propoxyphene hcl w/ acetaminophen propoxyphene/acetaminophen tab 65-650mg
propoxyphene napsylate DARVON-N TAB 100MG
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
pseudoeph-chlorphen w/ cod ZODRYL DAC 60 SUS
pseudoeph-chlorphen w/ cod ZODRYL DAC 80 SUS
pseudoephed hcl-chlorphen mal-dm hbr tannate chlorpheniramine/pseudo/dm tannate sus
pseudoephed-bromphen-dm ALLANHIST PDX DRO
pseudoephed-bromphen-dm ANDEHIST DM NR SYP
pseudoephed-bromphen-dm BROMFED DM SYP
pseudoephed-bromphen-dm BROVEX PSB DM LIQ
pseudoephed-bromphen-dm BROVEX PSE DM TAB
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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 22 of 26
Generic Name Product Description
pseudoephed-bromphen-dm TGQ 50PSE/3BRM/30DM SYP
pseudoephed-methscop & chlorphen-phenyleph-
methscop ALLERX DOSE PACK MIS
pseudoephedrine hcl-dextromethorphan hbr-
guaifenesin tannate Z-COF 12DM SUS
pseudoephedrine tan-bromphen tan-
dextromethorphan tan ANAPLEX DMX SUS
pseudoephedrine tan-chlorphen tan-
dextromethorphan tan DICEL DM SUS
pseudoephedrine tan-dexchlorphen tan-
dextromethorphan tan DUR-TANN FORTE SUS
pseudoephedrine tan-dexchlorphen tan-
dextromethorphan tan SUTAN-DM SUS
pseudoephedrine tan-dexchlorphen tan-
dextromethorphan tan TANAFED DMX SUS
pseudoephedrine tannate-carbetapentane tannate PSEUDACARB CHW 75-25MG
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
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/ dm-gg ALDEX GS DM TAB
pseudoephedrine w/ dm-gg AMBI 60PSE/400GFN/20DM TAB
pseudoephedrine w/ dm-gg DONATUSS XP SUS
pseudoephedrine w/ dm-gg DONATUSSIN DM SYP
pseudoephedrine w/ dm-gg pseudo cough liq
pseudoephedrine w/ dm-gg pseudoephedrine/dextromethorphan/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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 23 of 26
Generic Name Product Description
pseudoephedrine w/ dm-gg TUSNEL-DM PEDIATRIC LIQ DRO
pseudoephedrine w/ dm-gg Z-COF 8DM SUS
pseudoephedrine w/ dm-gg Z-COF I SUS
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
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
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
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-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-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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 24 of 26
Generic Name Product Description
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
ramelteon ROZEREM TAB 8MG
remifentanil hcl ULTIVA INJ 1MG
remifentanil hcl ULTIVA INJ 2MG
remifentanil hcl ULTIVA INJ 5MG
rizatriptan benzoate MAXALT TAB 10MG
rizatriptan benzoate MAXALT TAB 5MG
rizatriptan benzoate MAXALT-MLT TAB 10MG
rizatriptan benzoate MAXALT-MLT TAB 5MG
secobarbital sodium SECONAL CAP 100MG
somatropin GENOTROPIN INJ 12MG
somatropin GENOTROPIN INJ 5MG
somatropin GENOTROPIN MINIQUICK INJ 0.2MG
somatropin GENOTROPIN MINIQUICK INJ 0.4MG
somatropin GENOTROPIN MINIQUICK INJ 0.6MG
somatropin GENOTROPIN MINIQUICK INJ 0.8MG
somatropin GENOTROPIN MINIQUICK INJ 1.2MG
somatropin GENOTROPIN MINIQUICK INJ 1.4MG
somatropin GENOTROPIN MINIQUICK INJ 1.6MG
somatropin GENOTROPIN MINIQUICK INJ 1.8MG
somatropin GENOTROPIN MINIQUICK INJ 1MG
somatropin GENOTROPIN MINIQUICK INJ 2MG
somatropin HUMATROPE COMBO PACK INJ 5MG
somatropin HUMATROPE INJ 12MG
somatropin HUMATROPE INJ 24MG
somatropin HUMATROPE INJ 6MG
somatropin NORDITROPIN CARTRIDGE INJ 15/1.5ML
somatropin NORDITROPIN FLEXPRO INJ 10/1.5ML
somatropin NORDITROPIN FLEXPRO INJ 5/1.5ML
somatropin NORDITROPIN NORDIFLEX PEN INJ 15/1.5ML
somatropin NORDITROPIN NORDIFLEX PEN INJ 30/3ML
somatropin NUTROPIN AQ INJ 10MG/2ML
somatropin NUTROPIN AQ NUSPIN 5 INJ 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
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 25 of 26
Generic Name Product Description
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 8.8MG
somatropin (non-refrigerated) SEROSTIM INJ 6MG
sufentanil citrate sufentanil citrate inj 50mcg/ml
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 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-naproxen sodium TREXIMET TAB 85-500MG
tapentadol hcl NUCYNTA TAB 100MG
tapentadol hcl NUCYNTA TAB 50MG
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
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 tab 100mg
tramadol hcl tramadol hcl ER tab 200mg
tramadol hcl tramadol hcl tab 50mg
tramadol hcl ULTRAM ER TAB 300MG
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
triprolidine & pseudoephedrine PEDIATEX TD LIQ
Kaiser Permanente Mail Order Pharmacy Maintenance Medication Exclusion List
Medications listed are not considered 'Maintenance Drugs' and cannot be provided under the mail order incentive. Revision date: December 2011 Page 26 of 26
Generic Name Product Description
triprolidine & pseudoephedrine ZYMINE-D LIQ 1.25-45
triprolidine hcl TRIPOHIST LIQ 1.25/5ML
triprolidine tannate ZYMINE XR SUS 2.5MG
triprolidine tannate-pseudoephedrine tannate ZYMINE DXR SUS 2.5-45MG
triprolidine-phenylephrine PROHIST LQ LIQ
urofollitropin purified BRAVELLE INJ 75UNIT
varenicline tartrate CHANTIX PAK 0.5& 1MG
varenicline tartrate CHANTIX PAK 1MG
varenicline tartrate CHANTIX TAB 0.5MG
zaleplon zaleplon cap 10mg
zaleplon zaleplon cap 5mg
ziconotide 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
zolpidem 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