Foresters PlanRight Whole Life Insurance

Transcription

1 Foresters PlanRight Whole Life Insurance Premium Rate Table (per 1,000) Product information and premium rates contained in this rate table are for reference purposes only and are subject to state restrictions, variations and eligibility requirements. If there is any discrepancy between premium rates contained in this rate table and the illustration software, the illustration software shall take precedence. Foresters is the trade name and a trademark of The Independent Order of Foresters, a fraternal benefit society, 789 Don Mills Road, Toronto, Ontario, Canada, M3C 1T9 For Producer Use Only US (07/12)

2 Certificate Fees, Modal Factors & Premium Calculations Premium Mode Certificate Fees Modal Factors Monthly PAC Quarterly $36 annually, subject to 0.26 Semi-Annual modal factors 0.51 Annual 1.00 How to calculate modal premium Foresters PlanRight premium calculation a) Find the rate per thousand in the premium rate table... b) Multiply by the face amount per thousand... $ (x) 1 Base premium amount = $ Accidental Death Rider (ADR) premium calculation - Available on PlanRight Only a) Find the rate per thousand in the premium rate table... b) Multiply by the benefit amount per thousand... $ (x) 1 Rider premium amount = $ Total modal premium a) Base premium amount (1)... b) Add the ADR premium (2)... c) Add the annual certificate fee... d) Multiply by the modal factor... Example (+) (+) (x) Total modal premium ($) Foresters PlanRight () monthly premium Male, Non-Tobacco Age: 55 Face amount: $25,000 ADR Amount: $25,000 Foresters PlanRight premium calculation a) Find the rate per thousand in the premium rate table... b) Multiply by the face amount per thousand... $ Base premium amount = $ Accidental Death Rider (ADR) premium calculation - Available on PlanRight Only a) Find the rate per thousand in the premium rate table... $2.25 b) Multiply by the benefit amount per thousand Rider premium amount = $56.25 Total modal premium a) Base premium amount (1)... b) Add the ADR premium (2)... c) Add the annual certificate fee... d) Multiply by the modal factor... $ $56.25 $ Total modal premium = $ Rounded to the nearest penny Certain member benefits are only available to members insured under a certificate with a face amount of $10,000 or more and are subject to eligibility requirements and limitations For Producer Use Only US (07/12)

3 PlanRight Premium Rate Table (per 1,000) - Non-Tobacco Monthly premium rates per $1,000 of coverage, except for: - annual certificate fee Age: 50-80: $2,000* to $35, : $2,000* to $15,000 Age: 50-80: $2,000* to $20, : $2,000* to $10,000 Age: 50-80: $2,000* to $15, : Not Available to Not Available Male Non-Tobacco Female Issue Age Base ADR Base ADR 50 $30.78 $2.00 $47.88 $49.68 $22.80 $1.25 $38.76 $ $32.17 $2.00 $50.74 $52.70 $24.01 $1.25 $39.89 $ $33.56 $2.00 $53.59 $55.73 $25.22 $1.25 $41.02 $ $34.96 $2.00 $56.45 $58.75 $26.44 $1.25 $42.14 $ $36.35 $2.25 $59.30 $61.78 $27.65 $1.25 $43.27 $ $37.74 $2.25 $62.16 $64.80 $28.86 $1.25 $44.40 $ $39.57 $2.25 $65.42 $68.04 $30.28 $1.50 $45.98 $ $41.39 $2.50 $68.69 $71.28 $31.70 $1.50 $47.57 $ $43.22 $2.50 $71.95 $74.52 $33.13 $1.50 $49.15 $ $45.04 $2.75 $75.22 $77.76 $34.55 $1.50 $50.74 $ $46.87 $2.75 $78.48 $81.00 $35.97 $1.75 $52.32 $ $48.83 $3.00 $82.29 $85.75 $37.63 $1.75 $55.21 $ $50.78 $3.00 $86.10 $90.50 $39.30 $1.75 $58.10 $ $52.74 $3.25 $89.90 $95.26 $40.96 $2.00 $61.00 $ $54.69 $3.25 $93.71 $ $42.63 $2.00 $63.89 $ $56.65 $3.50 $97.52 $ $44.29 $2.00 $66.78 $ $60.50 $3.50 $ $ $46.66 $2.25 $70.90 $ $64.36 $3.75 $ $ $49.04 $2.25 $75.01 $ $68.21 $4.00 $ $ $51.41 $2.50 $79.13 $ $72.07 $4.25 $ $ $53.79 $2.50 $83.24 $ $75.92 $4.50 $ $ $56.16 $2.75 $87.36 $ $82.16 $4.75 $ $ $60.74 $2.75 $95.26 $ $88.40 $5.00 $ $ $65.31 $3.00 $ $ $94.64 $5.25 $ $ $69.89 $3.25 $ $ $ $5.50 $ $ $74.46 $3.50 $ $ $ $6.00 $ $ $79.04 $3.75 $ $ $ $6.50 $ $ $86.53 $4.00 $ $ $ $7.00 $ $ $94.02 $4.25 $ $ $ $7.75 $ $ $ $4.75 $ $ $ $9.00 $ $ $ $5.50 $ $ $ $11.00 $ $ $ $6.75 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ *Certain member benefits are only available to members insured under a certificate with a face amount of $10,000 or more and are subject to eligibility requirements and limitations For Producer Use Only US (07/12)

4 PlanRight Premium Rate Table (per 1,000) - Tobacco Monthly premium rates per $1,000 of coverage, except for: - annual certificate fee Age: 50-80: $2,000* to $35, : $2,000* to $15,000 Age: 50-80: $2,000* to $20, : $2,000* to $10,000 Age: 50-80: $2,000* to $15, : Not Available to Not Available Male Tobacco Female Issue Age Base ADR Base ADR 50 $44.03 $2.00 $65.72 $66.00 $36.89 $1.25 $48.36 $ $46.13 $2.00 $70.00 $70.80 $38.33 $1.25 $50.30 $ $48.23 $2.00 $74.28 $75.60 $39.77 $1.25 $52.25 $ $50.32 $2.00 $78.56 $80.40 $41.20 $1.25 $54.19 $ $52.42 $2.25 $82.84 $85.20 $42.64 $1.25 $56.14 $ $54.52 $2.25 $87.12 $90.00 $44.08 $1.25 $58.08 $ $57.30 $2.25 $91.83 $95.04 $46.21 $1.50 $60.03 $ $60.07 $2.50 $96.54 $ $48.34 $1.50 $61.98 $ $62.85 $2.50 $ $ $50.46 $1.50 $63.93 $ $65.62 $2.75 $ $ $52.59 $1.50 $65.88 $ $68.40 $2.75 $ $ $54.72 $1.75 $67.83 $ $72.48 $3.00 $ $ $57.10 $1.75 $71.66 $ $76.56 $3.00 $ $ $59.47 $1.75 $75.50 $ $80.64 $3.25 $ $ $61.85 $2.00 $79.33 $ $84.72 $3.25 $ $ $64.22 $2.00 $83.17 $ $88.80 $3.50 $ $ $66.60 $2.00 $87.00 $ $93.51 $3.50 $ $ $68.69 $2.25 $92.45 $ $98.22 $3.75 $ $ $70.78 $2.25 $97.90 $ $ $4.00 $ $ $72.86 $2.50 $ $ $ $4.25 $ $ $74.95 $2.50 $ $ $ $4.50 $ $ $77.04 $2.75 $ $ $ $4.75 $ $ $83.03 $2.75 $ $ $ $5.00 $ $ $89.02 $3.00 $ $ $ $5.25 $ $ $95.02 $3.25 $ $ $ $5.50 $ $ $ $3.50 $ $ $ $6.00 $ $ $ $3.75 $ $ $ $6.50 $ $ $ $4.00 $ $ $ $7.00 $ $ $ $4.25 $ $ $ $7.75 $ $ $ $4.75 $ $ $ $9.00 $ $ $ $5.50 $ $ $ $11.00 $ $ $ $6.75 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ *Certain member benefits are only available to members insured under a certificate with a face amount of $10,000 or more and are subject to eligibility requirements and limitations For Producer Use Only US (07/12)

5 Foresters PlanRight Whole Life Insurance Medical Reference Guide It is the responsibility of the Underwriting Department to properly evaluate all applicants for insurance coverage. This requires sound, underwriting practices consistent with Foresters philosophy for the selection of risks. In order to provide the best possible service, Foresters Underwriting Team must also rely on the producer to develop complete and accurate information at point of sale. This manual is a guide intended to help the producer understand the probable underwriting action for commonly encountered medical histories. Naturally, the final action on an application is the decision of the Underwriter, based upon the varying circumstances that each particular case may present. It is important to recognize that the underwriting guide is meant as a basis for decision-making, and that other factors, including Foresters Underwriter s judgment, may affect the final decision. This document was prepared for the exclusive use of appointed producers. It is not intended for public distribution, nor is it to be used in any solicitation or marketing of Foresters products. For producer use only. Current as of July 30, The information contained in this guide is general in nature and is subject to the appropriate certificate and rider wording US (07/12)

6 TABLE OF CONTENTS MEDICAL DEFINITIONS... 3 MEDICATION REFERENCE CHART... 8 Drug Combinations Alphabetical Drug List BUILD CHART Pg 2

7 MEDICAL DEFINITIONS The following definitions are provided for the conditions contained in the Medical Questions. Activities of Daily Living (ADLs) Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), Human Immunodeficiency Virus (HIV) Alcohol Abuse/ Addiction Alzheimer s disease Amyotrophic Lateral Sclerosis (ALS) (Lou Gehrig s Disease) Amputation due to Complications of Aneurysm Angina Aricept, Cognex, Donepezil, Exelon, Razadyne, Namenda Basal Cell Skin Activities of daily living (ADLs) are the things we normally do in daily living, including any basic activity we perform, such as feeding ourselves, bathing, dressing, taking medications and toileting. Acquired immune deficiency syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV). This condition progressively reduces the effectiveness of the immune system and leaves individuals susceptible to infections and tumors. Use of alcohol becomes a primary focus, interfering with other activities. When alcohol abuse progresses to alcoholism, also called alcohol addiction or alcohol dependence, alcohol becomes essential to function, including a physical dependence on alcohol, and inability to stop despite severe physical and psychological consequences. Alzheimer's disease is a progressive degenerative disease of the brain resulting in loss of memory, thinking and language skills and behavioral changes. It is the most common cause of dementia. Amyotrophic lateral sclerosis is a form of motor neuron disease. ALS is a progressive, fatal, disease caused by the degeneration of the nerve cells in the central nervous system that control voluntary muscle movement. A complication of diabetic neuropathy in which there is an increased risk of injury to extremities because of loss of sensation. Infections can progress to ulceration which may require surgical removal of the affected extremity. An aneurysm is a localized abnormal dilatation of a blood vessel which if ruptured may lead to death. The most common aneurysm locations are the brain, abdomen, heart, legs, neck and spleen. Pain, discomfort or pressure localized in the chest and caused by insufficient blood supply to the heart muscles. Medications that can be used to treat the symptoms of Alzheimer s or Dementia. A common malignancy of the epidermis usually occurs with chronic sun exposure. Melanoma is a more serious form of skin cancer and is not excluded from Forester s definition of cancer. If assistance is required to perform any ADL s - No coverage Diagnosed, treated or advised to receive treatment within the past Death Within 2 yrs of diagnosis or if it has not been removed - Death Within Death Any current or previous use - No Coverage Death Pg 3

8 Bone Marrow Transplant Brain Tumor Cardiomyopathy Chronic Bronchitis Chronic Hepatitis Chronic Obstructive Pulmonary Disease (COPD) Circulatory Surgery Cirrhosis of the Liver Congestive Heart Failure () A procedure in which bone marrow that is diseased or damaged is replaced with healthy bone marrow. A brain tumor is an abnormal growth of cells within the brain or inside the skull, which can be cancerous or non-cancerous (benign). is a class of diseases in which a group of cells display uncontrolled growth, invasion (intrusion on and destruction of adjacent tissues), and sometimes metastasis (spread to other locations in the body). Cardiomyopathy is a chronic disease of the heart muscle. The muscle is enlarged, thickened and stiffened which leads to deterioration of the function of the heart. People with cardiomyopathy are often at risk of irregular heartbeats or heart failure. See Chronic Obstructive Pulmonary Disease (COPD). Hepatitis implies injury to the liver characterized by the presence of inflammatory cells in the tissue of the organ. The disease may impair liver functions that include, among other things, removal of harmful substances, regulation of blood composition, and production of bile to help digestion. Chronic obstructive pulmonary disease (COPD) or Chronic obstructive lung disease (COLD) is a group of lung diseases characterized by narrowing of the airways leading to a limitation of air flow to and from the lungs. This causes shortness of breath which is generally not reversible and progresses over time. Diseases classified under the heading of COPD include emphysema, chronic bronchitis and bronchiectasis. Circulatory surgery is surgery performed on any of the arteries of the body, including but not limited to coronary arteries, the aorta, arteries in the neck, legs and abdomen. In cirrhosis of the liver scar tissue replaces normal healthy liver tissue which blocks the flow of blood through the organ and inhibits normal liver function. Congestive heart failure () occurs when the pumping action of the heart fails to maintain adequate circulation of blood to the body and causes shortness of breath, swollen feet and ankles and chronic fatigue. Within 2 yrs of diagnosis or if it has not been removed - Death Currently has cancer, or had one or more recurrences or had more than one type of cancer If diagnosis or treatment within 3 years Death Had or diagnosed within - Death Death Death Death Within 2 yrs - Death Death Pg 4

9 Dementia Coma Diagnostic Test Drug Abuse / Addiction Emphysema End-Stage Disease Heart Attack Heart Surgery Home Healthcare Hospice Care Dementia is a general term that describes a group of symptoms such as loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. Coma is a medical emergency in which a person with diabetes mellitus is unconscious due to too much sugar and too little insulin in the blood. A diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease or condition. Drug abuse, also known as substance abuse, involves the repeated and excessive use of chemical substances to achieve a certain effect. These substances may be street or illicit drugs, or may be drugs obtained with a prescription, used for pleasure rather than for medical reasons. Abuse quickly leads to addiction for many drugs. See Chronic Obstructive Pulmonary Disease (COPD). A condition caused by injury, disease, or illness which has resulted in severe and permanent deterioration, indicated by incapacity and complete physical dependency, and for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective. Myocardial infarction (MI) commonly known as a heart attack occurs when the blood supply to part of the heart is interrupted causing some heart cells to die. Heart surgery or cardiac surgery is surgery performed on the heart including heart valves, coronary arteries or any other tissue of the heart. Heart surgery includes angioplasty, stent placement, ablation, pacemaker or implantable cardioverter defibrillator (ICD) insertion. Health care or supportive care provided in the patient s home by licensed healthcare professionals such as Licensed Practical nurses, Registered nurses, Home Care Aids, Social Workers, Physical Therapists, Occupational Therapists, Speech and language pathologists and Dietitians. Hospice care in the United States is a type of care which focuses on the reduction of symptoms for the terminally ill. These symptoms can be physical, emotional, or social in nature. Within 2 yrs - Death Advised to have within the past 12 months and not completed or results unknown No Coverage Diagnosed, treated or advised to receive treatment within the past Death Death Within 2 yrs - Death Within 2 yrs - Death Currently receiving or advised to receive Receiving or advised to receive - No Coverage Pg 5

10 Insulin Shock Kidney Dialysis Kidney Disease Liver Disease Nephropathy/ Neuropathy/ Nursing home, skilled nursing facility, hospital, psychiatric or correctional facility Organ transplant Oxygen Equipment Insulin Shock is a medical emergency in which a person with diabetes mellitus is unconscious due to too much insulin in the blood. Used to provide an artificial replacement for lost kidney function due to kidney or renal failure. Any damage that reduces the functioning of the kidney. Also called renal disease, it may lead to complications such as cardiovascular disease, anemia, and kidney failure. General term for any damage that reduces the functioning of the liver. Kidney disease from long-standing or poorly controlled diabetes. Nerve damage caused by diabetes that leads to numbness and sometimes pain and weakness in the hands, arms, feet, and legs. neuropathy can affect the digestive tract, heart, and genitalia. A nursing home, convalescent home, Skilled Nursing Facility, care home or rest home provides care for residents. Residents include the elderly and younger adults with physical or mental disabilities. Organ transplant is the moving of an organ from one body to another (or from a donor site on the patient's own body), for the purpose of replacing the recipient's damaged or failing organ with a working one from the donor site. Oxygen therapy is the administration of oxygen to prevent hypoxemia (not enough oxygen in the blood). Oxygen delivery systems are classified as stationary, portable, or ambulatory. Oxygen can be administered by nasal cannula, mask, and tent. CPAP machines used for sleep apnea are not considered oxygen equipment. Within 2 yrs - Death Had or advised to have within the past 12 months No Coverage Death Death Within 2 yrs Death Within 2 yrs Death Current resident of any facilities mentioned - No Coverage Within 12 months - Parkinson s Disease Retinopathy/ Nebulizers are not considered oxygen equipment, however if used for COPD, Chronic bronchitis or emphysema the appropriate question should be answered affirmatively. Parkinson's disease is a degenerative disorder of the central nervous system that often impairs motor skills, speech, and other functions. retinopathy is damage to the eye's retina that occurs with long-term or poorly controlled diabetes. Death if able to perform all ADL s, otherwise - No Coverage Within 2 yrs - Death Pg 6

11 Skilled Nursing Care Stroke Systemic Lupus (SLE) Terminal Illness Transient Ischemic Attack (TIA) Wheelchair Use Care or treatment given or supervised by a Registered Nurse. Examples of skilled nursing needs include complex wound dressings, rehabilitation, tube feedings, observation during periods of acute or unstable illness; administration of intravenous fluids and intravenous or intramuscular medications. A stroke is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. Systemic lupus erythematosus (SLE) or lupus is a chronic autoimmune connective tissue disease that can affect any part of the body. SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidneys and nervous system. A condition caused by injury, disease, or illness that would reasonably be expected to cause death within 12 months. A transient ischemic attack (TIA) is caused by the changes in the blood supply to a particular area of the brain resulting in brief neurologic dysfunction that persists, by definition, for less than 24 hours. This is sometimes referred to as a mini-stroke. Use of a wheelchair due to chronic illness, disease or as a result of permanent physical or neurological damage. This does not include occasional or regular use for activities such as shopping, sightseeing or because of arthritis or temporary use post injury or surgery. Currently receiving or advised to receive Within 2 yrs - Death Death Within 2 yrs - Death Pg 7

12 MEDICATION REFERENCE CHART Prescription medications are always changing. Foresters will make every effort to keep this chart current. Please make sure that you regularly go onto our producer website to access the most recent version of this guide. Please note that the lists provided are not exhaustive. Applicants with a history of Congestive Heart Failure () are not eligible for PlanRight, regardless of when diagnosed or treated. Drug Combinations Any applicant who has been prescribed certain combinations of 3 or more medications may not be offered coverage, depending on the drug combinations. There are a few rare 2-drug combinations which could also lead to no coverage. If a client has been prescribed a medication from List A in combination with at least 2 medications from two other Lists (List B, C, or D) at the same time, they may not be eligible for coverage. LIST A LIST B LIST C LIST D ALDACTAZIDE BUMETANIDE ACCUPRIL ACEBUTOLOL HCL ALDACTONE BUMEX ACCURETIC ATENOLOL SPIRONOLACTONE DEMADEX ACEON BETAPACE METOLAZONE DYAZIDE ALTACE BISOPROLOL FUMARATE MYKROX DYRENIUM ATACAND BREVIBLOC ZAROXOLYN EDECRIN AVALIDE BYSTOLIC FUROSEMIDE AVAPRO CARTROL LASIX AZOR CARVEDILOL MAXZIDE BENAZEPRIL HCL COREG MODURETIC 5-50 BENICAR CORGARD SODIUM EDECRIN CAPOTEN CORZIDE TORSEMIDE CAPTOPRIL DIGITEK TRIAMTERENE COZAAR DIGOXIN TRIAMTERENE/HYDROCHLOROTH DIOVAN INDERAL ENALAPRIL MALEATE INDERIDE EXFORGE LABETALOL HCL FOSINOPRIL SODIUM LANOXIN HYZAAR LOPRESSOR LISINOPRIL METOPROLOL SUCCINATE ER LOTENSIN METOPROLOL TARTRATE LOTREL PINDOLOL MAVIK PROPRANOLOL HCL MICARDIS SECTRAL MONOPRIL SOTALOL HCL PRINIVIL TENORMIN QUINAPRIL HCL TOPROL XL RAMIPRIL VISKEN TARKA ZEBETA TEVETEN ZIAC UNIVASC VALTURNA Pg 8

13 Applicants who have diabetic kidney disease (nephropathy) or diabetic nerve/circulatory (neuropathy) disease may be eligible for the death benefit. Any applicant, who is taking medications from the nephropathy list and diabetes list, or medications from the neuropathy list and diabetes list, within the past, may be offered the death benefit. Nephropathy Neuropathy ARANESP CARBAMAZEPINE ACTOPLUS CALCITRIOL CARBATROL ACTOS CALCIUM ACETATE DEPACON AMARYL CARNITOR DEPAKENE AVANDAMET CYSTAGON EPITOL AVANDARYL FOSRENOL GABAPENTIN AVANDIA HECTOROL LAMICTAL DIABETA PHOSLO LAMOTRIGINE DIABINESE RENVELA LYRICA FORTAMET ROCALTROL NEURONTIN GLIPIZIDE SENSIPAR TEGRETOL GLUCOPHAGE ZEMPLAR VALPROIC ACID GLUCOTROL GLYBURIDE GLYNASE HUMALOG HUMULIN ILETIN JANUMET JANUVIA LANTUS LEVEMIR METFORMIN MICRONASE NOVOLIN NOVOLOG PRANDIN STARLIX TOLBUTAMIDE TOLINASE Pg 9

14 Alphabetical Drug List Where medications that can be used for more than one condition exist, the alternate uses and appropriate level of coverage has been indicated. The Rx Fill Within column means the drug was prescribed within the time period noted. For some circulatory/heart and cancer medications, the Rx Fill Within column notes First Fill. This refers to when the medication was originally prescribed. Medication Indication Rx Fill Within Eligibility Abilify Psychotic Disorder Abraxane Accupril Accuretic Acebutolol HCL Aceon Acetyl L-Carnitine Alzheimer s / Dementia Actiq Pain Severe Pain Activase Stroke/TIA/Heart Attack Actoplus Actos Adalat Adriamycin Adrucil Advair Asthma COPD / Emphysema Afinitor Agenerase AIDS Aggrastat Heart Attack Aggrenox Stroke / TIA First Fill <2years First Fill >2 years Agrylin Akineton Parkinson s Other Use Albuterol Asthma COPD Aldactazide Aldactone Aldomat Pg 10

15 Alimta Alkeran Allopurinol Gout Aloxi Alprazolam Anxiety Disorder Altace Amantadine HCL Parkinson s Amaryl Ambisome AIDS Amifostine Amiloride HCL Amlodipine Besylate/Benaz Amyl Nitrate Angina Anagrelide HCL Angiomax Circulatory Surgery Antabuse Alcohol / Drugs Anastrozole First Fill <3years First Fill >3 years Anzemet Aptivus AIDS Apokyn Parkinson s Apresoline Aranesp Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Arcapta Neohaler COPD Aredia Argatroban Circulatory Surgery Aricept Alzheimer s / Dementia Arimidex First Fill <3years First Fill >3 years Aromasin First Fill <3years First Fill >3 years Arranon Pg 11

16 Arsenic Trioxide Arzerra Atacand Atamet Parkinson s Atenolol Atgam Organ / Tissue Transplant Ativan Anxiety Disorder Atripla AIDS Atrovent/Atrovent HFA Atrovent (Nasal) COPD Allergies Avalide Avandia Avapro Avastin Avonex Multiple Sclerosis Azilect Parkinson s Azasan Organ / Tissue Transplant Rheumatoid Arthritis Systemic Lupus Azathioprine Azmacort Azor Organ / Tissue Transplant Rheumatoid Arthritis Systemic Lupus Asthma COPD / Emphysema Baclofen Multiple Sclerosis Baraclude Liver Disorder Benazepril HCL Benicar Benlysta Systemic Lupus Benztropine Mesylate Parkinson s Other Use Betapace Heart Arrhythmia Betaseron Multiple Sclerosis Betaxolol HCL Bexxar Bicnu BiDil Pg 12

17 Bisoprolol Fumarate Blenoxane Bleomycin Sulphate Blocadren Brevibloc Brovana COPD Bromocriptine Mesylate Parkinson s Bumetadine Bumex Buprenex Alcohol / Drugs Busulflex Bystolic Calcijex Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Calcitriol Calcium Acetate Kidney Dialysis Kidney Disease/Failure Nephropathy Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year 1 year Calan Campath Campral Alcohol / Drugs Camptosar Capoten Capozide Captopril Carbamazepine Seizures Neuropathy Carbatrol Seizures Neuropathy Carbidopa Parkinson s Carboplatin Cardioplegic Circulatory Surgery Cardizem Cardura Pg 13

18 Carnitor Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Cartia Cartrol Carvedilol Catapress Casodex CeeNu Celebrex Arthritis Cellcept Organ / Tissue Transplant Cerubidine Cesamet Chlorambucil Chlorpromazine Psychotic Disorder Cisplatin Citalopram Depressive Disorder Cladribine Clolar Clopidogrel Stroke/TIA/Heart Attack First Fill <2years First Fill >2 years Cogentin Parkinson s Other Use Cognex Alzheimer s/dementia Combivent COPD Combivir AIDS Complera AIDS Comtan Parkinson s Copaxone Multiple Sclerosis Copegus Liver Disorder Cordarone Arrythmia Coreg Corgard Corzide Cosmegen Pg 14

19 Coumadin Cozaar Cardiac Valve Replacement TIA/Stroke Pulmonary Embolism Thrombosis Crixivan AIDS Cyclophosphamide Cyclosporine Organ / Tissue Transplant Cyclosporine Organ / Tissue Transplant Cystagon Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Cytarabine Cytogam Organ / Tissue Transplant Cytosar-U Cytovene AIDS Cytoxan Dacarbazine Dacogen Dactinomycin Daliresp COPD Daunorubicin HCL Daunoxome Demadex Depacon Seizures Neuropathy Depade Alcohol / Drugs Depakene Seizures Neuropathy Depakote Seizure Disorder Depocyt Dexrazoxane Diabeta Diabinese Diazoxide Didanosine AIDS Pg 15

20 Digitek Atrial Fibrillation Digoxin Atrial Fibrillation Dilacor Dilantin Seizure Disorder Dilatrate SR Angina Dilor Asthma COPD / Emphysema Diltiazem Diovan Disulfiram Alcohol / Drugs Dolophine Opioid Dependence 1 year Donepezil HCL Alzheimer s / Dementia Doxil Doxorubicin HCL Dronabinol DTIC-Dome Duoneb COPD Dyazide Dynacirc Dyrenium Edecrin Edurant AIDS Eldepryl Parkinson s Eligard Eliphos Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Elitek Ellence Eloxatin Elspar Emcyt Emend Emtriva AIDS Pg 16

21 Enalapril Maleate Enalaprilat Epitol Seizures Neuropathy Epivir AIDS Epizicom AIDS Eplerenone Erbitux Ergoloid Mesylates Alzheimer s / Dementia Eskalith Bipolar Disorder Esmolol HCL Estinyl Ethyol Etopophos Etoposide Eulexin Evista Osteoporosis Exelon Alzheimer s / Dementia Exforge Fareston Faslodex Felodipine Femara First Fill <3years First Fill >3 years Fentanyl Citrate Pain Severe Pain Fentora Pain Severe Pain Floxuridine Fludara Fludarabine Phosphate Fluoxymesterone Flutamide Pg 17

22 Folotyn Fortamet Fortovase AIDS Foscarnet Sodium AIDS Foscavir AIDS Fosinopril Sodium Fosrenol Fortesta FUDR Furosemide Fusilev Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Fuzeon AIDS Gabapentin Seizures Neuropathy Gabitril Seizure Disorder Galantamine Alzheimer s / Dementia Gallium Nitrate Ganciclovir AIDS Ganite Gemzar Gengraf Organ / Tissue Transplant Gleevec Gliadel Wafer Glipizide Glucophage Glucotrol Glyburide Glynase Granisetron HCL Pg 18

23 Granisol Halaven Haldol Psychotic Disorder Haloperidol Psychotic Disorder Halotestin HCTZ HCTZ/Triamterene Hectoral Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Heparin Pulmonary Embolism Thrombosis Hepsera Liver Disorder Herceptin Hexalen Hivid AIDS Humalog Humulin Hycamtin Hydralazine HCL Hydrea Hydroxyurea Hydergine Alzheimer s /Dementia Hydroxychloroquine Systemic Lupus Malaria Rheumatoid Arthritis Hyperstat IV Hytrin Hyzaar Idamycin PFS Idarubicin Ifex Ifex/Mesnex Combo Pack Ifosfamide Pg 19

24 Iletin Angina Organ / Tissue Transplant Rheumatoid Arthritis Systemic Lupus Imdur Imuran Inamrinone Inderal Inderide Infergen Liver Disorder Innopran XL Inspra Insulin Intelence AIDS Intron-A Hepatitis C Invirase AIDS Ipratropium Bromide COPD Allergies Iressa Irinotecan Ismo Angina Isochron Angina Isodax Isoptin Isordil Angina Isosorbide Dinitrate/Mononitrate Angina Ixempra Janumet Januvia Jetvana Kaletra AIDS Parkinson s Kemadrin Other Use Pg 20

25 Kepivance Kerlone Kytril Labetaolol Lamictal Seizures Neuropathy Lamtrogine Seizures Neuropathy Lanoxicaps Atrial Fibrillation Lanoxin Atrial Fibrillation Lantus Lasix Larodopa Parkinson s Leucovorin Calcium Leukeran Leukine Leuprolide Leustatin Levatol Levodopa Parkinson s Levamisole HCL Levemir Levocarnitine Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Lexiva AIDS Lexxel Lipitor Cholesterol Lisinopril Lithium Bipolar Disorder Lodosyn Parkinson s Lopressor Losartan Potassium Lotensin Pg 21

26 Lotrel Loxapine Psychotic Disorder Loxitane Psychotic Disorder Lozol Lupron Lyrica Seizures Neuropathy Lysodren Lytensopril Marinol Matulane Maxzide Mavik Mellaril Psychotic Disorder Melphalan Hydrochloride Mepron AIDS Mercaptopurine Mesna Mesnex Metformin Methadone Opioid Dependence 1 year Methadose Opioid Dependence 1 year Methotrexate Rheumatoid Arthritis Methyldopa Metolazone Metoprolol Tartrate/Succinate Metoprolol HCTZ Mevacor Cholesterol Micardis Micronase Midamor Milrinone Pg 22

27 Minipress Minitran Angina Mirapex Parkinson s Other Use Mithracin Mitomycin Mitoxantrone HCL Moban Psychotic Disorder Moduretic Moexipril HCL Monoket Angina Monopril Mustargen Mutamycin Mycobutin AIDS Myfortic Organ / Tissue Transplant Mykrok Myleran Mylocel Mylotarg Mysoline Seizure Disorder Nadolol Namenda Alzheimer s /Dementia Narcan Alcohol / Drugs Naloxone Alcohol / Drugs Naltrexone Alcohol / Drugs Natrecor Navane Psychotic Disorder Navelbine Nebupent AIDS Neosar Neulasta Neumega Neupro Parkinson s Neurontin Seizures Neuropathy Neutrexin AIDS Pg 23

28 Nexavar Nifedipine Nilandron Nimodipine Stroke/TIA/Aneurysm First Fill <2years First Fill >2 years Nimotop Stroke/TIA/Aneurysm First Fill <2years First Fill >2 years Nipent Nitrek Angina Nitro-bid Angina Nitro-dur Angina Nitroglycerine/Nitrota b/nitroquick/nitrostat Angina Nitrol Angina Nitromist Angina Nolvadex First Fill <3years First Fill >3 years Normodyne Norpace Arrythmia Norvasc Norvir AIDS Novolin Novolog Novanitrone Noxafil Octreotide Acetate Oforta Olanzapine Psychotic Disorder Omontys Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Oncaspar Pg 24

29 Ondansetron Onsolis Pain Severe Pain Ontak Onxol Orthoclone OKT3 Organ / Tissue Transplant Pacerone Arrythmia NA Paclitaxel Pamidronate Disodium Panretin AIDS Paraplatin Parcopa Parkinson s Parlodel Parkinson s Paxil Depressive Disorder Pentam 300 AIDS Pentamidine Isethionate AIDS Pentostatin Pegasys Liver Disorder Peg-Intron Liver Disorder Pepcid Stomach Disorder Pergolide Mesylate Parkinson s Perindopril Erbumine Permax Parkinson s Phenobarbital Seizure Disorder Phoslo Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Photofrin Pindolol Plaquenil Platinol AQ Plavix Systemic Lupus Malaria Rheumatoid Arthritis Stroke/TIA/Heart Attack First Fill <2years First Fill >2 years Plegisol Circulatory Surgery Plenaxis Plendil Prandin Pg 25

30 Pravachol Cholesterol Prazosin Prezista AIDS Primacor Prinivil Prinzide Procardia Prograf Organ / Tissue Transplant Proleukin Prolixin Psychotic Disorder Propanolol HCL Provenge Proventil Asthma COPD / Emphysema Prozac Depressive Disorder Purinethol Quadramet Quetiapine Psychotic Disorder Quinapril Quinaretic Ramipril Ranexa Angina Ranitidine Stomach Disorder Rapamune Organ / Tissue Transplant Razadyne Alzheimer s / Dementia Rebetol Liver Disorder Rebetron Liver Disorder Rebif Multiple Sclerosis Reglan Stomach Disorder Requip Parkinson s Other Use Reminyl Alzheimer s / Dementia Renagel Renvela Kidney Dialysis Kidney Disease/Failure Nephropathy Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year 1 year Rescriptor AIDS Retrovir AIDS Revex Alcohol / Drugs Revia Alcohol / Drugs Revlimid Reyataz AIDS Ribapak Liver Disorder Pg 26

31 Ribasphere Liver Disorder Ribatab Liver Disorder Ribavirin Liver Disorder Rilutek ALS Risperdal Psychotic Disorder Risperidone Psychotic Disorder Rituxan Rheumatoid Arthritis Rivastigmine Tartrate Alzheimer s / Dementia Rocaltrol Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Roferon Ropinirole Rubex Hepatitis C Parkinson s Other Use Rythmol Arrythmia Sancuso Sandimmune Organ / Tissue Transplant Sandostatin Sectral Selegiline HCL Parkinson s Selzentry AIDS Sensipar Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Serevent Asthma COPD / Emphysema Seroquel Psychotic Disorder Simvastatin Cholesterol Simulect Organ / Tissue Transplant Sinemet/Sinemet CR Parkinson s Sodium Edecrin Soltalol Hydrochloride Soltamox First Fill <3years First Fill >3 years Sorine Sotalol HCL Spiriva COPD Spironolactone Pg 27

32 Sprycel Stalevo Parkinson s Starlix Stilphostrol Sublimaze Pain Severe Pain Suboxone Alcohol / Drugs Subutex Alcohol / Drugs Sustiva AIDS Sutent Symbicort Asthma COPD / Emphysema Symmetrel Parkinson s Tabloid Tagamet Stomach Disorder Tambocor Arrythmia Tamoxifen First Fill <3years First Fill >3 years Tarceva Targretin Tarka Tasigna Tasmar Parkinson s Taxol Taxotere Tegretol Seizures Neuropathy Temodar Tenex Tenoretic Tenormin Teslac Teveten Thalomid Theodur Asthma COPD / Emphysema Pg 28

33 Theophylline Asthma COPD / Emphysema Theracys Thioplex Thioridazine Psychotic Disorder Thiotepa Thiothixene Psychotic Disorder Thymoglobulin Organ / Tissue Transplant Thorazine Psychotic Disorder Tiazac Tice BCG Ticlid Stroke/TIA/Heart Attack First Fill <2years First Fill >2 years Tilade Asthma COPD / Emphysema Timolide Timolol Maleate Tolazamide Tolbutamide Tolinase Toposar Topotecan Totect Torisel Torsemide Toprol XL Trandate Trandolapril Treanda Trelstar Tretinoin Pg 29

34 Triamterene Triamterene/HCTZ Tribenzor Trisenox Trihexyphenidyl HCL Parkinson s Other Use Trizivir AIDS Truvada AIDS Twynsta Tykerb Tyzeka Liver Disorder Uniretic Univasc Uvadex Valcyte AIDS Valproic Acid Seizures Neuropathy Valstar Valturna Vascor Angina Vaseretic Vasotec Velcade Ventolin Asthma COPD / Emphysema Vepisid Verapamil Vesanoid Viadur Viaspan Organ / Tissue Transplant Victrelis Liver Disorder Vidaza Videx AIDS Vinblastine Sulfate Vincasar PFS Vincristine Sulfate Pg 30

35 Vinorelbine Tartrate Viracept AIDS Viramune AIDS Viread AIDS Visken Vistide AIDS Vivitrol Alcohol / Drugs Votrient Vumon Warfarin Xeloda Xgeva Xopenex Zanosar Cardiac Valve Replacement TIA/Stroke Pulmonary Embolism Thrombosis Asthma COPD / Emphysema Zantac Stomach Disorder Zaroxolyn Zebeta Zelapar Parkinson s Zenapax Organ / Tissue Transplant Zemplar Kidney Dialysis Kidney Disease/Failure Nephropathy 1 year Zerit AIDS Zestoretic Zestril Zevalin Y-90 Ziac Ziagen AIDS Zidovudine AIDS Zinecard Zocor Cholesterol Zofran Zoladex Pg 31

36 Zolinza Zoloft Depressive Disorder Zometa Zortress Organ / Tissue Transplant Zuplenz Zyprexa Psychotic Disorder Pg 32

37 BUILD CHART As part of the underwriting process, the height and weight of the Proposed Insured is checked to ensure it is within Foresters height and weight guidelines. Insurance will be declined if the Proposed Insured is outside of the minimum or maximum weight for their height, per the chart below. Height Minimum Weight All Plans Max Weight PlanRight Max Weight PlanRight Max Weight PlanRight Pg 33