MEDICARE SUPPLEMENT INSURANCE
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1 MEDICARE SUPPLEMENT INSURANCE Declinable drug list for American Retirement Life Insurance Company indicates that the drug will result in a decline. Make sure to list ALL medications on the application. Prescription medications may be used for multiple reasons. ALWAYS determine how the medication is used. Insurability is based on the conditions listed on the actual application. There may be additional medications and conditions not listed that could result in a decline. If the applicant is currently taking, or has recently taken, a medication in this list for a use that is NOT listed on this application, we will REQUIRE a SIGNED and DATED letter from the prescribing physician. This letter MUST state the condition for which the medication is being taken AND must state that the applicant does not have the declinable condition on this list. Failure to include this letter WITH the application may lead to the declination of the application. Please note that the underwriter will make the final determination in all cases. Drug Name Use Exceptions Abacavir AIDS Abatacept Rheumatoid Arthritis Abilify Schizophrenia Acamprosate Calcium Alcoholism Acetate Megace Cancer Aclidinium Bromide COPD Actemra Rheumatoid Arthritis Actigall Cirrhosis, Liver Disease Adalimumab Rheumatoid Arthritis Adriamycin Cancer Afinitor Cancer Agenerase AIDS Aggrastat Angina, Angioplasty Agrylin Myeloproliferative Disorders, Blood Disorders Akineton Parkinson's Disease Alfa Epogen Renal Failure, Dialysis Alkeran Cancer Altretamine Cancer Amantadine Parkinson's Disease Ambenonium Chloride Myasthenia Gravis Amiodarone Irregular Heartbeat CSB MS 1/13
2 Amprenavir AIDS Ampyra Multiple Sclerosis Anagrelide Myeloproliferative Disorders, Blood Disorders Anagrelide HCl Blood Disorder Anagrelide Hydrochloride Myeloproliferative Disorders, Blood Disorders Anastrozole Cancer Anoro Ellipta COPD Antabuse Alcoholism Apokyn Parkinson's Disease Apomorphine HCl Parkinson's Disease Aptivus HIV Aranesp Chronic Renal Failure Arcapta COPD Arformoterol Tartrate COPD Aricept Alzheimer's Disease, Dementia Arimidex Cancer Aripiprazole Schizophrenia Aromasin Cancer Arsenic Trioxide Leukemia Artane Parkinson's Disease Asenapine Bipolar Disorder, Schizophrenia Atripla AIDS Atrovent COPD (Nasal Spray OK for Allergies) Avastin Cancer Avonex Multiple Sclerosis Axona Alzheimer's Disease, Dementia Azasan Rheumatoid Arthritis Azathioprine Rheumatoid Arthritis Azilect Parkinson's Disease AZT AIDS Baclofen Multiple Sclerosis (OK for Restless Leg Syndrome) Bendopa Parkinson's Disease Benztropine Mesylate Parkinson's Disease Betaseron Multiple Sclerosis Bevacizumab Cancer Bicalutamide Oral Cancer BiDil Congestive Heart Failure CSB MS 2/13
3 Biperiden Hydrochloride Parkinson's Disease Blenoxane Cancer Bleomycin Cancer Boceprevir Hepatitis C Bortezomib Multiple Myeloma, Lymphoma Breo COPD Bromide Spiriva COPD Bromocriptine Parkinson's Disease (OK for Restless Leg Syndrome) Brovana COPD Buprenorphine Opioid Dependence Busulfan Cancer Busulfex Cancer Calcitriol Renal Failure, Dialysis Campral Alcoholism Capecitabine Cancer Caprylidene Alzheimer's Disease, Dementia Carbex Parkinson's Disease Carbidopa Parkinson's Disease Casodex Cancer Cellcept Rheumatoid Arthritis Cerefolin Alzheimer's Disease, Dementia Certolizumab Pegol Rheumatoid Arthritis Chlorambucil Cancer Chlorotianisene Cancer Chlorotrianisene Cancer Chlorpromazine Bipolar Disorder, Schizophrenia Cilostazol Peripheral Vascular Disease Cimzia Rheumatoid Arthritis Cisplatin Cancer Cogentin Parkinson's Disease Cognex Alzheimer's Disease, Dementia Combivent COPD Comtan Parkinson's Disease Copaxone Multiple Sclerosis Cordarone Irregular Heartbeat Cortef Addison s disease Corvert Atrial Fibrillation Creon Disease of the Pancreas Crixivan AIDS CSB MS 3/13
4 Cyclophosphamide Cancer Cyclosporine Immunosuppressant Cycrimine Parkinson's Disease Cycrimine Hydrochloride Parkinson's Disease Cytoxan Cancer D4T AIDS Dalfampridine Multiple Sclerosis Daliresp COPD Dantrium Multiple Sclerosis Dantrolene Multiple Sclerosis Darbepoetin Alfa Chronic Renal Failure Deapril Dementia Delavirdine AIDS Depade Alcoholism, Opioid Dependence Depakote Bipolar Disorder (OK for migraines and epilepsy) Depen Rheumatoid Arthritis Dialyvite Renal Failure, Dialysis Didanosine AIDS Digitek Atrial Fibrillation Digoxin Atrial Fibrillation Dilaudid Opioid Analgesic Dipyridamole Heart Valve Replacement Disoproxil Fumarate AIDS Disopyramide Phosphate Irregular Heartbeat Disulfiram Alcoholism Dofetilide Atrial Fibrillation Dolophine Opioid Analgesic, Opioid Dependence Donepezil Alzheimer's Disease, Dementia Dopar Parkinson's Disease Doxorubicin Cancer Dronedarone Atrial Fibrillation Duoneb COPD Duragesic Opioid Analgesic Duvadilan Peripheral Vascular Disease Edrophonium Chlorides Myasthenia Gravis Efavirenz AIDS Effient Angioplasty, Stent Eldepryl Parkinson's Disease Eligard Cancer CSB MS 4/13
5 Emcyt Cancer Emtricitabine AIDS Emtriva AIDS Enfolast Alzheimer's Disease, Dementia Entacapone Parkinson's Disease Epivir AIDS Epoetin Renal FaIlure, Dialysis Epogen Renal Failure, Dialysis Ergamisol Cancer Ergoloid Mesylates Memory Loss, Dementia Erlotinib Cancer Eskalith Bipolar Disorder, Schizophrenia Estinyl Cancer (OK for other uses) Estramustine Cancer Etaposide Cancer Etophopos Cancer Etravirine HIV Eulexin Cancer Everolimus Cancer Exelon Alzheimer's Disease, Dementia Exemestane Cancer Fareston Cancer Faslodex Cancer Femara Cancer Fentanyl Opioid Analgesic Filgrastim Cancer Filgratim Cancer Fingolimod Multiple Sclerosis Flecainide Atrial Fibrillation Fluphenazine Hydrochloride Schizophrenia Flutamide Cancer Forteo Osteoporosis with fractures Fortovase AIDS Foscarnet AIDS Foscavir AIDS Fulvestrant Cancer Gablofen Multiple Sclerosis (OK for Restless Leg Syndrome) Galantamine Alzheimer's Disease, Dementia Gallium Nitrate Cancer CSB MS 5/13
6 Ganite Cancer Gemtuzumab Ozogamicin Leukemia Gengraf Rheumatoid Arthritis Gentuzumab Ozogamicin Leukemia Geodon Bipolar Disorder, Schizophrenia Gerimal Dementia Gilenya Multiple Sclerosis Glatiramer Multiple Sclerosis Gleevec Cancer Gold Shots Rheumatoid Arthritis Goserelin Cancer Haldol Schizophrenia Haloperidol Schizophrenia Hecoria Immunosuppressant Herceptin Cancer Hexalen Cancer Histrelin Cancer Hivid AIDS Humira Rheumatoid Arthritis Hydergine Memory Loss, Dementia Hydrea Cancer Hydrochloride Pagitane Parkinson's Disease Hydromorphone Opioid Analgesic Hydroxychloroquine Lupus, Rheumatoid Arthritis (OK for if Rheumatoid Arthritis is not present) Hydroxyurea Cancer, Blood Disorders Hyoscyamine Parkinson's Disease (OK for IBS, colon spasms) Ibutilide Atrial Fibrillation Imatinib Mesylate Cancer Imdur Angina Imuran Rheumatoid Arthritis Incruse Ellipta COPD Indacaterol COPD Indinavir AIDS Infliximab Rheumatoid Arthritis Insulin (Over 50 units per day - All brands and formulations) Diabetes Intelence HIV Interferon Beta - 1a Multiple Sclerosis CSB MS 6/13
7 Interferon Beta-1a Multiple Sclerosis, Cancer Interferon-Alfa Hepatitis C Intron Cancer Invirase AIDS Ipilimumab Melanoma Ipratropium Bromide COPD (Nasal Spray OK for Allergies) Isordil Angina Isosorbide Angina Isosorbide/Hydralazine Congestive Heart Failure Isoxsuprine Peripheral Vascular Disease Kaletra AIDS Kemadrin Parkinson's Disease Kogenate Hemophilia Lamictal Bipolar Disorder Lamivudine AIDS Lamotrigine Bipolar Disorder Lanoxin Atrial Fibrillation Larodopa Parkinson's Disease L-Dopa Parkinson's Disease Lenalidomide Cancer Letrozole Cancer Leucovorin Cancer and Rheumatoid Arthritis Leukeran Cancer Leuprolide Cancer Levamisole Cancer Levodopa Parkinson's Disease Levsin Parkinson's Disease (OK for IBS, colon spasms) Levsinex Parkinson's Disease (OK for IBS, colon spasms) Lioresal Multiple Sclerosis (OK for Restless Leg Syndrome) Lithane Bipolar Disorder, Schizophrenia Lithium Carbonate Bipolar Disorder, Schizophrenia Lithobid Bipolar Disorder, Schizophrenia Lithonate Bipolar Disorder, Schizophrenia Lithotabs Bipolar Disorder, Schizophrenia Lodosyn Parkinson's Disease Lopinavir AIDS Loxapine Schizophrenia Loxitane Schizophrenia Lupron Cancer CSB MS 7/13
8 Lysodren Cancer Matulane Hodgkin s Disease Megace Cancer Megestrol Cancer Megestrol Acetate Cancer Mellaril Schizophrenia Melphalan Cancer Memantine Hydrochloride Alzheimer's Disease, Dementia Mercaptopurine Leukemia, Blood Disorders Mesoridazine Schizophrenia Mestinon Myasthenia Gravis Metanx Diabetes with Peripheral Neuropathy Methadone Opioid Analgesic, Opioid Dependence Methadose Opioid Dependence Methotrexate Rheumatoid Arthritis Mirapex Parkinson's Disease (OK for Restless Leg Syndrome) Mitomycin Cancer Mitotane Cancer Mitoxantrone Multiple Sclerosis, Leukemia Moban Schizophrenia Molindone Schizophrenia Morphine (Includes all brands and formulations) Opioid Analgesic Multaq Atrial Fibrillation Mutamycin Cancer Mycophenolate Mofetil Rheumatoid Arthritis Mycophenolic Acid Organ Transplant Myfortic Organ Transplant Myfortic Organ Transplant Myleran Cancer Mylotarg Leukemia Mytelase Myasthenia Gravis Naloxone Opioid Dependence Naltrexone HCl Alcoholism, Opioid Dependence Namenda Alzheimer's Disease, Dementia Narcan Opioid Dependence Natalizumab Multiple Sclerosis Natrecor Congestive Heart Failure Navane Schizophrenia CSB MS 8/13
9 Nefazadone Bipolar Disorder, Major Depression Nelfinavir AIDS Neoral Rheumatoid Arthritis Neosar Cancer Neostigmine Myasthenia Gravis Nesiritide Congestive Heart Failure Neupogen Cancer Neupro Parkinson's Disease Nevirapine AIDS Nilandron Cancer Niloric Dementia Nilutamide Cancer Nitro Patch Angina Nitro-bid Angina Nitroglycerin Angina Nitrotab Angina Nolvadex Cancer Norpace Irregular Heartbeat Norvir AIDS Novantrone Multiple Sclerosis, Leukemia Olanzapine Schizophrenia Oncovin Cancer, Leukemia Orencia Rheumatoid Arthritis Oxcarbazepine Bipolar Disorder Oxygen Any Condition Pacerol Atrial Fibrillation Pacerone Irregular Heartbeat Pagitane Parkinson's Disease Pancrecarb Disease of the Pancreas Pancrelipase Disease of the Pancreas Papaverine Angina, Irregular Heartbeat, Peripheral Vascular Disease Paracalcitol Renal Failure, Dialysis Parcopa Parkinson's Disease Parlodel Parkinson's Disease (OK for Restless Leg Syndrome) Parsidol Parkinson's Disease Parsitan Parkinson's Disease Pavabid Angina, Irregular Heartbeat, Peripheral Vascular Disease CSB MS 9/13
10 Peginterferon Hepatitis C Pencillamine Rheumatoid Arthritis Pentam 300 AIDS Pentamidine AIDS Pentoxifylline Peripheral Vascular Disease Pergolide Parkinson's Disease (OK for Restless Leg Syndrome) Permax Parkinson's Disease (OK for Restless Leg Syndrome) Perphenazine Schizophrenia Persantine Heart Valve Replacement Plaquenil Lupus, Rheumatoid Arthritis (OK for if Rheumatoid Arthritis is not present) Platinol Cancer Pletal Peripheral Vascular Disease Pramipexole Dihydrochloride Parkinson's Disease (OK for Restless Leg Syndrome) Prasugrel Angioplasty, Stent Procarbazine Hydrochloride Hodgkin s Disease Procrit Renal Failure, Dialysis Procyclidine Hydrochloride Parkinson's Disease Prolixin Schizophrenia Prolixin Schizophrenia Propafenone Atrial Fibrillation Prostigmin Myasthenia Gravis Purinethol Leukemia, Blood Disorders Pyridostigmine Myasthenia Gravis Quetiapine Schizophrenia Quinidine Sulfate Atrial Fibrillation Ranexa Angina Ranolazine Angina Rapamune Organ Transplant Rasagiline Parkinson's Disease Razadyne Alzheimer's Disease, Dementia Razadyne Reminyl Alzheimer's Disease, Dementia Rebif Multiple Sclerosis Remicade Rheumatoid Arthritis Reminyl Alzheimer's Disease, Dementia Renagel Renal Failure, Dialysis Renvela Renal Failure, Dialysis Requip Parkinson's Disease (OK for Restless Leg Syndrome) Rescriptor AIDS Retrovir AIDS CSB MS 10/13
11 Revia Alcoholism, Opioid Dependence Revlimid Cancer Rheumatrex Rheumatoid Arthritis Ribavirin Hepatitis C Rilutek Amyotrophic Lateral Sclerosis Riluzole Amyotrophic Lateral Sclerosis Risperdal Schizophrenia Risperidone Schizophrenia Ritonavir AIDS Rituxan Rheumatoid Arthritis, Non-Hodgkin's Lymphoma Rituximab Rheumatoid Arthritis, Non-Hodgkin's Lymphoma Rivastigmine Alzheimer's Disease, Dementia Roferon HIV Roflumilast COPD Ropinirole Hydrochloride Parkinson's Disease (OK for Restless Leg Syndrome) Rotigotine Parkinson's Disease Rythmol Atrial Fibrillation Sandimmune Organ Transplant Saphris Bipolar Disorder, Schizophrenia Saquinavir AIDS Selegiline Parkinson's Disease Serentil Schizophrenia Seroquel Schizophrenia Serzone Bipolar Disorder, Major Depression Sevelamer Renal Failure, Dialysis Sinemet Parkinson's Disease Sirolimus Organ Transplant Soltamox Cancer Sorbitrate Angina Sotalol Atrial Fibrillation Spiriva COPD Stalevo Parkinson's Disease Stavudine AIDS Stelazine Schizophrenia Steroids COPD Stocrin AIDS Suboxone Opioid Dependence Subutex Opioid Dependence CSB MS 11/13
12 Sustiva AIDS Symadine Parkinson's Disease (OK for use as an anti-infective) Symax Parkinson's Disease (OK for IBS, colon spasms) Symmetrel Parkinson's Disease (OK for use as an anti-infective) TACE Cancer Tacrine Alzheimer's Disease, Dementia Tacrolimus Immunosuppressant Tambocor Atrial Fibrillation Tamoxifen Cancer Tarceva Cancer Tasmar Parkinson's Disease Telaprevir Hepatitis C Temsirolimus Cancer Tenofovir AIDS Tensilon Myasthenia Gravis Teriparatide Osteoporosis with fractures Thalidomide AIDS, Cancer Thioridazine Schizophrenia Thiothixene Schizophrenia Thorazine Bipolar Disorder, Schizophrenia Tikosyn Atrial Fibrillation Tiotropium COPD Tiotropium Bromide COPD Tipranavir HIV Tirofiban Hydrochloride Angina, Angioplasty Tocilizumab Rheumatoid Arthritis Tofacitinib Citrate Rheumatoid Arthritis Tolcapone Parkinson's Disease Toremifene Cancer Torisel Cancer Trastuzumab Cancer Trelstar Cancer Tremin Parkinson's Disease Trental Angioplasty, Peripheral Vascular Disease, Stent Trexall Rheumatoid Arthritis Trexan Alcoholism, Opioid Dependence Trifluoperazine HCl Schizophrenia Trihexane Parkinson's Disease Trihexyphenidyl Parkinson's Disease CSB MS 12/13
13 Trilafon Schizophrenia Trileptal Bipolar Disorder Triptorelin Cancer Trisenox Leukemia Triveen-Cf Alzheimer's Disease, Dementia Tudorza COPD Tumor Necrosis Factor AIDS Tysabri Multiple Sclerosis Umeclidinium Bromide/Vilanterol COPD Urso Cirrhosis, Liver Disease Ursodiol Cirrhosis, Liver Disease Valproic Acid Bipolar Disorder Vantas Cancer Vasodilan Peripheral Vascular Disease Velcade Multiple Myeloma, Lymphoma Videx AIDS Viibryd Major Depression Vilazodone HCL Major Depression Viracept AIDS Viramune AIDS Viread AIDS Wellferon HIV agrid Myeloproliferative Disorders, Blood Disorders eljanz Rheumatoid Arthritis eloda Cancer Yervoy Melanoma Zalcitabine AIDS Zelapar Parkinson's Disease Zemplar Renal Failure, Dialysis Zenpep Disease of the Pancreas Zerit AIDS Ziagen AIDS Zidovudine AIDS Ziprasidone Bipolar Disorder, Schizophrenia Zoladex Cancer Zyprexa Schizophrenia All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including American Retirement Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 215 Cigna. CSB MS 13/13
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