Supplemental Benef its DECLINABLE DRUG LIST
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1 Supplemental Benef its DECLINABLE DRUG LIST This Declinable Drug List applies to Medicare Supplement Insurance, insured by American Retirement Life Insurance Company and Loyal American Life Insurance Company. Make sure to list ALL medications on the application. 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. Please note that the Underwriter will make the final determination in all cases. *Not Declinable in ID, MI, MN and OR. Drug Name Abatacept Abacavir Abilify Acamprosate Calcium Acetate Megace Actigall Adalimumab Adriamycin Agenerase Agrylin Akineton Alfa Epogen Alkeran Altretamine Amantadine Ambenonium Chloride Amiodarone Amprenavir Anagrelide Hydrocholoride (aka Anagrelide) Anastrozole Antabuse Apokyn Apomorphine HCl Aranesp Arformoterol Tartrate Aricept Arimidex Aripiprazole Aromasin Arsenic Trioxide Artane Asenapine Atrovent Avastin Avonex Axona Azathioprine Azilect Alcoholism Cirrhosis/Liver Disease Blood Disorder Disease Blood Disorder Alcoholism Chronic Renal Failure Luekemia /Bipolar Disorder (Nasal Spray OK for Allergies) CSB MS 1/9 For Agent Only
2 AZT Baclofen Bendopa Benztropine Mesylate Betapace* Betaseron Bevacizumab Bicalutamide Oral Biperiden Hydrochloride Blenoxane Bleomycin Bromide Spiriva Bromocriptine Brovana Buprenorphine Busulfan Campral Capecitabine Carbex Carbidopa Casodex Cellcept Cerefolin Certolizumab Pegol Chlorambucil Chlorotianisene Chlorpromazine Cilostazol Cimzia Cisplatin Cogentin Cognex Combivent Comtan Copaxone Cordarone* Cortef Corvert* Crixivan Cyclophosphamide Cyclosporine Cycrimine Cycrimine Hydrochloride Cytoxan (OK for Restless Leg Syndrome) Prostate (OK for Restless Leg Syndrome) Opiate Addiction Alcoholism Colon/Breast Prostate Dementia and disease Peripheral Vascular Disease Disease Addison s disease CSB MS 2/9 For Agent Only
3 D4T Dantrium Dantrolene Darbepoetin Alfa Deapril Delavirdine Depade Depakote Didanosine Digoxin* Dilaudid Disulfiram Dofetilide* Dolophine Donepezil Dopar Doxorubicin Dronedarone* Duoneb Edrophonium Chlorides Efavirenz Effient Eldepryl Eligard Emcyt Enfolast Entacapone Epivir Epoetin Epogen Ergamisol Ergoloid Mesylates Erlotinib Eskalith Estinyl Estramustine Etravirine Eulexin Exelon Exemestane Fareston Faslodex Femara Fentanyl Chronic Renal Failure Dementia Alcoholism / Opioid Dependence Bipolar Disorder (OK for migraines and epilepsy) Narcotic Analgesic Alcoholism Narcotic Angioplasty Dementia and disease Disease Memory Loss/Dementia Psychosis/Depression (other use is ok) HIV Narcotic Analgesic CSB MS 3/9 For Agent Only
4 Filgratim Flecainide* Fluphenazine Hydrochloride Flutamide Forteo Fortovase Foscarnet Foscavir Fulvestrant Galantamine Gallium Nitrate Ganite Gemtuzumab Ozogamicin Gengraf Geodon Gerimal Glatiramer Gleevec Gold Shots Goserelin Haldol Haloperidol Herceptin Hexalen Histrelin Hivid Humira Hydergine Hydrea Hydrochloride Pagitane Hydromorphone Hydroxychloroquine Hydroxyurea Hyoscyamine Ibutilide* Imatinib Mesylate Imdur Imuran Indinavir Infliximab Insulin (Over 50 units per day - All brands and formulations) (Any amount in ID, MI, MN and OR) Intelence Interferon Beta - 1a Psychosis/Depression Osteoporosis with fractures Leukemia Immunosuppresant Dementia Breast Prostate Memory Loss/Dementia Disease Narcotic Analgesic Systemic Lupus/Connective Tissue Disease and Blood Disorders (OK for IBS, colon spasms) Diabetes HIV CSB MS 4/9 For Agent Only
5 Intron Invirase Ipratropium Bromide Isordil Isosorbide Kaletra Kemadrin Kogenate Lamictal Lamivudine Lamotrigine Lanoxin* Larodopa L-Dopa Letrozole Leucovorin Leukeran Leuprolide Levamisole Levodopa Levsin Levsinex Lioresal Lithium Lodosyn Lopinavir Loxapine Loxitane Lupron Megace Megestrol Megestrol Acetate Mellaril Melphalan Memantine Hydrochloride Mesoridazine Mestinon Metanx Methadone Methadose Methotrexate Mirapex Mitomycin Mitoxantrone (Nasal Spray OK for Allergies) Heart, Heart Hemophilia Bipolar Disorder Bipolar Disorder and Prostate Disease (OK for IBS, colon spasms) (OK for IBS, colon spasms) (OK for Restless Leg Syndrome) Psychosis/Depression Prostate Diabetes with Peripheral Neuropathy Narcotic Narcotic (OK for Restless Leg Syndrome) / Leukemia CSB MS 5/9 For Agent Only
6 Moban Molindone Morphine (Includes all brands and formulations) Multaq* Mutamycin Mycophenolate Mofetil Myleran Mylotarg Mytelase Naloxone Naltrexone HCl Namenda Narcan Natalizumab Navane Nefazadone Nelfinavir Neoral Neosar Neostigmine Neupogen Neupro Nevirapine Nilandron Niloric Nilutamide Nitro Patch Nitro-bid Nitroglycerin Nitrotab Norvir Novantrone Olanzapine Orencia Oxcarbazepine Oxygen Pacerol* Pagitane Pancrecarb Pancrelipase Parcopa Parlodel Parsidol Parsitan Narcotic Analgesic Leukemia Opiate Addiction Alcoholism / Narcotic Dependence Opiate Addiction Major Depression/Bipolar Disorder Immunosuppresant Dementia / Leukemia Bipolar Any condition Disease of the Pancreas Disease of the Pancreas Disease (OK for Restless Leg Syndrome) CSB MS 6/9 For Agent Only
7 Pentam 300 Pentamidine Pentoxifylline Pergolide Permax Perphenazine Plaquenil Platinol Pletal Pramipexole Dihydrochloride Prasugrel Procrit Procyclidine Hydrochloride Prolixin Propafenone* Prostigmin Pyridostigmine Quetiapine Quinidine* Ranexa Ranolazine Rapamune Rasagiline Razadyne Razadyne Reminyl Rebif Remicade Reminyl Renagel Renvela Requip Rescriptor Retrovir Revia Rheumatrex Rilutek Riluzole Risperdal Risperidone Ritonavir Rituxan Rituximab Rivastigmine Roferon Peripheral Vascular Disease (OK for Restless Leg Syndrome) (OK for Restless Leg Syndrome) Systemic Lupus/Connective Tissue Disease Peripheral Vascular Disease (OK for Restless Leg Syndrome) Angioplasty Psychosis/Depression Immunosuppresant (OK for Restless Leg Syndrome) Alcoholism / Opioid Dependence ALS ALS / Non-Hodgkin's Lymphoma / Non-Hodgkin's Lymphoma CSB MS 7/9 For Agent Only HIV
8 Ropinirole Hydrochloride Rotigotine Rythmol* Sandimmune Saphris Saquinavir Selegiline Serentil Serlect Seroquel Serzone Sevelamer Sinemet Sirolimus Sorbitrate Sotalol* Spiriva Stalevo Stavudine Stelazine Steroids Stocrin Suboxone Subutex Sustiva Symadine Symax Symmetrel TACE Tacrine Tambocor* Tarceva Tasmar Tenofovir Tensilon Teriparatide Tetrabenazine Thalidomid T Thalidomide Thioridazine Thiothixene Thorazine Tikosyn* Tiotropium (OK for Restless Leg Syndrome) /Bipolar Disorder Major Depression/Bipolar Disorder Immunosuppresant Narcotic Dependence Opiate Addiction (OK for antifective) (Ok for IBS, colon spasms) (OK for antifective) Disease Osteoporosis with fractures Huntington s Disease, Leprosy,, Leprosy, CSB MS 8/9 For Agent Only
9 Drug Name Tiotropium Bromide Tofacitinib Citrate Tolcapone Toremifene Trastuzumab Breast Trelstar Tremin Trental Peripheral Vascular Disease Trexall Trifluoperazine HCl Trihexyphenidyl Trilafon Trileptal Bipolar Triptorelin Trisenox Luekemia Triveen-Cf Dementia and Tumor Tumor Necrosis Factor Tysabri Urso Cirrhosis/Liver Disease Ursodiol Cirrhosis/Liver Disease Valproic Acid Bipolar Disorder Vantas Prostate Videx Viibryd Major Depression Vilazodone HCL Major Depression Viracept Viramune Viread Wellferon HIV Xagrid Blood Disorder Xeljanz Xeloda Colon/Breast Xenazine Huntington s Disease Zalcitabine Zelapar Zerit Ziagen Zidovudine Ziprasidone Zoladex Zyprexa CSB MS 9/9 For Agent Only
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