supplemental Benefits DECLINABLE DRUG LIST
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1 supplemental Benefits DECLINABLE DRUG LIST This Declinable Drug List applies to Medicare Supplement Insurance insured by American Retirement Life Insurance Company. Always determine how the medication is used. Prescription medications may be used for multiple reasons. Insurability is based on the conditions listed on the actual application. There may be additional medications (conditions) not listed that could result in a decline. Make sure to list all medications on the application. Our Underwriting Department will have the final determination in all cases. 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 AZT Alcoholism Cirrhosis/Liver Disease Blood Disorder Disease Blood Disorder Alcoholism Chronic Renal Failure Luekemia /Bipolar Disorder (Nasal Spray OK for Allergies) CSB ARLIC 1/9 For Agent Only
2 Baclofen Bendopa Benztropine Mesylate Betapace Betaseron Bevacizumab Bicalutamide Oral Biperiden Hydrochloride Blenoxane Bleomycin Bromide Spiriva Bromocriptine Brovana 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 D4T Dantrium (OK for Restless Leg Syndrome) Prostate (OK for Restless Leg Syndrome) Alcoholism Colon/Breast Prostate Dementia and disease Peripheral Vascular Disease Disease Addison s disease CSB ARLIC 2/9 For Agent Only
3 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 Eulexin Exelon Exemestane Fareston Faslodex Femara Fentanyl Filgratim Flecainide Fluphenazine Hydrochloride 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) Narcotic Analgesic Psychosis/Depression CSB ARLIC 3/9 For Agent Only
4 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) Interferon Beta - 1a Intron Invirase Ipratropium Bromide Isordil Isosorbide 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 (Nasal Spray OK for Allergies) Heart, CSB ARLIC 4/9 For Agent Only Heart
5 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 Maltaq Megace Megestrol Megestrol Acetate Mellaril Melphalan Memantine Hydrochloride Mesoridazine Mestinon Metanx Methadone Methadose Methotrexate Mirapex Mitomycin Mitoxantrone Moban Molindone Morphine (Includes all brands and formulations) Mutamycin 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 Narcotic Analgesic CSB ARLIC 5/9 For Agent Only
6 Mycophenolate Mofetil Myleran Mylotarg Mytelase Naltrexone HCl Namenda 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 Pentam 300 Pentamidine Pentoxifylline Pergolide Permax Perphenazine Plaquenil Leukemia Alcoholism / Narcotic Dependence Major Depression/Bipolar Disorder Immunosuppresant Dementia / Leukemia Bipolar Any condition Disease of the Pancreas Disease of the Pancreas Disease (OK for Restless Leg Syndrome) Peripheral Vascular Disease (OK for Restless Leg Syndrome) (OK for Restless Leg Syndrome) Systemic Lupus/Connective Tissue Disease CSB ARLIC 6/9 For Agent Only
7 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 Ropinirole Hydrochloride Rotigotine Rythmol Sandimmune Saphris Saquinavir Selegiline 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 HIV (OK for Restless Leg Syndrome) /Bipolar Disorder CSB ARLIC 7/9 For Agent Only
8 Serentil Serlect Seroquel Serzone Sevelamer Sinemet Sirolimus Sorbitrate Sotalol Spiriva Stalevo Stavudine Stelazine Steroids Stocrin Suboxone Sustiva Symadine Symax Symmetrel TACE Tacrine Tambocor Tarceva Tasmar Tenofovir Tensilon Teriparatide Thalidomid T Thalidomide Thioridazine Thiothixene Thorazine Tikosyn Tiotropium Tiotropium Bromide Tolcapone Toremifene Trastuzumab Trelstar Tremin Trental Trexall Trifluoperazine HCl Major Depression/Bipolar Disorder Immunosuppresant Narcotic Dependence (OK for antifective) (Ok for IBS, colon spasms) (OK for antifective) Disease Osteoporosis with fractures, Leprosy,, Leprosy, Breast Peripheral Vascular Disease CSB ARLIC 8/9 For Agent Only
9 Trihexyphenidyl Trilafon Trileptal Triptorelin Trisenox Triveen-Cf Tumor Tumor Necrosis Factor Tysabri Urso Ursodiol Valproic Acid Vantas Videx Viracept Viramune Viread Wellferon Xagrid Xeloda Zalcitabine Zelapar Zerit Ziagen Zidovudine Ziprasidone Zoladex Zyprexa Bipolar Luekemia Dementia and Cirrhosis/Liver Disease Cirrhosis/Liver Disease Bipolar Disorder Prostate HIV Blood Disorder Colon/Breast CSB ARLIC 9/9 For Agent Only
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