Hospital Confinement & Surgical Fixed Indemnity DECLINABLE DRUG LIST
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- Raymond Stewart
- 10 years ago
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1 Hospital Confinement & Surgical Fixed DECLINABLE DRUG LIST indicates 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 Acetate Megace Cancer Actemra Rheumatoid Arthritis Actigall Cirrhosis, Liver Disease Adalimumab Rheumatoid Arthritis, Crohn's Adcirca Pulmonary Hypertension Adriamycin Cancer Afinitor Cancer Agenerase AIDS Aggrastat Angina, Angioplasty Agrylin Myeloproliferative Disorders, Blood Disorders Akineton Parkinson's Alfa Epogen Renal Failure, Dialysis Alkeran Cancer Altretamine Cancer Amantadine Parkinson's Ambenonium Chloride Myasthenia Gravis Ambrisentan Pulmonary Hypertension Amiodarone Heart, Ventricular Arrhythmia Amprenavir AIDS Anagrelide Myeloproliferative Disorders, Blood Disorders Anagrelide Hydrochloride Myeloproliferative Disorders, Blood Disorders Anastrozole Cancer Antabuse Alcoholism Antagon Infertility Treatments Apokyn Parkinson's Apomorphine Hydrochloride Parkinson's Apriso Ulcerative Colitis, Crohn's Aptivus HIV Aranesp Chronic Renal Failure Arformoterol Tartrate COPD Aricept Alzheimer's Arimidex Cancer Arixtra Blood Clots Aromasin Cancer Arsenic Trioxide Leukemia UTA /12 For Agent Only
2 Artane Parkinson's Asacol Ulcerative Colitis, Crohn's Atripla AIDS Atrovent COPD (Nasal Spray OK for Allergies) Avastin Cancer Avonex Multiple Sclerosis Axona Alzheimer's Azasan Organ Transplant, Rheumatoid Arthritis Azathioprine Organ Transplant, Rheumatoid Arthritis Azilect Parkinson's AZT AIDS Aztreonam Cystic Fibrosis Azulfidine Ulcerative Colitis, Crohn's Baclofen Multiple Sclerosis (OK for Restless Leg Syndrome) Balsalazide Ulcerative Colitis Banzel Seizure Disorders, Epilepsy Bendopa Parkinson's Benztropine Mesylate Parkinson's Berinert Hereditary Angioedema Betaseron Multiple Sclerosis Bevacizumab Cancer Bicalutamide Oral Cancer Biperiden Hydrochloride Parkinson's Blenoxane Cancer Bleomycin Cancer Boceprevir Hepatitis C Bortezomib Multiple Myeloma, Lymphoma Bosentan Pulmonary Hypertension Bravelle Infertility Treatments Brovana COPD Buprenorphine Narcotic Analgesic Busulfan Cancer Campral Alcoholism Canasa Ulcerative Colitis, Crohn's Capecitabine Cancer Carbamazepine Epilepsy Carbatrol Epilepsy Carbex Parkinson's Carbidopa Parkinson's Casodex Cancer Cayston Cystic Fibrosis Cellcept Organ Transplant, Rheumatoid Arthritis Cerefolin Dementia, Alzheimer's Cerespan Dementia UTA /12 For Agent Only
3 Certolizumag Pegol Rheumatoid Arthritis, Crohn's Cetrorelix Infertility Treatments Cetrotide Infertility Treatments Chlorambucil Cancer Chlorotrianisene Cancer Choriogonadotropin Alfa Infertility Treatments Chorionic Gonadotropin Infertility Treatments Cilostazol Peripheral Vascular Disease Cimzia Rheumatoid Arthritis, Crohn's Cinryze Hereditary Angioedema Cisplatin Cancer Clomid Infertility Treatments Clomifene Infertility Treatments Clomifert Infertility Treatments Clomiphene Citrate Infertility Treatments Clonazepam Seizure Disorders, Epilepsy Clopidogrel Bisulfate Angina, Heart Attack, Stroke, Peripheral Vascular Disease Cogentin Parkinson's Cognex Alzheimer's Colazal Ulcerative Colitis Combivent COPD Comtan Parkinson's Copaxone Multiple Sclerosis Cordarone Heart Attack, Ventricular Arrhythmia Coumadin Blood Clots Crixivan AIDS Cyclophosphamide Cancer Cycloserine Tuberculosis Cyclosporine Organ Transplant, Immuno suppressant Cycrimine Parkinson's Cycrimine Hydrochloride Parkinson's Cytoxan Cancer D4T AIDS Dalteparin Angina, Blood Clots Danaparoid Blood Clots Dantrium Multiple Sclerosis Dantrolene Multiple Sclerosis Darbepoetin Alfa Chronic Renal Failure Deapril Dementia Delavirdine AIDS Depade Alcoholism, Opioids Depakene Epilepsy (OK for Migraines) Depakote Epilepsy (OK for Migraines) UTA /12 For Agent Only
4 Depen Rheumatoid Arthritis Deprenyl Parkinson's Didanosine AIDS Digitek Heart Failure, Atrial Fibrillation Digoxin Heart Failure, Atrial Fibrillation Dilantin Epilepsy Dilaudid Narcotic Analgesic Dipentum Ulcerative Colitis Dipyridamole Peripheral Vascular Disease, Heart Disease Disoproxil Fumarate AIDS Disopyramide Phosphate Arrhythmias, Heart Disease Disulfiram Alcoholism Dolophine Narcotic Analgesic Donepezil Alzheimer's Dopar Parkinson's Dornase Alfa Cystic Fibrosis Doxorubicin Cancer Duoneb COPD Ecallantide Hereditary Angioedema Edrophonium Chlorides Myasthenia Gravis Efavirenz AIDS Effient Heart Disease with Angioplasty Eldepryl Parkinson's Eligard Cancer Emcyt Cancer Emtricitabine AIDS Emtriva AIDS Enfolast Dementia, Alzheimer's Entacapone Parkinson's Epivir AIDS Epoetin Renal Failure, Dialysis Epogen Renal Failure, Dialysis Epoprostenol Pulmonary Hypertension Ergamisol Cancer Ergoloid Mesylates Memory Loss, Dementia Erlotinib Cancer Estinyl Cancer (OK for other uses) Estramustine Cancer Etaposide Cancer Ethambutol Tuberculosis Ethosuximide Epilepsy Etophopos Cancer Eulexin Cancer Everolimus Cancer Exelon Alzheimer's UTA /12 For Agent Only
5 Exemestane Cancer Fareston Cancer Faslodex Cancer Felbatol Epilepsy Femara Cancer Fentanyl Narcotic Analgesic Fertinex Infertility Treatments Filgrastim Cancer Fingolimod Multiple Sclerosis Flolan Pulmonary Hypertension Flutamide Cancer Follistim Infertility Treatments Follitropin Alfa Infertility Treatments Follitropin Beta Infertility Treatments Fondaparinus Sodium Blood Clots Fortovase AIDS Foscarnet AIDS Foscavir AIDS Fragmin Angina, Blood Clots Fulvestrant Cancer Gabapentin Seizure Disorders, Epilepsy Gabitril Epilepsy Galantimine Alzheimer's Gallium Nitrate Cancer Ganirelix Infertility Treatments Ganite Cancer Gengraf Organ Transplant, Rheumatoid Arthritis Gentuzumab Ozogamicin Leukemia Gerimal Dementia Gilenya Multiple Sclerosis Glatiramer Multiple Sclerosis Gleevec Cancer Gold Shots Rheumatoid Arthritis Gonal-F Infertility Treatments Goserelin Cancer Heparin Blood Clots Herceptin Cancer Hexalen Cancer Histrelin Cancer Hivid AIDS Humegon Infertility Treatments Humira Rheumatoid Arthritis, Crohn's Hydergine Memory Loss, Dementia Hydrea Cancer Hydrochloride Pagitane Parkinson's UTA /12 For Agent Only
6 Hydromorphone Narcotic Analgesic Hydroxychloroquine Lupus, Connective Tissue Disease Hydroxyurea Cancer, Blood Disorders Hyoscamine Parkinson's (OK for IBS, Colon Spasms) Iloprost Pulmonary Hypertension Imatinib Mesylate Cancer Imdur Angina Imuran Organ Transplant, Rheumatoid Arthritis Indinavir AIDS Infliximab Rheumatoid Arthritis Innohep Blood Clots Insulin (All brands and Diabetes formulations) Interferon Beta-1a Multiple Sclerosis, Cancer Interferon-Alfa Hepatitis C Intron Cancer Invirase AIDS Ipilimumab Melanoma Ipratropium Bromide COPD (Nasal Spray OK for Allergies) Isoniazid Tuberculosis Isordil Heart, Angina Isosorbide Heart, Angina Isoxsuprine Cerebral Vascular Insufficiency, PVD Jantoven Blood Clots Kalbitor Hereditary Angioedema Kaletra AIDS Kemadrin Parkinson's Keppra Seizure Disorders, Epilepsy Klonopin Seizure Disorders, Epilepsy Kogenate Hemophilia Lacosamide Seizure Disorders, Epilepsy Lamictal Epilepsy Lamivudine AIDS Lamotrigine Epilepsy Lanoxin Heart Failure, Atrial Fibrillation Larodopa Parkinson's L-Dopa Parkinson's Letairis Pulmonary Hypertension Letrozole Cancer Leucovorin Cancer, Rheumatoid Arthritis Leukeran Cancer Leuprolide Cancer Levamisole Cancer Levetiracetam Seizure Disorders, Epilepsy UTA /12 For Agent Only
7 Levodopa Parkinson's Levsin Parkinson's (OK for IBS, colon spasms) Levsinex Parkinson's (OK for IBS, colon spasms) Lialda Ulcerative Colitis, Crohn's Lioresal Multiple Sclerosis (OK for Restless Leg Syndrome) Lodosyn Parkinson's Lopinavir AIDS Lupron Cancer Lyrica Seizure Disorders, Epilepsy Lysodren Cancer Matulane Hodgkin's Disease Megace Cancer Megestrol Cancer Megestrol Acetate Cancer Melphalan Cancer Memantine Hydrochloride Alzheimer's Menopur Infertility Treatments Menotropins Infertility Treatments Mentane Alzheimer's Disease Mercaptopurine Leukemia, Blood Disorders, Ulcerative Colitis Mesalamine Ulcerative Colitis, Crohn's Mestinon Myasthenia Gravis Metanx Diabetes with Peripheral Neuropathy Methadone Narcotic Analgesic Methotrexate Rheumatoid Arthritis, Crohn's Mirapex Parkinson's (OK for Restless Leg Syndrome) Mitomycin Cancer Mitotane Cancer Mitoxantrone Multiple Sclerosis, Leukemia Morphine (All brands and Narcotic Analgesic formulations) Mutamycin Cancer Myambutol Tuberculosis Mycophenolate Mofetil Organ Transplant, Rheumatoid Arthritis Mycophenolic Acid Organ Transplant Myfortic Organ Transplant Myleran Cancer Mylotarg Leukemia Mytelase Myasthenia Gravis Nafarelin Acetate Infertility Treatments Naloxone Opioid Dependence Naltrexone Hydrochloride Alcoholism, Narcotics Namenda Alzheimer's Disease Narcan Opioid Dependence UTA /12 For Agent Only
8 Natalizumab Multiple Sclerosis Natrecor Congestive Heart Failure Nelfinavir AIDS Neoral Organ Transplant, Rheumatoid Arthritis Neosar Cancer Neostigmine Myasthenia Gravis Nesiritide Congestive Heart Failure Neupogen Cancer Neupro Parkinson's Neurontin Seizure Disorders, Epilepsy Nevirapine AIDS Nilandron Cancer Niloric Dementia Nilutamide Cancer Nitro Patch Angina Nitro-bid Angina Nitroglycerin Angina Nitrotab Angina Nolvadex Cancer Norpace Arrhythmias, Heart Disease Norvir AIDS Novantrone Multiple Sclerosis, Leukemia Novarel Infertility Treatments Nydrazid Tuberculosis Olsalazine Ulcerative Colitis Oncovin Cancer, Leukemia Orencia Rheumatoid Arthritis Orgaran Blood Clots Ovidrel Infertility Treatments Oxcarbazepine Epilepsy Oxygen Any Condition Pacerone Heart, Ventricular Arrhythmia Pagitane Parkinson's Pancrecarb Disease of the Pancreas Pancrelipase Disease of the Pancreas Papaverine Stroke, Peripheral Vascular Disease Parcopa Parkinson's Parlodel Parkinson's (OK for Restless Leg Syndrome) Parsidol Parkinson's Parsitan Parkinson's Pavabid Stroke, Peripheral Vascular Disease Pegagtanib Sodium Macular Degeneration Peginterferon Hepatitis C Pencillamine Rheumatoid Arthritis Pentam 300 AIDS UTA /12 For Agent Only
9 Pentamidine AIDS Pentasa Ulcerative Colitis, Crohn's Pentoxifylline Peripheral Vascular Disease Pergolide Parkinson's (OK for Restless Leg Syndrome) Pergonal Infertility Treatments Permax Parkinson's (OK for Restless Leg Syndrome) Persantine Peripheral Vascular Disease, Heart Disease Phenobarbital Epilepsy Phenytoin Epilepsy Plaquenil Lupus, Connective Tissue Disease Platinol Cancer Plavix Angina, Heart Attack, Stroke, Peripheral Vascular Disease Pletal Peripheral Vascular Disease Pramipexole Di-Hydrochloride Parkinson's (OK for Restless Leg Syndrome) Prasugrel Heart Disease with Angioplasty Pregabalin Seizure Disorders, Epilepsy Pregnyl Infertility Treatments Priftin Tuberculosis Procarbazine Hydrochloride Hodgkin's Disease Procrit Renal Failure, Dialysis Procyclidine Hydrochloride Parkinson's Prostigmin Myasthenia Gravis Pulmozyme Cystic Fibrosis Purinethol Leukemia, Blood Disorders, Ulcerative Colitis Pyrazinamide Tuberculosis Pyridostigmine Myasthenia Gravis Quinidine Sulfate Arrhythmias, Heart Disease Ranexa Angina Ranibizumab Macular Degeneration Ranolazine Angina Rapamune Organ Transplant Rasagiline Parkinson's Razadyne Alzheimer's Disease Rebif Multiple Sclerosis Remicade Rheumatoid Arthritis Reminyl Alzheimer's Disease Remodulin Pulmonary Hypertension Renagel Renal Failure, Dialysis Renvela Renal Failure, Dialysis Repronex Infertility Treatments Requip Parkinson's (OK for Restless Leg Syndrome) Rescriptor AIDS Retrovir AIDS Revatio Pulmonary Hypertension UTA /12 For Agent Only
10 Revia Alcoholism, Opioids Rheumatrex Rheumatoid Arthritis, Crohn's Ribavirin Hepatitis C Rifadin Tuberculosis Rifamate Tuberculosis Rifampin Tuberculosis Rifapentine Tuberculosis Rifater Tuberculosis Rilutek Amyotrophic Lateral Sclerosis Riluzole Amyotrophic Lateral Sclerosis Rimactane Tuberculosis Ritonavir AIDS Rituxan Rheumatoid Arthritis, Non-Hodgkin's Lymphoma Rituximab Rheumatoid Arthritis, Non-Hodgkin's Lymphoma Rivastigmine Alzheimer's Disease Roferon HIV Ropinirole Hydrochloride Parkinson's (OK for Restless Leg Syndrome) Rotigotine Parkinson's Rowasa Ulcerative Colitis, Crohn's Rufinamide Seizure Disorders, Epilepsy Sabril Seizure Disorders, Epilepsy Sandimmune Organ Transplant Saquinavir AIDS Selegiline Parkinson's Seromycin Tuberculosis Serophene Infertility Treatments Sevelamer Renal Failure, Dialysis Sinemet Parkinson's Sirolimus Organ Transplant Sorbitrate Angina Spiriva COPD Stalevo Parkinson's Stavudine AIDS Steroids COPD Stocrin AIDS Suboxone Opioid Dependence Sulfasalazine Ulcerative Colitis, Crohn's Sustiva AIDS Symadine Parkinson's (OK for Anti-infective) Symax Parkinson's (Ok for IBS, Colon Spasms) Symmetrel Parkinson's (OK for Anti-infective) Synarel Infertility Treatments TACE Cancer Tacrine Alzheimer's Disease UTA /12 For Agent Only
11 Tadalafil Pulmonary Hypertension Tamoxifen Cancer Tarceva Cancer Tasmar Parkinson's Tegretol Epilepsy Telaprevir Hepatitis C Temsirolimus Cancer Tenofovir AIDS Tensilon Myasthenia Gravis Thalidomid T AIDS, Cancer Thalidomide AIDS, Cancer Ticlid Stroke, TIA, Cerebral Infarct Ticlopidine Hydrochloride Stroke, TIA, Cerebral Infarct Tinzaparin Blood Clots Tiotropium COPD Tiotropium Bromide COPD Tipranavir HIV Tirofiban Hydrochloride Angina, Angioplasty Tobi Cystic Fibrosis Tobramycin Solution for Cystic Fibrosis Inhalation Tocilizumab Rheumatoid Arthritis Tolcapone Parkinson's Topamax Epilepsy (OK for Migraines) Topiramate Epilepsy (OK for Migraines) Toremifene Cancer Torisel Cancer Tracleer Pulmonary Hypertension Trastuzumab Cancer Trelstar Cancer Tremin Parkinson's Trental Peripheral Vascular Disease Trepostinil Pulmonary Hypertension Trexall Rheumatoid Arthritis Trihexyphenidyl Parkinson's Trileptal Epilepsy Triptorelin Cancer Trisenox Leukemia Triveen-Cf Dementia, Alzheimer's Disease Tumor Necrosis Factor AIDS Tysabri Multiple Sclerosis Tyvaso Pulmonary Hypertension Urofollitropin Infertility Treatments Urso Cirrhosis, Liver Disease Ursodiol Cirrhosis, Liver Disease UTA /12 For Agent Only
12 Valproate Epilepsy Valproic Acid Epilepsy Vantas Cancer Vasodilan Cerebral Vascular Insufficiency, PVD Velcade Multiple Myeloma, Lymphoma Ventavis Pulmonary Hypertension Verteporfin Macular Degeneration Videx AIDS Vigabatrin Seizure Disorders, Epilepsy Vimpat Seizure Disorders, Epilepsy Viracept AIDS Viramune AIDS Viread AIDS Visudyne Macular Degeneration Warfarin Blood Clots Wellferon HIV agrid Myeloproliferative Disorders, Blood Disorders eloda Cancer Yervoy Melanoma Zalcitabine AIDS Zarontin Epilepsy Zelapar Parkinson's Zerit AIDS Ziagen AIDS Zidovudine AIDS Zoladex Cancer Zonegran Seizure Disorders, Epilepsy Zonisamide Seizure Disorders, Epilepsy UTA /12 For Agent Only
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