medication common uses rx fill within plan eligibility · aldactazide hypertension chf n/a n/a...

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PRESCRIPTION REFERENCE GUIDEWhere 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 medications, the “Rx Fill Within” column notes “First Fill”. “First Fill” refers to when the medication was originally prescribed.Medication Common Uses RX Fill Within Plan EligibilityAbilify Psychotic Disorder N/A Immediate Accupril Hypertension

CHF N/AN/A

Immediate No Coverage

Accuretic Hypertension CHF

N/AN/A


Acebutolol HCL Hypertension CHF

N/AN/A


Aceon Hypertension CHF

N/AN/A


Actoplus Diabetes * N/A ImmediateActos Diabetes * N/A ImmediateAdvair Asthma N/A Immediate

COPD / Emphysema 2 years3 years> 3 years

Return of PremiumGraded Immediate

Aggrenox Stroke / TIA 2 years3 years > 3 years

Return of Premium Graded Immediate

Albuterol Asthma N/A ImmediateCOPD / Emphysema 2 years

3 years> 3 years


Aldactazide Hypertension CHF

N/AN/A


Aldactone Hypertension CHF

N/AN/A


Allopurinol Gout N/A Immediate Altace Hypertension

CHF N/AN/A


Amantadine HCL Parkinson’s N/A Graded Amaryl Diabetes * N/A ImmediateAmbisome AIDS N/A No Coverage Amiloride HCL Hypertension

CHF N/AN/A


Amlodipine Besylate/Benaz Hypertension CHF

N/AN/A


NOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityAmyl Nitrate Angina 2 years

3 years> 3 years

Return of PremiumGradedImmediate

CHF N/A No CoverageAntabuse Alcohol / Drugs 2 years Return of Premium Apokyn Parkinson’s N/A Graded Apresoline Hypertension

CHF N/AN/A


Aptivus AIDS N/A No Coverage Aranesp Kidney Dialysis

Renal Insufficency/Failure Diabetic Nephropathy #

N/AN/AN/A

No coverage Return of Premium Return of Premium

Aricept Alzheimer’s / Dementia N/A No Coverage Arimidex Cancer 2 years

3 years> 3 years


Atacand Hypertension CHF

N/AN/A


Atamet Parkinson’s N/A Graded Atenolol Hypertension

CHF N/AN/A

ImmediateNo Coverage

Atgam Organ / Tissue Transplant N/A No coverage Atripla AIDS N/A No coverage Atrovent/Atrovent HFA Atrovent (Nasal)

Allergies N/A Immediate COPD 2 years

3 years> 3 years


Avalide Hypertension CHF

N/AN/A


Avandia Diabetes * N/A ImmediateAvapro Hypertension

CHF N/AN/A


Avonex Multiple Sclerosis N/A GradedAzasan Organ / Tissue Transplant

Rheumatoid ArthritisSystemic Lupus

N/AN/AN/A

No coverageImmediateReturn of Premium

Azathioprine Organ / Tissue TransplantRheumatoid ArthritisSystemic Lupus

N/AN/AN/A


Azilect Parkinson’s N/A Graded Azmacort Asthma N/A Immediate




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Medication Common Uses RX Fill Within Plan EligibilityAzor Hypertension

CHF N/AN/A


Baclofen Multiple Sclerosis N/A GradedBaraclude Liver Disorder / Hepatitis 2 years

3 years> 3 years


Benazepril HCL Hypertension CHF

N/AN/A


Benicar Hypertension CHF

N/AN/A


Benlysta Systemic Lupus N/A Return of PremiumBenztropine Mesylate Parkinson’s

Other Use N/AN/A

GradedImmediate

Betapace Heart ArrhythmiaCHF

N/AN/A


Betaseron Multiple Sclerosis N/A GradedBetaxolol HCL Hypertension

CHF N/AN/A


BiDil CHF N/A No CoverageBisoprolol Fumarate Hypertension

CHF N/A N/A


Bromocriptine Mesylate Parkinson’s N/A Graded Bumetadine Hypertension

CHF N/AN/A


Bumex Hypertension CHF

N/AN/A


Buprenex Alcohol / Drugs 2 years Return of Premium Bystolic Hypertension

CHF N/AN/A


Calcium Acetate Kidney DialysisRenal Insufficency/Failure Diabetic Nephropathy #

N/AN/AN/A

No coverageReturn of PremiumReturn of Premium

Campath Cancer 2 years3 years> 3 years


Campral Alcohol / Drugs 2 years Return of Premium Capoten Hypertension

CHF N/AN/A


Capozide Hypertension CHF

N/AN/A


Captopril Hypertension CHF

N/AN/A


Carbamazepine SeizuresDiabetic Neuropathy #

3 yearsN/A

GradedReturn of Premium


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Medication Common Uses RX Fill Within Plan EligibilityCarbatrol Seizures

Diabetic Neuropathy #3 yearsN/A


Carbidopa Parkinson’s N/A Graded Carvedilol Hypertension

CHF N/AN/A


Casodex Cancer 2 years3 years> 3 years


Celebrex Arthritis N/A Immediate Cellcept Organ / Tissue Transplant N/A No coverage Clopidogrel Stroke/TIA/Heart Attack

Stroke/Heart AttackStroke/Heart Attack

First Fill 2 yearsFirst Fill 3 years First Fill > 3 years


Cogentin Parkinson’sOther Use

N/AN/A

GradedImmediate

Cognex Alzheimer’s/Dementia N/A No coverage Combivent COPD 2 years

3 years> 3 years


Combivir AIDS N/A No Coverage Complera AIDS N/A No Coverage Copaxone Multiple Sclerosis N/A GradedCopegus Liver Disorder / Hepatitis C 2 years

3 years> 3 years


Cordarone Arrythmia N/A Immediate Coreg Hypertension

CHF N/AN/A


Corgard Hypertension CHF

N/AN/A


Corzide Hypertension CHF

N/AN/A


Coumadin Pulmonary Embolism Thrombosis

NANA

ImmediateImmediate

Cardiac Valve Replacement/TIA/Stroke/Heart Attack

First Fill 2 years Return of Premium

Cardiac Valve Replacement/Stroke/Heart Attack

First Fill 3 yearsFirst Fill > 3 years

GradedImmediate

Cozaar Hypertension CHF

N/AN/A


Cyclosporine Organ / Tissue Transplant N/A No Coverage Cyclosporine Modified Organ / Tissue Transplant N/A No Coverage NOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityCytoxan Cancer 2 years

3 years > 3 years


Demadex Hypertension CHF

N/AN/A


Depacon SeizuresDiabetic Neuropathy #

3 yearsN/A


Depade Alcohol / Drugs 2 years Return of Premium Depakene Seizures



Depakote Seizure Disorder 3 years GradedDiabeta Diabetes * N/A ImmediateDiabinese Diabetes * N/A ImmediateDigitek Atrial Fibrillation

CHF N/AN/A


Digoxin Atrial FibrillationCHF

N/AN/A


Dilantin Seizure Disorder N/A GradedDilatrate SR Angina 2 years

3 years> 3 years


CHF N/A No CoverageDilor Asthma N/A Immediate



Diovan Hypertension CHF

N/AN/A


Disulfiram Alcohol / Drugs 2 years Return of Premium Dolophine Opioid Dependence 2 years Return of Premium Donepezil HCL Alzheimer’s / Dementia N/A No coverage Duoneb COPD 2 years

3 years > 3 years


Dyazide Hypertension CHF

N/AN/A


Dynacirc Hypertension N/A Immediate Dyrenium Hypertension

CHF N/AN/A


Edecrin Hypertension CHF

N/AN/A


Edurant AIDS N/A No Coverage Eldepryl Parkinson’s N/A Graded NOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityEmtriva AIDS N/A No coverage Enalapril Maleate Hypertension

CHF N/AN/A


Enalaprilat Hypertension CHF

N/AN/A


Epitol SeizuresDiabetic Neuropathy #

3 yearsN/A


Epivir AIDS N/A No coverage Eskalith Bipolar Disorder N/A Immediate Esmolol HCL Hypertension

CHF N/AN/A


Exelon Alzheimer’s / Dementia N/A No coverage Exforge Hypertension

CHF N/AN/A

ImmediateReturn of Premium

Femara Cancer 2 years3 years> 3 years


Foscavir AIDS N/A No coverage Fosinopril Sodium Hypertension

CHF N/AN/A


Fosrenol Kidney DialysisRenal Insufficency/Failure Diabetic Nephropathy #

N/AN/AN/A


Furosemide Hypertension CHF

N/AN/A


Gabapentin SeizuresDiabetic Neuropathy # Restless Leg Syndrome

3 yearsN/A N/A

GradedReturn of PremiumImmediate

Galantamine Alzheimer’s / Dementia N/A No coverage Gleevec Cancer 2 years

3 years> 3 years


Glipizide Diabetes * N/A ImmediateGlucophage Diabetes * N/A ImmediateGlucotrol Diabetes * N/A ImmediateGlyburide Diabetes * N/A ImmediateGlynase Diabetes * N/A ImmediateHaldol Psychotic Disorder N/A Immediate Haloperidol Psychotic Disorder N/A Immediate HCTZ Hypertension N/A Immediate HCTZ/Triamterene Hypertension

CHF N/AN/A



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Medication Common Uses RX Fill Within Plan EligibilityHectoral Kidney Dialysis


N/AN/AN/A


Heparin Pulmonary Embolism Thrombosis

N/AN/A

ImmediateImmediate

Hepsera Liver Disorder / Hepatitis 2 years3 years> 3 years


Hizentra Immunodeficiency N/A DeclineHumalog Diabetes * N/A ImmediateHumulin Diabetes * N/A ImmediateHydralazine HCL Hypertension

CHF N/AN/A


Hydroxyurea Cancer 2 years 3 years> 3 years


Hydergine Alzheimer’s /Dementia N/A No coverage Hydroxychloroquine Systemic Lupus

MalariaRheumatoid Arthritis

N/AN/AN/A

Return of PremiumImmediateImmediate

Hyzaar Hypertension CHF

N/AN/A


Imdur Angina 2 years3 years> 3 years


CHF N/A No CoverageImuran Organ / Tissue Transplant

Rheumatoid ArthritisSystemic Lupus

N/AN/AN/A


Inamrinone CHF N/A No CoverageInderal Hypertension

CHF N/AN/A


Inderide Hypertension CHF

N/AN/A


Innopran XL Hypertension CHF

N/AN/A


Inspra CHF N/A No CoverageInsulin Diabetes * N/A ImmediateIntron-A Cancer 2 years

3 years> 3 years


Hepatitis C 2 year3 years> 3 years



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Medication Common Uses RX Fill Within Plan EligibilityInvirase AIDS N/A No coverage Ipratropium Bromide Allergies N/A Immediate



Isordil Angina 2 years3 years> 3 years


CHF N/A No CoverageIsosorbide Dinitrate/Mononitrate

Angina 2 years 3 years> 3 years


CHF N/A No CoverageJanumet Diabetes * N/A ImmediateJanuvia Diabetes * N/A ImmediateKaletra AIDS N/A No coverage Kemadrin Parkinson’s

Other Use N/AN/A

GradedImmediate

Kerlone Hypertension CHF

N/AN/A


Labetaolol Hypertension CHF

N/AN/A


Lamictal SeizuresDiabetic Neuropathy #

3 yearsN/A


Lamtrogine SeizuresDiabetic Neuropathy #

3 yearsN/A


Lanoxicaps Atrial FibrillationCHF

N/AN/A


Lanoxin Atrial FibrillationCHF

N/AN/A


Lantus Diabetes * N/A ImmediateLarodopa Parkinson’s N/A Graded Lasix Hypertension

CHF N/AN/A


Leukeran Cancer 2 years3 years > 3 years


Levatol Hypertension CHF

N/AN/A


Levemir Diabetes * N/A ImmediateLevocarnitine Kidney Dialysis

Renal Insufficency/FailureDiabetic Nephropathy #

N/AN/AN/A



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Medication Common Uses RX Fill Within Plan EligibilityLevodopa Parkinson’s N/A Graded Lexiva AIDS N/A No coverage Lexxel Hypertension

CHF N/AN/A


Lipitor Cholesterol N/A Immediate Lisinopril Hypertension

CHF N/AN/A


Lithium Bipolar Disorder N/A Immediate Lodosyn Parkinson’s N/A Graded Losartan Potassium Hypertension

CHF N/AN/A


Lotensin Hypertension CHF

N/AN/A


Loxapine Psychotic Disorder N/A Immediate Loxitane Psychotic Disorder N/A Immediate Lupron Cancer 2 years

3 years> 3 years


Lyrica SeizuresDiabetic Neuropathy #

3 yearsN/A


Mavik Hypertension CHF

N/AN/A


Maxzide Hypertension CHF

N/AN/A


Mellaril Psychotic Disorder N/A Immediate Mepron AIDS N/A No coverage Metformin Diabetes * N/A ImmediateMethadone Opioid Dependence 2 years Return of Premium Methadose Opioid Dependence 2 year Return of Premium Methotrexate Cancer 2 years

3 years> 3 years


Rheumatoid Arthritis N/A ImmediateMetolazone Hypertension

CHF N/AN/A


Metoprolol HCTZ Hypertension CHF

N/AN/A


Metoprolol Tartrate/ Succinate

Hypertension CHF

N/AN/A


Micardis Hypertension CHF

N/AN/A


Micronase Diabetes * N/A ImmediateNOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityMidamor Hypertension

CHF N/AN/A


Milrinone CHF N/A No Coverage Minitran Angina 2 years

3 years> 3 years


CHF N/A No CoverageMirapex Parkinson’s

Other Use N/AN/A

GradedImmediate

Moban Psychotic Disorder N/A Immediate Moduretic Hypertension

CHF N/AN/A


Moexipril HCL Hypertension CHF

N/AN/A


Monoket Angina 2 years3 years> 3 years


CHF N/A No CoverageMonopril Hypertension

CHF N/AN/A


Mykrok Hypertension CHF

N/AN/A


Mysoline Seizure Disorder N/A GradedNadolol Hypertension

CHF N/AN/A


Naloxone Alcohol / Drugs 2 years Return of Premium Naltrexone Alcohol / Drugs 2 years Return of Premium Namenda Alzheimer’s /Dementia N/A No coverage Narcan Alcohol / Drugs 2 years Return of Premium Natrecor CHF N/A No CoverageNavane Psychotic Disorder N/A Immediate Neurontin Seizures



Nimodipine Stroke/TIA/Heart AttackStroke/Heart AttackStroke/Heart Attack

First Fill 2 yearsFirst Fill 3 years First Fill > 3 years


Nimotop Stroke/TIA/Heart AttackStroke/Heart AttackStroke/Heart Attack

First Fill 2 yearFirst Fill 3 yearsFirst Fill > 3 years


Nitrek Angina 2 years3 years> 3 years


CHF N/A No CoverageNOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityNitro-bid Angina 2 year

3 years> 3 years


CHF N/A No CoverageNitro-dur Angina 2 years

3 years > 3 years


CHF N/A No CoverageNitroglycerine/Nitrota b/ Nitroquick/Nitrostat

Angina 2 years3 years> 3 years


CHF N/A No CoverageNitrol Angina 2 years

3 years> 3 years


CHF N/A No CoverageNitromist Angina 2 years

3 years> 3 years


CHF N/A No CoverageNormodyne Hypertension

CHF N/AN/A


Norpace Arrythmia N/A Immediate Norvir AIDS N/A No coverage Novolin Diabetes * N/A ImmediateNovolog Diabetes * N/A ImmediatePacerone Arrythmia NA Immediate Parcopa Parkinson’s N/A Graded Parlodel Parkinson’s N/A Graded Paxil Depressive Disorder N/A Immediate Pegasys Liver Disorder / Hepatitis C 2 years

3 years> 3 years


Peg-Intron Liver Disorder / Hepatitis C 2 years3 years> 3 years


Pentam 300 AIDS N/A No coverage Pentamidine Isethionate AIDS N/A No coverage Pepcid Stomach Disorder N/A Immediate Pergolide Mesylate Parkinson’s N/A Graded Perindopril Erbumine Hypertension

CHF N/AN/A


Permax Parkinson’s N/A Graded NOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityPhenobarbital Seizures 3 Years GradedPhoslo Kidney Dialysis


N/AN/AN/A


Pindolol Hypertension CHF

N/AN/A


Plaquenil Systemic LupusMalariaRheumatoid Arthritis

N/AN/AN/A

Return of PremiumImmediateImmediate

Plavix Stroke/TIA/Heart AttackStroke/Heart AttackStroke/Heart Attack

First Fill 2 years First Fill 3 yearsFirst Fill > 3 years


Prandin Diabetes * N/A ImmediatePrimacor CHF N/A No Coverage Prinivil Hypertension

CHF N/AN/A


Prinzide Hypertension CHF

N/AN/A


Prograf Organ / Tissue Transplant N/A No Coverage Proleukin Cancer 2 years

3 years> 3 years


Prolixin Psychotic Disorder N/A Immediate Propanolol HCL Hypertension

CHF N/AN/A


Proventil Asthma N/A ImmediateCOPD / Emphysema 2 years

3 years> 3 years


Prozac Depressive Disorder N/A Immediate Quinapril Hypertension

CHF N/AN/A


Quinaretic Hypertension CHF

N/AN/A


Ramipril Hypertension CHF

N/AN/A

ImmediateReturn of Premium

Rapamune Organ / Tissue Transplant N/A No Coverage Razadyne Alzheimer’s / Dementia N/A No Coverage Rebetol Liver Disorder / Hepatitis C 2 years

3 years > 3 years


Rebetron Liver Disorder / Hepatitis C 2 years3 years > 3 years



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Medication Common Uses RX Fill Within Plan EligibilityRebif Multiple Sclerosis N/A GradedReminyl Alzheimer’s / Dementia N/A No Coverage Renagel Kidney Dialysis


N/AN/AN/A


Renvela Kidney DialysisRenal Insufficency/Failure Diabetic Nephropathy #

N/AN/AN/A


Requip Parkinson’sOther Use

N/AN/A

GradedImmediate

Ribavirin Liver Disorder / Hepatitis C 2 year3 years > 3 years


Rilutek ALS (Lou Gehrig's Disease) N/A No Coverage Risperdal Psychotic Disorder N/A Immediate Risperidone Psychotic Disorder N/A Immediate Rituxan Cancer 2 year

3 years> 3 years


Rheumatoid Arthritis N/A ImmediateRivastigmine Tartrate Alzheimer’s / Dementia N/A No Coverage Ropinirole Parkinson’s N/A Graded

Diabetic Neuropathy # N/A Return of PremiumOther Use N/A Immediate

Rythmol Arrythmia N/A Immediate Sectral Hypertension

CHF N/AN/A


Serevent Asthma N/A ImmediateCOPD / Emphysema 2 year

3 years> 3 years


Seroquel Psychotic Disorder N/A Immediate Sinemet/Sinemet CR Parkinson’s N/A Graded Sodium Edecrin Hypertension

CHF N/AN/A


Soltalol Hydrochloride Hypertension CHF

N/AN/A


Sotalol HCL Hypertension CHF

N/AN/A


Spiriva COPD 2 year3 years> 3 years



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Medication Common Uses RX Fill Within Plan EligibilitySpironolactone Hypertension

CHF N/AN/A


Sprycel Cancer 2 year3 years> 3 years


Stalevo Parkinson’s N/A Graded Starlix Diabetes * N/A ImmediateSuboxone Alcohol / Drugs 2 years Return of Premium Subutex Alcohol / Drugs 2 years Return of Premium Sustiva AIDS N/A No Coverage Symbicort Asthma N/A Immediate

COPD / Emphysema 2 year3 years> 3 years


Symmetrel Parkinson’s N/A Graded Tambocor Arrythmia N/A Immediate Tamoxifen Cancer 2 years

3 years> 3 years


Tarka Hypertension CHF

N/AN/A


Tasmar Parkinson’s N/A Graded Tegretol Seizures



Tenoretic Hypertension CHF

N/AN/A


Tenormin Hypertension CHF

N/AN/A


Teveten Hypertension CHF

N/AN/A


Theodur Asthma N/A ImmediateCOPD / Emphysema 2 years

3 years> 3 years


Theophylline Asthma N/A ImmediateCOPD / Emphysema 2 years

3 years> 3 years


Thioridazine Psychotic Disorder N/A Immediate Thiothixene Psychotic Disorder N/A Immediate Thorazine Psychotic Disorder N/A Immediate Tolazamide Diabetes * N/A ImmediateTolbutamide Diabetes * N/A ImmediateNOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

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Medication Common Uses RX Fill Within Plan EligibilityTolinase Diabetes * N/A ImmediateToprol XL Hypertension

CHF N/AN/A


Torsemide Hypertension CHF

N/AN/A


Trandate Hypertension CHF

N/AN/A


Trandolapril Hypertension CHF

N/AN/A


Tresiba (Insulin) Diabetes* N/A ImmediateTrimterene Hypertension

CHF N/AN/A


Triamterene/HCTZ Hypertension CHF

N/AN/A


Tribenzor Hypertension CHF

N/AN/A


Trihexyphenidyl HCL Parkinson’sOther Use

N/AN/A

GradedImmediate

Truvada AIDS N/A No Coverage Twynsta Hypertension

CHF N/AN/A


Tyzeka Liver Disorder / Hepatitis 2 years3 years> 3 years


Uniretic Hypertension CHF

N/AN/A


Univasc Hypertension CHF

N/AN/A


Valcyte AIDS N/A No Coverage Valproic Acid Seizures



Valstar Cancer 2 year3 years> 3 years


Valturna Hypertension CHF

N/AN/A


Vascor Angina 2 years3 years> 3 years


Vaseretic Hypertension CHF

N/AN/A


Vasotec Hypertension CHF

N/AN/A



—33—

Medication Common Uses RX Fill Within Plan EligibilityVentolin Asthma N/A Immediate



Viaspan Organ / Tissue Transplant N/A No Coverage Viracept AIDS N/A No Coverage Viramune AIDS N/A No Coverage Viread AIDS N/A No Coverage Visken Hypertension

CHF N/AN/A


Vivitrol Alcohol / Drugs 2 years Return of Premium Warfarin Pulmonary Embolism

ThrombosisNANA

ImmediateImmediate

Cardiac Valve Replacement/ TIA/Stroke/Heart Attack

First Fill 2 years Return of Premium

Cardiac Valve Replacement/ Stroke/Heart Attack

First Fill 3 yearsFirst Fill > 3 years

GradedImmediate

Xeloda Cancer 2 years3 years> 3 years


Xopenex Asthma N/A ImmediateCOPD / Emphysema 2 years

3 years> 3 years


Zantac Stomach Disorder N/A Immediate Zaroxolyn Hypertension

CHF N/AN/A


Zebeta Hypertension CHF

N/AN/A


Zelapar Parkinson’s N/A Graded Zemplar Kidney Dialysis


N/AN/AN/A


Zestoretic Hypertension CHF

N/AN/A


Zestril Hypertension CHF

N/AN/A


Ziac Hypertension CHF

N/AN/A


Zocor Cholesterol N/A Immediate Zoloft Depressive Disorder N/A Immediate Zyprexa Psychotic Disorder N/A Immediate NOTE: Proposed Insureds taking both a medication marked with an asterisk (*) representing "diabetes" and a number sign (#) representing "retinopathy, nephropathy, neuropathy" should answer question # 4 on the application as YES (Return of Premium section). Question #4 asks – “Have you ever been medically diagnosed or treated for complications of diabetes, including insulin shock, diabetic coma, retinopathy (eye), nephropathy (kidney), neuropathy (nerve damage/pain), or used insulin prior to age 50?”

—34—

Senior Choice Impairment GuideThe following list is intended as a guide to assist the agent in determining the appropriate plan of coverage for which the proposed insured should apply. It is not intended to replace the health questions on the life application as the ultimate means for determining client eligibility.

Condition/ Concern Criteria

Plan to Apply For

Question on App*

Activities of Daily Living Require assistance (from anyone) with bathing, dressing, eating, or toileting

No Coverage 1

AIDS / HIV Been medically treated or diagnosed by a medical professional as having

No Coverage 3

Alcoholism/ Alcohol Abuse

Within the past 2 years abused alcohol or had, or been recommended to have, treatment or counseling for alcohol use or been advised to discontinue use of alcohol

Return of Premium 7d

Alzheimer’s disease Been medically diagnosed No Coverage 2Amputation Have had an amputation caused by disease No Coverage 1Amyotrophic Lateral Sclerosis (ALS) / (Lou Gehrig's Disease)

Been medically diagnosed No Coverage 2

Aneurysm Within the last 2 years Return of Premium 7bMedically diagnosed or treated, or hospitalized within the past 3 years

Graded 8a

Angina (Chest Pain)

Medically diagnosed or treated within the past 2 years Return of Premium 7aMedically diagnosed or treated, or hospitalized within the past 3 years Graded 8a

Angioplasty Within the past 2 years Return of Premium 7bWithin the past 3 years Graded 8a

Bed Confinement Currently confined to a bed No Coverage 1Cancer/ (excluding basal cell skin cancer)

Currently have cancer No Coverage 1More than one occurrence in a lifetime Return of Premium 5Within the past 2 years been medically diagnosed, treated, or taken medication for any form of cancer

Return of Premium 7c

Within the past 3 years been medically diagnosed or treated, or hospitalized for or taken medication for any form of cancer

Graded 8b

Cardiomyopathy Have ever been medically diagnosed, treated for Return of Premium 7aCatheterization (Heart) Within the past 2 years Return of Premium 7bChronic Bronchitis See Chronic Obstructive Pulmonary Disease (COPD).Chronic Hepatitis Medically diagnosed or treated within the past 2 years Return of Premium 7aChronic Kidney Disease Diagnosed, treated or taken medication for Return of Premium 5Chronic Pancreatitis Medically diagnosed or treated within the past 2 years Return of Premium 7aChronic Obstructive Pulmonary Disease (COPD)

Medically diagnosed or treated within the past 2 years Return of Premium 7aBeen medically diagnosed or treated, or hospitalized for, or taken medication for within the past 3 years

Graded 8b

Circulatory Surgery Within the past 2 years Return of Premium 7bWithin the past 3 years Graded 8a

Cirrhosis of the Liver Medically diagnosed or treated within the past 2 years Return of Premium 7aMedically diagnosed or treated, or hospitalized within the past 3 years

Graded 8b

Congestive Heart Failure (CHF)

Been medically diagnosed No Coverage 2

Coronary Artery Bypass Surgery

Within the last 2 years Return of Premium 7bWithin the past 3 years Graded 8a

Defibrillator Inserted within the past 2 years Return of Premium 7bDementia Been medically diagnosed No Coverage 2Diabetes Combined with any medical history of any of the following:

Retinopathy, Nephropathy, NeuropathyReturn of Premium 4

Taken Insulin shots prior to age 50 Return of Premium 4Treated for insulin shock or diabetic coma Return of Premium 4

—35—

Condition/ Concern Criteria

Plan to Apply For

Question on App*

Diagnostic Testing, Surgery, or Hospitalization

Recommended within the past 2 years by a medical professional which has not been completed or for which the results have not been received

Return of Premium 6

Drug Abuse / Addiction Used illegal drugs or abused drugs or had been recommended to have treatment or counseling for drug use or been advised to discontinue use of drugs within the past 2 years

Return of Premium 7d

Emphysema See Chronic Obstructive Pulmonary Disease (COPD)Heart Attack Within the past 2 years Return of Premium 7b

Within the past 3 years Graded 8aHeart Surgery Had or been medically advised to have within the past 2 years Return of Premium 7b

Medically diagnosed or treated, or hospitalized within the past 3 years Graded 8aHepatitis C Medically diagnosed or treated within the past 2 years Return of Premium 7a

Been medically diagnosed or treated, or hospitalized for, or taken medication for within the past 3 years

Graded 8b

Home Health Care Currently receiving No Coverage 1Hospice Care Currently receiving No Coverage 1Hospitalization Currently hospitalized No Coverage 1Kidney Dialysis Had or been medically advised to have No Coverage 2Kidney Failure Medically diagnosed, treated or taken medication for Return of Premium 5Liver Disease Medically diagnosed, treated or taken medication for liver failure No Coverage 2

Been medically diagnosed or treated, or hospitalized for, or taken medication for within the past 3 years

Graded 8b

Mental Incapacity Been medically diagnosed No Coverage 2Multiple Sclerosis (MS) Been medically diagnosed or treated, or hospitalized for within the

past 3 yearsGraded 8c

Muscular Dystrophy Been medically diagnosed or treated, or hospitalized for within the past 3 years

Graded 8c

Nursing Facility Currently confined No Coverage 1Organ Transplant Had or been medically advised to have No Coverage 2Oxygen Equipment Currently used to assist in breathing No Coverage 1

Have been required to use oxygen equipment to assist in breathing within the past 2 years

Return of Premium 7a

Pacemaker Inserted within the past 2 years Return of Premium 7bParalysis Been medically diagnosed or treated, or hospitalized for paralysis of

two or more extremities within the past 3 yearsGraded 8c

Parkinson's Disease Been medically diagnosed or treated, or hospitalized for within the past 3 years

Graded 8c

Renal Insufficiency Diagnosed, treated or taken medication for Return of Premium 5Respiratory Failure Been medically diagnosed No Coverage 2Seizures Been medically diagnosed or treated, or hospitalized for within the

past 3 yearsGraded 8c

Stroke Medically diagnosed within the past 2 years Return of Premium 7aMedically diagnosed or hospitalized within the past 3 years Graded 8a

Systemic Lupus (SLE) Been medically diagnosed, treated for within the past 2 years Return of Premium 7aTerminal Medical Condition or End Stage Disease

Been diagnosed or treated with condition that is expected to result in death in the next 12 months

No Coverage 2

TIA (Transient Ischemic Attack)

Medically diagnosed within the past 2 years Return of Premium 7aMedically diagnosed or hospitalized within the past 3 years Graded 8a

Ulcerative Colitis Medically diagnosed or treated, or hospitalized for or taken medication for within the past 3 years

Graded 8b

Wheelchair Use Currently confined to a wheelchair due to chronic illness or disease No Coverage 1* Applies to standard life application Form No. 9466 (AA, OL, PA, PS); Form GL213 (IAA). The question numbers

on some state specific applications may vary. Refer to the State Specifics section of this Agent Guide for plan availability.

medication common uses rx fill within plan eligibility · aldactazide hypertension chf n/a n/a...

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