FINAL EXPENSE€¦ · Aldactazide CHF (Congestive Heart Failure) Hypertension 2 years: Modified...

For Agent Use Only This piece is not intended to create public interest in an insurance product, an insurer, or an agent.

Prescription List

FINAL EXPENSE

Prosperity Life Group® is a marketing name for products and services provided by one or more of the member companies of Prosperity Life Insurance Group, LLC, including SBLI USA Life Insurance Company, Inc., and S.USA Life Insurance Company, Inc. and Shenandoah Life Insurance Company. Members not licensed in all states. Only SBLI USA Life Insurance Company, Inc. is licensed in New York. Each company offers a variety of insurance products and is solely responsible for its own financial and contractual obligations. SBLI USA Life Insurance Company, Inc. is not affiliated with The Savings Bank Life Insurance Company of Massachusetts or The Savings Bank Life Insurance Company of Connecticut. The rules, poli-cies and procedures of this Guide apply only to the sale, solicitation and negotiation of life insurance and annuity products issued by SBLI USA Life Insurance Company, Inc. and S.USA Life Insurance Company, Inc. (“Companies”). This Guide is not a contract and is not intended to create any contractual rights in favor of the Agent or the Companies. The Guide does not alter the current relationships between the Agent and any of the Companies. Furthermore, the Companies reserve the right to change, alter or amend any portion of this Guide at their discretion at any time.

New Business [email protected]: (212) 624-0818

Customer Service [email protected]: (877) 725-4872Fax: (212) 624-0820

[email protected]: (212) 624-0814

Agent Support [email protected] Phone: (866) 380-6413

Agent Portalhttps://www.insuranceadmin.com/agent

Home Office Contacts

Final Expense Prescription List Page 1 of 37 C-PDLFEXECW17 11-2019

Medication IndicationRx Fill Within

Benefit Eligibility - SBLI/SUSA Comments

Abacavir AIDS / HIV Ever No coverageAbacavir/Dolutegravir/LamIvudine AIDS / HIV Ever No coverage

Abacavir/Lamivudine AIDS / HIV Ever No coverage

Abarelix Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - Level

AbciximabHeart Condition

(Stroke, TIA, Heart Attack, Aneurysm)

2 years Modified

Abemaciclib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAbilify Psychotic Disorder Ever Graded

Abiraterone Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


AbitrexateCancer

Rheumatoid Arthritis3 years

Modified*Level

*If current treatment or reoccurrence of cancer -No coverage


Abraxane Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Abstral Cancer Pain 3 years Modified**If current treatment or reoccurrence - No coverage


Acalabrutinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAcamprosate Alcohol / Drug 2 years Modified

AccessPak for HIV Pep Basic AIDS / HIV Ever No coverage

AccunebCOPD / Emphysema

AsthmaEver

GradedLevel

AccuprilCHF (Congestive

Heart Failure) Hypertension

2 yearsModified

Level

AcebutololAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Aceon

Heart Condition (Stroke, TIA, Heart Attack,

Aneurysm)Hypertension

2 years ModifiedLevel

Acetyl L-Carnitine Alzheimer’s / Dementia Ever No coverage

AcetylcysteineCOPD / Emphysema

AsthmaEver

GradedLevel

Aclidinium COPD Ever Graded

Acova Circulatory Surgery

First Fill < 2 years

First Fill > 2 years

ModifiedLevel

*If fills are current within 2 years WITH concurrent fills for over 2 years = Level

**If fills are current within 2 years and fills are over 2 years but NOT CONCURRENT = Modified

**If ALL fills are within 2 years = Modified **If fills are NOT within 2 years and only show 2+ years

=Level

Acthar Gel, H.P.Systemic Lupus

Other UseEver

GradedLevel

Actigall Liver Disorder Ever Graded* *If Stage 3/C Cirrhosis - No coverage

Actiq Cancer Pain 3 years Modified**If current treatment or reoccurrence - No coverage


ActivaseHeart Condition


2 years Modified

AdalatAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Adcetris Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAdefovir;

Adefovir Dipivoxil Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Ado-Trastuzumab Emtansine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAdriamycin; Adriamycin PFS;

Adriamycin RDFCancer 3 years Modified*

*If current treatment or reoccurrence - No coverage If treatment free > 3 years - Level

Adrucil Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Final Expense Prescription List**This list is not all inclusive and drug ratings are subject to change**

If a medication is not shown, but suggests treatment for a condition stated on application, coverage may be restricted or denied. Please email the Home Office with any questions.






Advair, Advair Diskus, Advair HFACOPD / Emphysema

AsthmaEver

GradedLevel

Aerolate COPD / Emphysema

AsthmaEver

GradedLevel

Afatinib; Afatinib Dimaleate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Afeditab; Afeditab CRHeart Condition

Hypertension2 years

ModifiedLevel

Afinitor Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAgenerase AIDS / HIV Ever No coverage

AggrastatHeart Condition


2 years Modified

AggrenoxHeart Condition




ModifiedLevel



**If ALL fills are within 2 years = Modified **If fills are NOT within 2 years and only show 2+ years =

Level

AiretCOPD / Emphysema

AsthmaEver

GradedLevel

Akineton Parkinson’s Ever Graded

Akynzeo Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAlbuterol/Ipratropium COPD Ever Graded

Albuterol; Albuterol Sulfate COPD / Emphysema Asthma

EverGradedLevel

AldactazideCHF (Congestive


2 yearsModified

Level

AldactoneCHF (Congestive


2 yearsModified

Level

Aldesleukin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Alecensa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Alectinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Alemtuzumab Cancer

Multiple Sclerosis (MS)3 years

Modified*Level



Alferon N Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Alimta Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Aliqopa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAlitretinoin AIDS/ HIV Ever No coverage

Alkeran Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Aloxi Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Alpelisib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAlpha1-Proteinase Inhibitor COPD Ever Graded

AltaceCHF (Congestive


2 yearsModified

Level

AlteplaseHeart Condition


2 years Modified

Altretamine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


http://www.drugs.com/cdi/alemtuzumab.html






Alunbrig Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Alupent; Alupent InhalerCOPD / Emphysema

AsthmaEver

GradedLevel

AlvescoCOPD / Emphysema

AsthmaEver

GradedLevel

Amantadine Parkinson’sOther Use

EverGradedLevel

Ambisome AIDS / HIV Ever No coverage

AmicarHeart Condition


2 years Modified

Amifostine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Amiloride; Amiloride HCTZ;Amiloride-Hydrochlorothia

CHF (Congestive Heart Failure) Hypertension

2 yearsModified

Level

Aminocaproic Acid Heart Condition


2 years Modified

Aminophylline; Aminophylline Anhydrous; Aminophylline Dihydrate

COPD / Emphysema Asthma

EverGradedLevel

AmitriptylineNeuropathy (Diabetic

Complication) Other use

2 yearsModified*

Level*If used to treat Neuropathy due to Diabetic Complications

Amlodipine BesylateHeart Condition

Hypertension2 years

ModifiedLevel

Amphotericin B Liposome AIDS/ HIV Ever No coverageAmprenavir AIDS / HIV Ever No coverageAmyl Nitrate Angina (Chest Pain) 2 years Modified

Anastrozole Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


AngiomaxHeart Condition




ModifiedLevel



**If ALL fills are within 2 years = Modified**If fills are NOT within 2 years and only show 2+ years =

LevelAnoro Ellipta COPD Ever Graded

Antabuse Alcohol / Drug 2 years Modified

Anzemet Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Apalutamide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelApokyn Parkinson’s Ever Graded

Apomorphine Parkinson’s Ever Graded

AprepitantCancer

Other use3 years

Modified*Level


If treatment free > 3 years - LevelAptivus AIDS / HIV Ever No coverage

Aquazide HCHF (Congestive


2 yearsModified

Level

Aralast; Aralast NP COPD Ever Graded

Aralen; Aralen PhosphateSystemic Lupus

Other UseEver

GradedLevel

Aranesp Kidney Disorder Ever Graded

AranespCancer

Kidney Disorder 3 years

EverModified*

Graded*If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelArcapta; Arcapta Neohaler COPD Ever Graded

Aredia Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelArformoterol COPD Ever Graded






Argatroban Circulatory Surgery



ModifiedLevel




LevelAricept; Aricept ODT Alzheimer’s / Dementia Ever No coverage

Arimidex Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAripiprazole Psychotic Disorder Ever Graded

Aristada Psychotic Disorder Ever Graded

Aromasin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Arranon Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Arsenic Trioxide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ArtaneParkinson’s

Psychotic DisorderEver Graded

Arzerra Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAsenapine Psychotic Disorder Ever Graded

AsmanexCOPD / Emphysema

AsthmaEver

GradedLevel

Asparaginase Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Aspirin & DipyridamoleHeart Condition




ModifiedLevel




Level

AtacandCHF (Congestive


2 yearsModified

Level

Atamet Parkinson’s Ever GradedAtazanavir AIDS / HIV Ever No coverage

Atazanavir & Cobicistat AIDS / HIV Ever No coverage

AtenololAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Atezolizumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAtgam Kidney Failure Ever Graded

Atovaquone AIDS/ HIV Ever No coverageAtripla AIDS / HIV Ever No coverage

Atrovent; Atrovent HFACOPD / Emphysema

AsthmaEver

GradedLevel

AvaproKidney Disorder

Other useEver

GradedLevel

Avastin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Avelumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Axicabtagene Ciloleucel Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Axitinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Azacitidine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


AzasanKidney Failure

Systemic LupusRheumatoid Arthritis

EverGraded Graded Level

AzathioprineKidney Failure








Azedra Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelAzidothymidine Alzheimer’s / Dementia Ever No coverage

Azilect Parkinson’s Ever Graded

AzmacortCOPD / Emphysema

AsthmaEver

GradedLevel

AZT Alzheimer’s / Dementia Ever No coverage

Balversa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelBaraclude Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Basiliximab Kidney Failure Ever Graded

Bavencio Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


BCG (bacillus calmette-guerin) Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


BecloventCOPD / Emphysema

AsthmaEver

GradedLevel

Bedaquiline Tuberculosis (TB) Ever GradedBelatacept Kidney Failure Ever Graded

Belbuca Alcohol / Drug 2 years Modified

Beleodaq Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelBelimumab Systemic Lupus (SLE) Ever Graded

Belinostat Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


BenazeprilCHF (Congestive


2 yearsModified

Level

Bendamustine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bendamustine Hcl Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bendeka Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelBenlysta Systemic Lupus (SLE) Ever Graded

Benztropine Mesylate Parkinson’s


Besponsa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bevacizumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bexarotene Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bexxar; Bexxar 131 Iodine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bicalutamide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


BiCNU Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelBictegravir/Emtricitabine/Tenofovir

Alafenamide TabletsAIDS / HIV Ever No coverage

BiDilCHF (Congestive

Heart Failure) 2 years Modified

Biktarvy AIDS / HIV Ever No coverage

Binimetinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelBiperiden Parkinson’s Ever Graded

Bisoprolol FumarateCHF (Congestive

Heart Failure); Angina Hypertension

2 yearsModified

Level

BivalirudinHeart Condition




ModifiedLevel




Level






Blenoxane Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bleomycin Sulfate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Blinatumomab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Blincyto Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelBoceprevir; Boceprevir systemic Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Bortezomib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bosulif Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bosutinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Braftovi Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Braftovi + Mektovi Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Brentuximab Vedotin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Breo ElliptaCOPD / Emphysema

AsthmaEver

GradedLevel

Breo Ellipta 100/25 COPD Ever Graded

BrethineCOPD / Emphysema

AsthmaEver

GradedLevel

BrexpiprazolePsychotic Disorder

Other UseEver

Graded Level

Brigatinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Brilinta Heart Condition


2 years Modified

Bromocriptine Mesylate Parkinson’s Ever Graded

BroncodurCOPD / Emphysema

AsthmaEver

GradedLevel

BroncomarCOPD / Emphysema

AsthmaEver

GradedLevel

Brondelate COPD / Emphysema

AsthmaEver

GradedLevel

BronkosolCOPD / Emphysema

AsthmaEver

GradedLevel

Brovana COPD Ever Graded

BudesonideCOPD / Emphysema

AsthmaEver

GradedLevel

Bumel Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Bumetanide CHF (Congestive


2 yearsModified

Level

BumexCHF (Congestive


2 yearsModified

Level

Bunavail Alcohol / Drug 2 years ModifiedBuprenex Alcohol / Drug 2 years Modified

Buprenorphine & Naloxone Alcohol / Drug 2 years Modified

Buprenorphine; Buprenorphine HCL Alcohol / Drug 2 years Modified

Busulfan Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Busulfex Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelButrans Alcohol / Drug 2 years Modified

BystolicCHF (Congestive


2 yearsModified

Level






Cabazitaxel Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cabometyx Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cabozantinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Calcijex Kidney Dialysis

Kidney Disorder Other

1 yearEverEver

No coverageGradedLevel

Calcitriol Kidney Dialysis


1 yearEverEver


Calcium AcetateKidney Dialysis

Kidney Disorder1 yearEver

No coverageGraded

Calcium Folinate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CalphronKidney Dialysis


No coverageGraded

Calquence Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Campath Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelCampral Alcohol / Drug 2 years Modified

Camptosar Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Candesartan; Candesartan CilexetilCHF (Congestive


2 yearsModified

Level

Capecitabine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Capoten CHF (Congestive


2 yearsModified

Level

Caprelsa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CaptoprilCHF (Congestive


2 yearsModified

Level

CarbamazepinePsychotic Disorder

Seizures Ever

GradedLevel

CarbatrolPsychotic Disorder

Other UseEver

Graded Level

CarbidopaCarbidopa-Levodopa

Parkinson’s Ever Graded

Carboplatin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CardioplegicHeart Condition


2 years Modified

CardizemHeart Condition

Hypertension2 years

ModifiedLevel

Carfilzomib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelCarimune;

Carimune NanofilteredCancer 3 years Modified*


Cariprazine Psychotic Disorder Ever Graded

Carmustine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Carnitor; Carnitor SFKidney Dialysis


No coverageGraded

Cartia Heart Condition

Hypertension2 years

ModifiedLevel

CarvedilolCHF (Congestive


2 yearsModified

Level

Casodex Cancer 3 years Modified**If current treatment or reoccurrence - No coverage







Ceenu Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CellceptHeart Surgery

Kidney / Liver Disorder 2 years

EverModifiedGraded

Ceritinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cerubidine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cetuximab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - Level Chantix Smoking Cessation 1 year Smoker Rates* *If last use within 12 months

Chlorambucil Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ChlordiazepoxideAlcohol / Drug

Other use2 years

ModifiedLevel

Chloroquine; Chloroquine PhosphateSystemic Lupus

Other UseEver

GradedLevel

ChlorothiazideCHF (Congestive


2 yearsModified

Level

Chlorpromaz, Chlorpromazine Psychotic Disorder Ever Graded

ChlorthalidoneCHF (Congestive


2 yearsModified

Level

CholedylCOPD / Emphysema

AsthmaEver

GradedLevel

Cibalith S-Solution Psychotic Disorder Ever Graded

CiclesonideCOPD / Emphysema

AsthmaEver

GradedLevel

Cidofovir AIDS / HIV Ever No coverageCimduo AIDS / HIV Ever No coverage

Cinacalcet Kidney Dialysis 1 year No coverage

CIS-DDP Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cisplatin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelCiticoline Alzheimer’s / Dementia Ever No coverage

Cladribine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelClenbuterol COPD Ever Graded

Clofarabine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Clolar Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ClonidineCancer PainOther Use

3 yearsModified*

Level*If current treatment or reoccurrence - No coverage


Clopidogrel (300 mg)Heart Condition


2 years Modified

Clopidogrel (75 mg)Heart Condition




ModifiedLevel




Level

ClorazepateAlcohol / Drug

Other use2 years

ModifiedLevel

Clozapine Psychotic Disorder Ever GradedClozaril Psychotic Disorder Ever Graded

Cobicistat AIDS / HIV Ever No coverage

Cobimetinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CogentinParkinson’s


Cognex Alzheimer’s / Dementia Ever No coverageCognizin Alzheimer’s / Dementia Ever No coverage






Combivent; Combivent Respimat

COPD Ever Graded

Combivir AIDS / HIV Ever No coverage

Cometriq Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CompazinePsychotic Disorder

Other UseEver

Graded Level

Complera AIDS / HIV Ever No coverage

ComproPsychotic Disorder

Other UseEver

Graded Level

Comtan Parkinson’s Ever Graded

ConZipNeuropathy (Diabetic

Complication)Other use

2 yearsModified*


Copanlisib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelCopegus Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Copiktra Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Coreg; Coreg CR CHF (Congestive


2 yearsModified

Level

CorgardAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Corlanor CHF (Congestive Heart Failure) 2 years Modified

CorticotropinSystemic Lupus

Other UseEver

GradedLevel

Cosmegen Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cotellic Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Coumadin

Cardiac Valve ReplacementTIA/Stroke

Pulmonary EmbolismThrombosis

< 2 years*< 2 years*

EverEver

Modified Modified

Level Level




Level

CozaarCHF (Congestive


2 yearsModified

Level

Crixivan AIDS / HIV Ever No coverage

Crizotinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Cromolyn SodiumCOPD / Emphysema

AsthmaEver

GradedLevel

Cyclophosphamide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CyclosporineHeart Surgery


EverModifiedGraded

Cyfos Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CymbaltaNeuropathy (Diabetic


2 yearsModified*


Cyramza Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelCystagon Kidney Disorder Ever Graded

Cysteamine Bitartrate Kidney Disorder Ever Graded

Cytarabine; Cytarabine Liposomal Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


CytogamHeart Surgery


EverModifiedGraded

Cytosar-U Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelCytovene AIDS / HIV Ever No coverage






Cytoxan Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Dabrafenib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Dacarbazine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDaclatasvir; Daclatasvir systemic;

Daclatasvir DihydrochlorideLiver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Daclizumab Kidney Failure Ever Graded

Dacogen Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Dacomitinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Dactinomycin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDaklinza Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage Daliresp COPD Ever Graded

DalproPsychotic Disorder

SeizuresEver

Graded Level

DalteparinHeart Condition




ModifiedLevel




LevelDaranavir/Cobicistat AIDS / HIV Ever No coverage

Daratumumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Darbepoetin AlfaCancer

Kidney Disorder 3 years

EverModified*



Darolutamide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDarunavir AIDS / HIV Ever No coverage

Darunavir/Cobicistat AIDS / HIV Ever No coverageDarunavir/Cobicistat/Emtricitabine/Ten

ofovir Alafenamide TabletsAIDS / HIV Ever No coverage

Darzalex Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Dasabuvir; Dasabuvir/Ombitasvir/Paritaprevir

/Ritonavir SystemicLiver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Dasatinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDaunorubicin; Daunorubicin HCL;

Daunorubicin LiposomalCancer 3 years Modified*


Daunoxome Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Daurismo Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Decitabine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


DecostriolKidney Dialysis


1 yearEverEver


Defibrotide; Defibrotide Sodium Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Defitelio Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Degarelix, Degarelix Acetate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDelavirdine AIDS / HIV Ever No coverage

Delflex Kidney Dialysis 1 year No coverageDelstrigo AIDS / HIV Ever No coverage






DemadexCHF (Congestive


2 yearsModified

Level

Denileukin Diftitox Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


DenosumabCancer

Other use3 years

Modified*Level


If treatment free > 3 years - LevelDenzapine Psychotic Disorder Ever Graded

Depade Alcohol / Drug 2 years Modified

Depakene; Depakene SolutionPsychotic Disorder

SeizuresEver

Graded Level

Depakote; Depakote ERPsychotic Disorder

SeizuresEver

Graded Level

Depa-Syrup SolutionPsychotic Disorder

SeizuresEver

Graded Level

Depocyt Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Depo-Provera Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


DeproicPsychotic Disorder

SeizuresEver

Graded Level

DescovyAIDS / HIVHIV PrEP

EverNo coverage

Level

Dexrazoxane Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Dextromethorphan ALS (Amyotrophic Lateral Sclerosis;); Lou Gehrig's

Ever No coverage

DiazepamAlcohol / Drug

Other use2 years

ModifiedLevel

Didanosine AIDS / HIV Ever No coverage

Digitalis

CHF (Congestive Heart Failure)

Atrial Fibrillation2 years

ModifiedLevel

DigitekCHF (Congestive

Heart Failure)Atrial Fibrillation

2 yearsModified

Level

Digitoxin



ModifiedLevel

DigoxinCHF (Congestive Heart Failure)


ModifiedLevel

Dilacor Heart Condition

Hypertension2 years

ModifiedLevel

Dilatrate SRHeart Condition


2 years Modified

DilorCOPD / Emphysema

AsthmaEver

GradedLevel

Diltiazem; Diltiazem HCI; Diltiazem HCL

Angina (Chest Pain)Hypertension

2 yearsModified

Level

Dinutuximab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


DiovanCHF (Congestive


2 yearsModified

Level

Dipyridamole Heart Condition




ModifiedLevel




LevelDisulfiram Alcohol / Drug 2 years Modified






DiurilCHF (Congestive


2 yearsModified

Level

DivalproexPsychotic Disorder

SeizuresEver

Graded Level

Dobutamine HCL; Dobutamine HCL/D5W; Dobutamine-Dextrose


2 years Modified

Dobutrex CHF (Congestive


Docefrez Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Docetaxel Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDolophine Alcohol / Drug 2 years Modified

Dolutegravir AIDS / HIV Ever No coverageDolutegravir/Lamivudine AIDS / HIV Ever No coverageDolutegravir/Rilpivirine AIDS / HIV Ever No coverage

Donepezil Alzheimer’s / Dementia Ever No coverage

DopamineHeart Condition


2 years Modified

Doravirine AIDS / HIV Ever No coverageDoravirine/Lamivudine/Tenofovir

Disoproxil FumarateAIDS / HIV Ever No coverage

Dovato AIDS / HIV Ever No coverageDoxercalciferol Kidney Dialysis 1 year No coverage

Doxil Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDoxorubicin HCL;

Doxorubicin LiposomalCancer 3 years Modified*


DroperidolPsychotic Disorder

Other UseEver

GradedLevel

DroxiaCancer

Sickle Cell3 years

EverModified*



DTIC-Dome Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


DuleraCOPD / Emphysema

AsthmaEver

GradedLevel

Duloxetine; Duloxetine HydrochlorideNeuropathy (Diabetic


2 yearsModified*


Duoneb COPD Ever Graded

DuraclonCancer PainOther Use

3 yearsModified*

Level*If current treatment or reoccurrence - No coverage


Durvalumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Duvelisib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelDylix COPD Ever Graded

DyphyllineCOPD / Emphysema

AsthmaEver

GradedLevel

Dyphysin COPD / Emphysema

AsthmaEver

GradedLevel

DyreniumCHF (Congestive


2 yearsModified

Level

ED-BRON GCOPD / Emphysema

AsthmaEver

GradedLevel

EdecrinCHF (Congestive



Edurant AIDS / HIV Ever No coverageEfavirenz AIDS / HIV Ever No coverage

Efavirenz/Lamivudine/Tenofavir DF AIDS / HIV Ever No coverage






EffientHeart Condition


2 years Modified

Egrifta AIDS / HIV Ever No coverageElbasvir & Grazoprevir Hepatitis Ever Graded

Eldepryl Parkinson’s Ever Graded

Eligard Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


EliphosKidney Dialysis


No coverageGraded

Elitek Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ElixophyllinCOPD / Emphysema

AsthmaEver

GradedLevel

Ellence Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Elotuzumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Eloxatin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Elspar Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelElvitegravir AIDS / HIV Ever No coverage

Emcyt Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Emend Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


EmendCancer

Other use3 years

Modified*Level



Empliciti Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelEmtricitabine;

Emtricitabine-tenofovirEmtricitabine-nelfinavir-tenofovir; Emtricitabine-rilpivirine-tenofovir

AIDS / HIV Ever No coverage

Emtriva AIDS / HIV Ever No coverage

Enalapril Enalapril Maleate

CHF (Congestive Heart Failure) Hypertension

2 yearsModified

Level

EnalaprilatCHF (Congestive


2 yearsModified

Level

Enasidenib; Enasidenib Mesylate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Encorafenib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Encorafenib + Binimetinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelEnfuvirtide AIDS / HIV Ever No coverage

Enoxaparin Sodium Heart Condition


2 years Modified

Entacapone Parkinson’s Ever GradedEntecavir Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Entrectinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


EntrestoCHF (Congestive


Enzalutamide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelEpclusa Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Epirubicin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


EpitolPsychotic Disorder

Seizures Ever

GradedLevel

http://www.drugs.com/cdi/enfuvirtide.html






Epivir; Epivir HBV AIDS / HIVHepatitis

Ever No coverageGraded

EplerenoneCHF (Congestive


2 yearsModified

Level

Epoetin AlfaKidney Dialysis


No coverageGraded

EpogenKidney Dialysis


No coverageGraded

Epzicom AIDS/ HIV Ever No coverageEpzicom AIDS / HIV Ever No coverageEquetro Psychotic Disorder Ever Graded

Erbitux Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Erdafitinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ergamisol Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelErgoloid Mesylates Alzheimer’s / Dementia Ever No coverage

Eribulin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Erleada Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Erlotinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Erwinaze Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


EsidrixCHF (Congestive


2 yearsModified

Level

Eskalith Psychotic Disorder Ever GradedEstramustine;

Estramustine PhosphateCancer 3 years Modified*


Ethambutol Tuberculosis (TB) Ever Graded

Ethyol Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Etopophos Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Etoposide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelEtravirine AIDS / HIV Ever No coverage

Eulexin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Everolimus (afinitor) Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Everolimus (zortress)Kidney Failure Liver Disorder

Ever Graded

Eviplera AIDS / HIV Ever No coverageEvotaz AIDS / HIV Ever No coverage

EvzioAlcohol/Drug Dependency

Other use2 years

ModifiedLevel

Exelon Alzheimer’s / Dementia Ever No coverage

Exemestane Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelFanapt Psychotic Disorder Ever Graded

Fareston Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Farydak Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Faslodex Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelFazaclo Psychotic Disorder Ever Graded

Femara Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Fentanyl Citrate Cancer Pain 3 years Modified**If current treatment or reoccurrence - No coverage







Fentora Cancer Pain 3 years Modified**If current treatment or reoccurrence - No coverage


Firmagon Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Flebogamma; Flebogamma DIF Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelFlovent; Flovent Diskus;

Flovent Rotadisk; Flovent HFACOPD / Emphysema

AsthmaEver

GradedLevel

Floxuridine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Fludara Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Fludarabine Phosphate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Fluorouracil Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Fluoxymesterone Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelFluphenazine Fluphenazine HCL;

Fluphenazine DecanoatePsychotic Disorder Ever Graded

Flutamide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


FluticasoneCOPD / Emphysema

AsthmaEver

GradedLevel

Fluticasone Furoate COPD Ever Graded

Folotyn Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ForadilCOPD / Emphysema

AsthmaEver

GradedLevel

Fortovase AIDS / HIV Ever No coverageFosamprenavir AIDS / HIV Ever No coverage

Fosamprenavir Calcium AIDS / HIV Ever No coverageFoscarnet Sodium AIDS / HIV Ever No coverage

Foscavir AIDS / HIV Ever No coverage

Fosinopril SodiumCHF (Congestive


2 yearsModified

Level

Fosrenol Kidney Disorder Ever Graded

FragminHeart Condition




ModifiedLevel



**If ALL fills are within 2 years = Modified***If fills are NOT within 2 years and only show 2+ years =

Level

FUDR Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Fulvestrant Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


FurosemideCHF (Congestive


2 yearsModified

Level

Fusilev Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelFuzeon AIDS / HIV Ever No coverage

GabapentinNeuropathy (Diabetic


2 yearsModified*


Galantamine; Galantamine Hydrobromide

Alzheimer’s / Dementia Ever No coverage

Gamimune, Gammagard, Gammaplex, Gamunex

Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelGanciclovir AIDS / HIV Ever No coverage

Gazyva Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Gefitinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


http://www.drugs.com/cdi/fosamprenavir.html






Gemcitabine; Gemcitabine HCL Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Gemtuzumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Gemzar Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


GengrafHeart Surgery


EverModifiedGraded

Genvoya AIDS / HIV Ever No coverageGeodon Psychotic Disorder Ever Graded

Gilotrif Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Gilteritinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Glasdegib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelGlassia COPD Ever Graded

Glecaprevir/Pibrentasvir Hepatitis Ever Graded

Gleevec Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Gliadel Wafer Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelGlycopyrrolate COPD Ever Graded

Goserelin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


GraliseNeuropathy (Diabetic


2 yearsModified*


Guaifenesin;Guaifenesin-theophylline

COPD / Emphysema Asthma

EverGradedLevel

Habitrol Smoking Cessation 1 year Smoker Rates* *If last use within 12 months

Halaven Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelHaldol; Haldol Decanoate Psychotic Disorder Ever Graded

Haloperidol; Haloperidol Decanoate Psychotic Disorder Ever Graded

Halotestin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelHarvoni Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage Hectorol Kidney Dialysis 1 year No coverage

HemangeolAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Hepsera Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Herceptin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Hexalen Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelHivid AIDS / HIV Ever No coverage

HorizantNeuropathy (Diabetic


2 yearsModified*


Hycamtin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelHydergine Alzheimer’s / Dementia Ever No coverage

Hydralazine HCL CHF (Congestive


2 yearsModified

Level

Hydrea Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


HydrochlorothiazideCHF (Congestive


2 yearsModified

Level

Hydrochlorothiazide & LosartanHeart DiseaseHypertension

2 yearsModified

Level

HydroDIURILCHF (Congestive


2 yearsModified

Level






HydroflumethiazideCHF (Congestive


2 yearsModified

Level

HydroxychloroquineSystemic Lupus

MalariaRheumatoid Arthritis

EverGraded Level

Level

Hydroxyurea Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


HygrotonCHF (Congestive


2 yearsModified

Level

HyzaarHeart DiseaseHypertension

2 yearsModified

LevelIbalizumab AIDS / HIV Ever No coverage

Ibrance Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ibritumomab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ibrutinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Iclusig Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Idamycin PFS Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Idarubicin; Idarubicin HCL Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Idelalisib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Idhifa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelIfex

Iflex Mesnex Combo PackCancer 3 years Modified*


Ifosfamide; Ifosfamide-Mesna; Ifosfamidum


If treatment free > 3 years - LevelIloperidone Psychotic Disorder Ever Graded

Imatinib Mesylate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Imbruvica Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelImdur Heart Disease - Angina 2 years Modified

Imfinzi Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ImipramineNeuropathy (Diabetic


2 years Modified*Level

*If used to treat Neuropathy due to Diabetic Complications

Imlygic Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Immune Globulin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


ImuranKidney Failure



InamrinoneCHF (Congestive


InapsinePsychotic Disorder

Other UseEver

GradedLevel

Incivek Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage Incruse Ellipta COPD Ever Graded

Indacaterol COPD Ever Graded

IndapamideCHF (Congestive


2 yearsModified

Level

Indapamide CHF (Congestive


2 yearsModified

Level

Inderal; Inderal LA; Inderal XLAngina (Chest Pain)

Hypertension2 years

ModifiedLevel






Indinavir; Indinavir Sulfate AIDS / HIV Ever No coverageInfergen Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Inlyta Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Innopran XLAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Inotuzumab Ozogamicin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


InspraCHF (Congestive


2 yearsModified

Level

Integrilin Heart Condition


2 years Modified

Intelence AIDS / HIV Ever No coverageInterferon alfacon-1 Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Intron ACancer

Hepatitis C3 years2 years

Modified Graded


Invega, Invega Sustenna Psychotic Disorder Ever GradedInvirase AIDS / HIV Ever No coverage

Iobenguane I 131 Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ipilimumab Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ipratropium BromideCOPD / Emphysema

AsthmaEver

GradedLevel

IrbesartanKidney Disorder

Other useEver

GradedLevel

IrenkaNeuropathy (Diabetic


2 years Modified*Level

*If used to treat Neuropathy due to Diabetic Complications

Iressa Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Irinotecan Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelIron Sucrose Kidney Disorder Ever Graded

Isentress AIDS / HIV Ever No coverageIsmo Angina (Chest Pain) 2 years Modified

Isochron Angina (Chest Pain) 2 years ModifiedIsoditrate Angina (Chest Pain) 2 years Modified

IsoetharineCOPD / Emphysema

AsthmaEver

GradedLevel

Isoniazid Tuberculosis (TB) Ever Graded

IsoproterenolCOPD / Emphysema

AsthmaEver

GradedLevel

IsordilHeart Condition


2 years Modified

Isosorbide; Isosorbide Dinitrate;Isosorbide Mononitrate


Aneurysm)2 years Modified

Istodax Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelIstradefylline Parkinson’s Ever Graded

Isuprel COPD / Emphysema

AsthmaEver

GradedLevel

Ivarbradine CHF (Congestive Heart Failure) 2 years Modified

IVIG Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ivosidenib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ixabepilone Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Ixazomib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


http://www.drugs.com/cdi/indinavir.html






Ixempra Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Jakafi Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Jantoven

Cardiac Valve ReplacementTIA/Stroke

Pulmonary EmbolismThrombosis

< 2 years*< 2 years*

EverEver

Modified Modified

Level Level




Level

Jevtana Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelJuluca AIDS / HIV Ever No coverage

Kadcyla Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelKaletra AIDS / HIV Ever No coverage

Kemadrin Parkinson’s Ever Graded

Kepivance Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Keytruda Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Kisqali Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelKivexa AIDS / HIV Ever No coverage

Kyprolis Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


LamictalPsychotic Disorder

SeizuresEver

Graded Level

LamivudineAIDS / HIVHepatitis B

EverNo coverage

GradedLamivudine & Tenofovir Disoproxil

Fumarate AIDS / HIV Ever No coverage

LamotriginePsychotic Disorder

SeizuresEver

Graded Level

Lanoxin; LanoxicapsCHF (Congestive Heart Failure)


ModifiedLevel

Lanreotide; Lanreotide Acetate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelLanthanum Kidney Disorder Ever Graded

Lapatinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Lariago; Lariago-DSSystemic Lupus

Other UseEver

GradedLevel

Larodopa Parkinson’s

Restless Leg SyndromeEver

GradedLevel

Larotrectinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


LasixCHF (Congestive


2 yearsModified

Level

Latuda Psychotic Disorder Ever GradedLedipasvir-sofosbuvir Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Lemtrada Cancer


Modified*Level



Lenvatinib; Lenvatinib Mesylate Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Lenvima Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Letrozole Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Leucovorin Calcium Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Leukeran Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


http://www.drugs.com/cdi/alemtuzumab.html






Leukine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Leuprolide Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Leustatin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


LevalbuterolCOPD / Emphysema

AsthmaEver

GradedLevel

Levamisole HCL Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


LevocarnitineKidney Dialysis


No coverageGraded

Levodopa Parkinson’s Ever GradedLevomethadyl Acetate HCl Alcohol / Drug 2 years Modified

Lexiva AIDS / HIV Ever No coverage

LibriumAlcohol / Drug

Other use2 years

ModifiedLevel

Lipodox Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


LisinoprilCHF (Congestive


2 yearsModified

Level

Lithium; Lithium Carbonate;Lithium Citrate

Psychotic Disorder Ever Graded

Lithobid Psychotic Disorder Ever GradedLodosyn Parkinson’s Ever Graded

Lomustine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelLonhala Magnair COPD Ever Graded

Lonsurf Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelLopinavir;

Lopinavir-ritonavirAIDS / HIV Ever No coverage

Lorbrena Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Lorlatinib Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Losartan; Losartan PotassiumCHF (Congestive


2 yearsModified

Level

LotensinCHF (Congestive


2 yearsModified

Level

LovenoxHeart Condition


2 years Modified

Loxapine; Loxapine Succinate Psychotic Disorder Ever GradedLoxitane Psychotic Disorder Ever Graded

LozolCHF (Congestive


2 yearsModified

Level

LufyllinCOPD / Emphysema

AsthmaEver

GradedLevel

Lumoxiti Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Lupron; Lupron Depot Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelLurasidone Psychotic Disorder Ever Graded

Lymphocyte Immune Globulin Kidney Failure Ever Graded

Lynparza Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


LyricaNeuropathy (Diabetic


2 yearsModified*


Lysodren Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelMaraviroc AIDS / HIV Ever No coverage

http://www.drugs.com/cdi/lopinavir-ritonavir.htmlhttp://www.drugs.com/cdi/lopinavir-ritonavir.htmlhttp://www.drugs.com/cdi/maraviroc.html






Matulane Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Matzim LAHeart Condition

Hypertension 2 years

ModifiedLevel

MavikHeart Condition

Hypertension 2 years

ModifiedLevel

Mavyret Hepatitis Ever Graded

MaxairCOPD / Emphysema

AsthmaEver

GradedLevel

Mechlorethamine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Megace ESAIDS / HIV

Cancer Ever

3 yearsNo coverage

Modified*



Megestrol, Megestrol AcetateAIDS / HIV

Cancer Ever

3 yearsNo coverage

Modified*



Mekinist Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Mektovi Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelMellaril Psychotic Disorder Ever Graded

MelphalanMelphalanHydrochloride


If treatment free > 3 years - LevelMemantine, Memantine HCL Alzheimer’s / Dementia Ever No coverage

Mepron AIDS / HIV Ever No coverage

Mercaptopurine Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Mesna Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Mesnex Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelMesoridazine Psychotic Disorder Ever Graded

MetaproterenolCOPD / Emphysema

AsthmaEver

GradedLevel

Metastron Cancer 3 years Modified**If current treatment or reoccurrence - No coverage

If treatment free > 3 years - LevelMethadone HCL Alcohol / Drug 2 years Modified

Methadose Alcohol / Drug 2 years Modified

MethotrexateCancer

Rheumatoid Arthritis3 years

Modified*Level



MethyclothiazideCHF (Congestive



MetolazoneCHF (Congestive


2 yearsModified

Level

Metoprolol, Metoprolol TartrateCHF (Congestive


2 yearsModified

Level

Micardis


Aneurysm)Hypertension

2 yearsModified

Level

MicrozideCHF (Congestive


2 yearsModified

Level

MidamorCHF (Congestive


2 yearsModified

Level

Midostaurin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


MilrinoneCHF (Congestive







MinitranHeart Condition


2 Years Modified

Mirapex Parkinson’s

Restless Leg SyndromeEver

GradedLevel

Mitomycin Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Mitotane Cancer 3 years Modified**If current treatment or reoccurrence - No coverage


Mitoxantrone HCLCancer


Modified*Level


If treatment free > 3 years - LevelMoban Psychotic Disorder Ever Graded

Moderiba Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

ModureticCHF (Congestive


2 yearsModified

Level

Moexipril CHF (Congestive


2 yearsModified

Level

Mogamulizumab-kpkc Cancer 3 years Modified**If current treatment or

FINAL EXPENSE€¦ · Aldactazide CHF (Congestive Heart Failure) Hypertension 2 years: Modified...

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Transcript of FINAL EXPENSE€¦ · Aldactazide CHF (Congestive Heart Failure) Hypertension 2 years: Modified...