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

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 50 C-PDLFEXECW17 12-2018

Medication IndicationRx Fill Within

Benefit Eligibility - SBLI/SUSA Comments

Abacavir AIDS / HIV Ever No coverageAbacavir/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 -


Abilify Psychotic Disorder Ever Graded

Abiraterone Cancer 3 years Modified**If current treatment or reoccurrence -


AbitrexateCancer

Rheumatoid Arthritis3 years

Modified*Level

*If current treatment or reoccurrence of cancer -No coverage

If treatment free > 3 years - Level

Abraxane Cancer 3 years Modified**If current treatment or reoccurrence -


Abstral Cancer Pain 3 years Modified**If current treatment or reoccurrence -


Acalabrutinib Cancer 3 years Modified**If current treatment or reoccurrence -


Acamprosate Alcohol / Drug 2 years ModifiedAccessPak 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 yearsModified

Level

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

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.






Actiq Cancer Pain 3 years Modified**If current treatment or reoccurrence -


ActivaseHeart Condition


2 years Modified

AdalatAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Adcetris Cancer 3 years Modified**If current treatment or reoccurrence -


Adefovir; 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 -


Adriamycin; Adriamycin PFS; Adriamycin RDF

Cancer 3 years Modified**If current treatment or reoccurrence -


Adrucil Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


Afeditab; Afeditab CRHeart Condition

Hypertension2 years

ModifiedLevel

Afinitor Cancer 3 years Modified**If current treatment or reoccurrence -


Agenerase AIDS / HIV Ever No coverage

AggrastatHeart Condition


2 years Modified

AggrenoxHeart Condition




ModifiedLevel




AiretCOPD / Emphysema

AsthmaEver

GradedLevel

Akineton Parkinson’s Ever Graded

Akynzeo Cancer 3 years Modified**If current treatment or reoccurrence -


Albuterol/Ipratropium COPD Ever GradedAlbuterol; Albuterol Sulfate COPD / Emphysema

AsthmaEver

GradedLevel






AldactazideCHF (Congestive


2 yearsModified

Level

AldactoneCHF (Congestive


2 yearsModified

Level

Aldesleukin Cancer 3 years Modified**If current treatment or reoccurrence -


Alecensa Cancer 3 years Modified**If current treatment or reoccurrence -


Alectinib Cancer 3 years Modified**If current treatment or reoccurrence -


Alemtuzumab Cancer

Multiple Sclerosis (MS)3 years

Modified*Level



Alferon N Cancer 3 years Modified**If current treatment or reoccurrence -


Alimta Cancer 3 years Modified**If current treatment or reoccurrence -


Aliqopa Cancer 3 years Modified**If current treatment or reoccurrence -


Alitretinoin AIDS/ HIV Ever No coverage

Alkeran Cancer 3 years Modified**If current treatment or reoccurrence -


Aloxi Cancer 3 yearsModified*

*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 -


Alunbrig Cancer 3 years Modified**If current treatment or reoccurrence -


Alupent; Alupent InhalerCOPD / Emphysema

AsthmaEver

GradedLevel

AlvescoCOPD / Emphysema

AsthmaEver

GradedLevel

Amantadine Parkinson’sOther Use

EverGraded

Level Ambisome AIDS / HIV Ever No coverage

AmicarHeart Condition


2 yearsModified

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






Amifostine Cancer 3 years Modified**If current treatment or reoccurrence -


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

EverGraded

Level

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 -


AngiomaxHeart Condition




ModifiedLevel




Anoro Ellipta COPD Ever GradedAntabuse Alcohol / Drug 2 years Modified

Anzemet Cancer 3 years Modified**If current treatment or reoccurrence -


Apalutamide Cancer 3 years Modified**If current treatment or reoccurrence -


Apokyn Parkinson’s Ever GradedApomorphine Parkinson’s Ever Graded

AprepitantCancer

Other use3 years

Modified*Level



Aptivus 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








Arcapta; Arcapta Neohaler COPD Ever Graded

Aredia Cancer 3 years Modified**If current treatment or reoccurrence -


Arformoterol COPD Ever Graded

Argatroban Circulatory Surgery



ModifiedLevel




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

Arimidex Cancer 3 years Modified**If current treatment or reoccurrence -


Aripiprazole Psychotic Disorder Ever GradedAristada Psychotic Disorder Ever Graded

Aromasin Cancer 3 years Modified**If current treatment or reoccurrence -


Arranon Cancer 3 years Modified**If current treatment or reoccurrence -


Arsenic Trioxide Cancer 3 years Modified**If current treatment or reoccurrence -


ArtaneParkinson’s

Psychotic DisorderEver Graded

Arzerra Cancer 3 yearsModified*


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

AsmanexCOPD / Emphysema

AsthmaEver

GradedLevel

Asparaginase Cancer 3 years Modified**If current treatment or reoccurrence -


Aspirin & DipyridamoleHeart Condition




ModifiedLevel




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 -


Atgam Kidney Failure Ever GradedAtovaquone AIDS/ HIV Ever No coverage

Atripla 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 -


Avelumab Cancer 3 years Modified**If current treatment or reoccurrence -


Axicabtagene Ciloleucel Cancer 3 years Modified**If current treatment or reoccurrence -


Axitinib Cancer 3 years Modified**If current treatment or reoccurrence -


Azacitidine Cancer 3 years Modified**If current treatment or reoccurrence -


AzasanKidney Failure

Systemic LupusRheumatoid Arthritis

EverGraded Graded

Level

AzathioprineKidney Failure


EverGraded Graded

Level

Azedra Cancer 3 years Modified**If current treatment or reoccurrence -


Azidothymidine Alzheimer’s / Dementia Ever No coverageAzilect Parkinson’s Ever Graded

AzmacortCOPD / Emphysema

AsthmaEver

GradedLevel

AZT Alzheimer’s / Dementia Ever No coverage

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

Basiliximab Kidney Failure Ever Graded

Bavencio Cancer 3 yearsModified*



BCG (bacillus calmette-guerin) Cancer 3 years Modified**If current treatment or reoccurrence -


BecloventCOPD / Emphysema

AsthmaEver

GradedLevel

Belatacept Kidney Failure Ever Graded

Beleodaq Cancer 3 years Modified**If current treatment or reoccurrence -


Belimumab Systemic Lupus (SLE) Ever Graded






Belinostat Cancer 3 years Modified**If current treatment or reoccurrence -


BenazeprilCHF (Congestive


2 yearsModified

Level

Bendamustine Cancer 3 years Modified**If current treatment or reoccurrence -


Bendamustine Hcl Cancer 3 years Modified**If current treatment or reoccurrence -


Bendeka Cancer 3 years Modified**If current treatment or reoccurrence -


Benlysta Systemic Lupus (SLE) Ever Graded

Benztropine Mesylate Parkinson’s


Besponsa Cancer 3 years Modified**If current treatment or reoccurrence -


Bevacizumab Cancer 3 years Modified**If current treatment or reoccurrence -


Bexarotene Cancer 3 years Modified**If current treatment or reoccurrence -


Bexxar; Bexxar 131 Iodine Cancer 3 years Modified**If current treatment or reoccurrence -


Bicalutamide Cancer 3 years Modified**If current treatment or reoccurrence -


BiCNU Cancer 3 years Modified**If current treatment or reoccurrence -


BiDilCHF (Congestive

Heart Failure) 2 years Modified

Binimetinib Cancer 3 years Modified**If current treatment or reoccurrence -


Biperiden Parkinson’s Ever Graded

Bisoprolol FumarateCHF (Congestive

Heart Failure); Angina Hypertension

2 yearsModified

Level

BivalirudinHeart Condition




ModifiedLevel




Blenoxane Cancer 3 years Modified**If current treatment or reoccurrence -







Bleomycin Sulfate Cancer 3 years Modified**If current treatment or reoccurrence -


Blinatumomab Cancer 3 years Modified**If current treatment or reoccurrence -


Blincyto Cancer 3 years Modified**If current treatment or reoccurrence -


Boceprevir; Boceprevir systemic Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Bortezomib Cancer 3 years Modified**If current treatment or reoccurrence -


Bosulif Cancer 3 years Modified**If current treatment or reoccurrence -


Bosutinib Cancer 3 years Modified**If current treatment or reoccurrence -


Braftovi Cancer 3 years Modified**If current treatment or reoccurrence -


Braftovi + Mektovi Cancer 3 years Modified**If current treatment or reoccurrence -


Brentuximab Vedotin Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


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 -







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 ModifiedBuprenorphine; Buprenorphine HCL Alcohol / Drug 2 years Modified

Busulfan Cancer 3 years Modified**If current treatment or reoccurrence -


Busulfex Cancer 3 years Modified**If current treatment or reoccurrence -


Butrans Alcohol / Drug 2 years Modified

BystolicCHF (Congestive


2 yearsModified

Level

Cabazitaxel Cancer 3 years Modified**If current treatment or reoccurrence -


Cabometyx Cancer 3 years Modified**If current treatment or reoccurrence -


Cabozantinib Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


CalphronKidney Dialysis


No coverageGraded

Calquence Cancer 3 years Modified**If current treatment or reoccurrence -


Campath Cancer 3 years Modified**If current treatment or reoccurrence -


Campral Alcohol / Drug 2 years Modified

Camptosar Cancer 3 years Modified**If current treatment or reoccurrence -


Candesartan; Candesartan CilexetilCHF (Congestive


2 yearsModified

Level

Capecitabine Cancer 3 years Modified**If current treatment or reoccurrence -







Capoten CHF (Congestive


2 yearsModified

Level

Caprelsa Cancer 3 years Modified**If current treatment or reoccurrence -


CaptoprilCHF (Congestive


2 years ModifiedLevel

CarbamazepinePsychotic Disorder

Seizures Ever Graded

Level

CarbatrolPsychotic Disorder

Other UseEver

Graded Level

CarbidopaCarbidopa-Levodopa

Parkinson’s Ever Graded

Carboplatin Cancer 3 years Modified**If current treatment or reoccurrence -


CardioplegicHeart Condition


2 years Modified

CardizemHeart Condition

Hypertension2 years

ModifiedLevel

Carfilzomib Cancer 3 years Modified**If current treatment or reoccurrence -


Carimune; Carimune Nanofiltered



Cariprazine Psychotic Disorder Ever Graded

Carmustine Cancer 3 yearsModified*



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 -


Ceenu Cancer 3 years Modified**If current treatment or reoccurrence -


CellceptHeart Surgery

Kidney / Liver Disorder 2 years

EverModifiedGraded

Ceritinib Cancer 3 years Modified**If current treatment or reoccurrence -


Cerubidine Cancer 3 years Modified**If current treatment or reoccurrence -


Cetuximab Cancer 3 years Modified**If current treatment or reoccurrence -







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

Chlorambucil Cancer 3 years Modified**If current treatment or reoccurrence -


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 coverageCinacalcet Kidney Dialysis 1 year No coverage

CIS-DDP Cancer 3 years Modified**If current treatment or reoccurrence -


Cisplatin Cancer 3 years Modified**If current treatment or reoccurrence -


Citicoline Alzheimer’s / Dementia Ever No coverage

Cladribine Cancer 3 years Modified**If current treatment or reoccurrence -


Clenbuterol COPD Ever Graded

Clofarabine Cancer 3 years Modified**If current treatment or reoccurrence -


Clolar Cancer 3 years Modified**If current treatment or reoccurrence -


ClonidineCancer PainOther Use

3 yearsModified*

Level



Clopidogrel (300 mg)Heart Condition


2 years Modified

Clopidogrel (75 mg)Heart Condition




ModifiedLevel




ClorazepateAlcohol / Drug

Other use2 years

ModifiedLevel

Clozapine Psychotic Disorder Ever Graded






Clozaril Psychotic Disorder Ever GradedCobicistat AIDS / HIV Ever No coverage

Cobimetinib Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


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


2 yearsModified*



Copanlisib Cancer 3 yearsModified*



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

Coreg; Coreg CR CHF (Congestive


2 yearsModified

Level

CorgardAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

CorlanorCHF (Congestive Heart

Failure) 2 years Modified

CorticotropinSystemic Lupus

Other UseEver

GradedLevel

Cosmegen Cancer 3 years Modified**If current treatment or reoccurrence -


Cotellic Cancer 3 years Modified**If current treatment or reoccurrence -


Coumadin

Cardiac Valve ReplacementTIA/Stroke

Pulmonary EmbolismThrombosis

2 years*2 years*

EverEver

Modified* Modified*

Level Level




CozaarCHF (Congestive


2 yearsModified

Level

Crixivan AIDS / HIV Ever No coverage






Crizotinib Cancer 3 years Modified**If current treatment or reoccurrence -


Cromolyn SodiumCOPD / Emphysema

AsthmaEver

GradedLevel

Cyclophosphamide Cancer 3 years Modified**If current treatment or reoccurrence -


CyclosporineHeart Surgery


EverModifiedGraded

Cyfos Cancer 3 years Modified**If current treatment or reoccurrence -


CymbaltaNeuropathy (Diabetic


2 yearsModified*



Cyramza Cancer 3 years Modified**If current treatment or reoccurrence -


Cystagon Kidney Disorder Ever GradedCysteamine Bitartrate Kidney Disorder Ever Graded

Cytarabine; Cytarabine Liposomal Cancer 3 years Modified**If current treatment or reoccurrence -


CytogamHeart Surgery


EverModifiedGraded

Cytosar-U Cancer 3 years Modified**If current treatment or reoccurrence -


Cytovene AIDS / HIV Ever No coverage

Cytoxan Cancer 3 years Modified**If current treatment or reoccurrence -


Dabrafenib Cancer 3 years Modified**If current treatment or reoccurrence -


Dacarbazine Cancer 3 years Modified**If current treatment or reoccurrence -


Daclatasvir; Daclatasvir systemic; Daclatasvir Dihydrochloride

Liver 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 -


Dactinomycin Cancer 3 years Modified**If current treatment or reoccurrence -


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

Daliresp COPD Ever Graded

DalproPsychotic Disorder

SeizuresEver

Graded Level






DalteparinHeart Condition




ModifiedLevel




Daranavir/Cobicistat AIDS / HIV Ever No coverage

Daratumumab Cancer 3 years Modified**If current treatment or reoccurrence -


Darbepoetin AlfaCancer

Kidney Disorder 3 years

EverModified*

Graded


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

Darzalex Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


Daunorubicin; Daunorubicin HCL; Daunorubicin Liposomal



Daunoxome Cancer 3 years Modified**If current treatment or reoccurrence -


Decitabine Cancer 3 years Modified**If current treatment or reoccurrence -


DecostriolKidney Dialysis


1 yearEverEver


Defibrotide; Defibrotide Sodium Cancer 3 years Modified**If current treatment or reoccurrence -


Defitelio Cancer 3 years Modified**If current treatment or reoccurrence -


Degarelix, Degarelix Acetate Cancer 3 years Modified**If current treatment or reoccurrence -


Delavirdine AIDS / HIV Ever No coverageDelflex Kidney Dialysis 1 year No coverage

DemadexCHF (Congestive



Denileukin Diftitox Cancer 3 years Modified**If current treatment or reoccurrence -







Denosumab Cancer 3 yearsModified*


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 -


Depo-Provera Cancer 3 years Modified**If current treatment or reoccurrence -


DeproicPsychotic Disorder

SeizuresEver

Graded Level

Descovy AIDS / HIV Ever No coverage

Dexrazoxane Cancer 3 years Modified**If current treatment or reoccurrence -


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

Ever No coverage

DiazepamAlcohol / Drug

Other use2 years

ModifiedLevel

Didanosine AIDS / HIV Ever No coverage

DigitalisCHF (Congestive

Heart Failure)Atrial Fibrillation

2 yearsModified

Level

DigitekCHF (Congestive


2 yearsModified

Level

DigitoxinCHF (Congestive


2 yearsModified

Level

DigoxinCHF (Congestive Heart Failure)

Atrial Fibrillation2 years

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 -


DiovanCHF (Congestive


2 yearsModified

Level






Dipyridamole Heart Condition




ModifiedLevel




Disulfiram Alcohol / Drug 2 years Modified

DiurilCHF (Congestive



DivalproexPsychotic Disorder

SeizuresEver

Graded Level

Dobutamine HCL; Dobutamine HCL/D5W; Dobutamine-Dextrose

CHF (Congestive Heart Failure)

2 years Modified

Dobutrex CHF (Congestive


Docefrez Cancer 3 years Modified**If current treatment or reoccurrence -


Docetaxel Cancer 3 years Modified**If current treatment or reoccurrence -


Dolophine Alcohol / Drug 2 years ModifiedDolutegravir AIDS / HIV Ever No coverage

Donepezil Alzheimer’s / Dementia Ever No coverage

DopamineHeart Condition


2 yearsModified

Doxercalciferol Kidney Dialysis 1 year No coverage

Doxil Cancer 3 years Modified**If current treatment or reoccurrence -


Doxorubicin HCL; Doxorubicin Liposomal



DroperidolPsychotic Disorder

Other UseEver

GradedLevel

DroxiaCancer

Sickle Cell3 years

EverModified*

Graded



DTIC-Dome Cancer 3 years Modified**If current treatment or reoccurrence -


DuleraCOPD / Emphysema

AsthmaEver

GradedLevel

Duloxetine; Duloxetine HydrochlorideNeuropathy (Diabetic


2 yearsModified*



Duoneb COPD Ever Graded

DuraclonCancer PainOther Use

3 yearsModified*

Level








Durvalumab Cancer 3 years Modified**If current treatment or reoccurrence -


Dylix 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


2 yearsModified

Level

Edurant AIDS / HIV Ever No coverageEfavirenz 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 -


EliphosKidney Dialysis


No coverageGraded

Elitek Cancer 3 years Modified**If current treatment or reoccurrence -


ElixophyllinCOPD / Emphysema

AsthmaEver

GradedLevel

Ellence Cancer 3 years Modified**If current treatment or reoccurrence -


Elotuzumab Cancer 3 years Modified**If current treatment or reoccurrence -


Eloxatin Cancer 3 years Modified**If current treatment or reoccurrence -


Elspar Cancer 3 years Modified**If current treatment or reoccurrence -


Elvitegravir AIDS / HIV Ever No coverage

Emcyt Cancer 3 years Modified**If current treatment or reoccurrence -


Emend Cancer 3 yearsModified*



EmendCancer

Other use3 years

Modified*Level



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






Empliciti Cancer 3 years Modified**If current treatment or reoccurrence -


Emtricitabine;Emtricitabine-tenofovir

Emtricitabine-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 -


Encorafenib Cancer 3 years Modified**If current treatment or reoccurrence -


Encorafenib + Binimetinib Cancer 3 years Modified**If current treatment or reoccurrence -


Enfuvirtide AIDS / HIV Ever No coverage

Enoxaparin Sodium Heart Condition


2 years Modified

Entacapone Parkinson’s Ever Graded

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

EntrestoCHF (Congestive


Enzalutamide Cancer 3 years Modified**If current treatment or reoccurrence -


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

Epirubicin Cancer 3 years Modified**If current treatment or reoccurrence -


EpitolPsychotic Disorder

Seizures Ever

GradedLevel

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 -







Ergamisol Cancer 3 years Modified**If current treatment or reoccurrence -


Ergoloid Mesylates Alzheimer’s / Dementia Ever No coverage

Eribulin Cancer 3 years Modified**If current treatment or reoccurrence -


Erleada Cancer 3 years Modified**If current treatment or reoccurrence -


Erlotinib Cancer 3 years Modified**If current treatment or reoccurrence -


Erwinaze Cancer 3 years Modified**If current treatment or reoccurrence -


EsidrixCHF (Congestive


2 yearsModified

Level

Eskalith Psychotic Disorder Ever Graded

Estramustine; Estramustine Phosphate



Ethambutol Tuberculosis (TB) Ever Graded

Ethyol Cancer 3 years Modified**If current treatment or reoccurrence -


Etopophos Cancer 3 years Modified**If current treatment or reoccurrence -


Etoposide Cancer 3 years Modified**If current treatment or reoccurrence -


Etravirine AIDS / HIV Ever No coverage

Eulexin Cancer 3 years Modified**If current treatment or reoccurrence -


Everolimus (afinitor) Cancer 3 years Modified**If current treatment or reoccurrence -


Everolimus (zortress)Kidney Failure Liver Disorder

Ever Graded

Eviplera AIDS / HIV Ever No coverageEvotaz AIDS / HIV Ever No coverageEvzio Alcohol / Drugs 2 years Modified

Exelon Alzheimer’s / Dementia Ever No coverage

ExemestaneCancer

3 years Modified**If current treatment or reoccurrence -


Fanapt Psychotic Disorder Ever Graded

Fareston Cancer 3 years Modified**If current treatment or reoccurrence -


Farydak Cancer 3 years Modified**If current treatment or reoccurrence -


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






Faslodex Cancer 3 years Modified**If current treatment or reoccurrence -


Fazaclo Psychotic Disorder Ever Graded

Femara Cancer 3 years Modified**If current treatment or reoccurrence -


Fentanyl Citrate Cancer Pain 3 years Modified**If current treatment or reoccurrence -


Fentora Cancer Pain 3 years Modified**If current treatment or reoccurrence -


Firmagon Cancer 3 years Modified**If current treatment or reoccurrence -


Flebogamma; Flebogamma DIF Cancer 3 years Modified**If current treatment or reoccurrence -


Flovent; Flovent Diskus; Flovent Rotadisk; Flovent HFA


EverGraded

Level

Floxuridine Cancer 3 years Modified**If current treatment or reoccurrence -


Fludara Cancer 3 years Modified**If current treatment or reoccurrence -


Fludarabine Phosphate Cancer 3 yearsModified*



Fluorouracil Cancer 3 years Modified**If current treatment or reoccurrence -


Fluoxymesterone Cancer 3 years Modified**If current treatment or reoccurrence -


Fluphenazine Fluphenazine HCL; Fluphenazine Decanoate

Psychotic Disorder Ever Graded

Flutamide Cancer 3 years Modified**If current treatment or reoccurrence -


FluticasoneCOPD / Emphysema

AsthmaEver

GradedLevel

Fluticasone Furoate COPD Ever Graded

Folotyn Cancer 3 years Modified**If current treatment or reoccurrence -


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




FUDR Cancer 3 years Modified**If current treatment or reoccurrence -


Fulvestrant Cancer 3 years Modified**If current treatment or reoccurrence -


FurosemideCHF (Congestive


2 yearsModified

Level

Fusilev Cancer 3 years Modified**If current treatment or reoccurrence -


Fuzeon AIDS / HIV Ever No coverage

GabapentinNeuropathy (Diabetic


2 yearsModified*



Galantamine; Galantamine Hydrobromide

Alzheimer’s / Dementia Ever No coverage

Gamimune, Gammagard, Gammaplex, Gamunex



Ganciclovir AIDS / HIV Ever No coverage

Gazyva Cancer 3 years Modified**If current treatment or reoccurrence -


Gefitinib Cancer 3 years Modified**If current treatment or reoccurrence -


Gemcitabine; Gemcitabine HCL Cancer 3 years Modified**If current treatment or reoccurrence -


Gemtuzumab Cancer 3 years Modified**If current treatment or reoccurrence -


Gemzar Cancer 3 years Modified**If current treatment or reoccurrence -


GengrafHeart Surgery


EverModifiedGraded

Genvoya AIDS / HIV Ever No coverageGeodon Psychotic Disorder Ever Graded

Gilotrif Cancer 3 years Modified**If current treatment or reoccurrence -


Glassia COPD Ever GradedGlecaprevir/Pibrentasvir Hepatitis Ever Graded






Gleevec Cancer 3 yearsModified*



Gliadel Wafer Cancer 3 years Modified**If current treatment or reoccurrence -


Goserelin Cancer 3 yearsModified*



GraliseNeuropathy (Diabetic


2 yearsModified*



Guaifenesin;Guaifenesin-theophylline


EverGraded

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

Halaven Cancer 3 yearsModified*


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 -


Harvoni 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 -


Hexalen Cancer 3 years Modified**If current treatment or reoccurrence -


Hivid AIDS / HIV Ever No coverage

HorizantNeuropathy (Diabetic


2 yearsModified*



Hycamtin Cancer 3 years Modified**If current treatment or reoccurrence -


Hydergine Alzheimer’s / Dementia Ever No coverage

Hydralazine HCL CHF (Congestive


2 yearsModified

Level

Hydrea Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


HygrotonCHF (Congestive


2 yearsModified

Level

HyzaarHeart DiseaseHypertension

2 yearsModified

Level

Ibrance Cancer 3 years Modified**If current treatment or reoccurrence -


Ibritumomab Cancer 3 years Modified**If current treatment or reoccurrence -


Ibrutinib Cancer 3 yearsModified*



Iclusig Cancer 3 yearsModified*



Idamycin PFS Cancer 3 years Modified**If current treatment or reoccurrence -


Idarubicin; Idarubicin HCL Cancer 3 years Modified**If current treatment or reoccurrence -


Idelalisib Cancer 3 years Modified**If current treatment or reoccurrence -


Idhifa Cancer 3 years Modified**If current treatment or reoccurrence -


Ifex Iflex Mesnex Combo Pack



Ifosfamide; Ifosfamide-Mesna; Ifosfamidum



Iloperidone Psychotic Disorder Ever Graded

Imatinib Mesylate Cancer 3 years Modified**If current treatment or reoccurrence -


Imbruvica Cancer 3 years Modified**If current treatment or reoccurrence -


Imdur Heart Disease - Angina 2 years Modified

Imfinzi Cancer 3 years Modified**If current treatment or reoccurrence -


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






ImipramineNeuropathy (Diabetic


2 yearsModified*



Imlygic Cancer 3 years Modified**If current treatment or reoccurrence -


Immune Globulin Cancer 3 years Modified**If current treatment or reoccurrence -


ImuranKidney Failure


EverGraded Graded

Level

InamrinoneCHF (Congestive


InapsinePsychotic Disorder

Other UseEver

GradedLevel

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

Incruse Ellipta COPD Ever GradedIndacaterol 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 coverage

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

Inlyta Cancer 3 years Modified**If current treatment or reoccurrence -


Innopran XLAngina (Chest Pain)

Hypertension2 years

ModifiedLevel

Inotuzumab Ozogamicin Cancer 3 years Modified**If current treatment or reoccurrence -


InspraCHF (Congestive


2 yearsModified

Level

Integrilin Heart Condition


2 years Modified

Intelence AIDS / HIV Ever No coverage

Interferon alfacon-1 Liver Disorder / Hepatitis Ever Graded* * If Stage 3/C Cirrhosis - No coverage

Intron ACancer

Hepatitis C3 years2 years

Modified Graded


If treatment free > 3 years - LevelInvega, Invega Sustenna Psychotic Disorder Ever Graded

Invirase AIDS / HIV Ever No coverage

Iobenguane I 131 Cancer 3 years Modified**If current treatment or reoccurrence -







Ipilimumab Cancer 3 years Modified**If current treatment or reoccurrence -


Ipratropium BromideCOPD / Emphysema

AsthmaEver

GradedLevel

IrbesartanKidney Disorder

Other useEver

GradedLevel

IrenkaNeuropathy (Diabetic


2 yearsModified*



Iressa Cancer 3 years Modified**If current treatment or reoccurrence -


Irinotecan Cancer 3 years Modified**If current treatment or reoccurrence -


Iron Sucrose Kidney Disorder Ever GradedIsentress AIDS / HIV Ever No coverage

Ismo Angina (Chest Pain) 2 years ModifiedIsochron 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 -


Isuprel COPD / Emphysema

AsthmaEver

GradedLevel

IvarbradineCHF (Congestive Heart

Failure) 2 years Modified

IVIG Cancer 3 yearsModified*



Ixabepilone Cancer 3 years Modified**If current treatment or reoccurrence -


Ixazomib Cancer 3 years Modified**If current treatment or reoccurrence -


Ixempra Cancer 3 years Modified**If current treatment or reoccurrence -


Jakafi Cancer 3 years Modified**If current treatment or reoccurrence -


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






Jantoven

Cardiac Valve ReplacementTIA/Stroke

Pulmonary EmbolismThrombosis

< 2 years*< 2 years*

EverEver

Modified Modified

Level Level




Jevtana Cancer 3 years Modified**If current treatment or reoccurrence -


Kadcyla Cancer 3 years Modified**If current treatment or reoccurrence -


Kaletra AIDS / HIV Ever No coverageKemadrin Parkinson’s Ever Graded

Kepivance Cancer 3 years Modified**If current treatment or reoccurrence -


Keytruda Cancer 3 years Modified**If current treatment or reoccurrence -


Kisqali Cancer 3 years Modified**If current treatment or reoccurrence -


Kivexa AIDS / HIV Ever No coverage

Kyprolis Cancer 3 years Modified**If current treatment or reoccurrence -


LamictalPsychotic Disorder

SeizuresEver

Graded Level

LamivudineAIDS / HIVHepatitis B

EverNo coverage

Graded

LamotriginePsychotic Disorder

SeizuresEver

Graded Level

Lanoxin; LanoxicapsCHF (Congestive Heart Failure)

Atrial Fibrillation2 years

ModifiedLevel

Lanreotide; Lanreotide Acetate Cancer 3 years Modified**If current treatment or reoccurrence -


Lanthanum Kidney Disorder Ever Graded

Lapatinib Cancer 3 years Modified**If current treatment or reoccurrence -


Lariago; Lariago-DSSystemic Lupus

Other UseEver

GradedLevel

Larodopa Parkinson’s

Restless Leg SyndromeEver

GradedLevel

LasixCHF (Congestive


2 yearsModified

Level

Latuda Psychotic Disorder Ever Graded

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

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






Lemtrada Cancer

Multiple Sclerosis (MS)3 years Modified*

Level



Lenvatinib; Lenvatinib Mesylate Cancer 3 yearsModified*



Lenvima Cancer 3 years Modified**If current treatment or reoccurrence -


Letrozole Cancer 3 years Modified**If current treatment or reoccurrence -


Leucovorin Calcium Cancer 3 years Modified**If current treatment or reoccurrence -


Leukeran Cancer 3 yearsModified*



Leukine Cancer 3 years Modified**If current treatment or reoccurrence -


Leuprolide Cancer 3 years Modified**If current treatment or reoccurrence -


Leustatin Cancer 3 years Modified**If current treatment or reoccurrence -


LevalbuterolCOPD / Emphysema

AsthmaEver

GradedLevel

Levamisole HCL Cancer 3 years Modified**If current treatment or reoccurrence -


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 -


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 -


Lonsurf Cancer 3 years Modified**If current treatment or reoccurrence -


Lopinavir; Lopinavir-ritonavir

AIDS / HIV Ever No coverage

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






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

Lupron; Lupron Depot Cancer 3 years Modified**If current treatment or reoccurrence -


Lurasidone Psychotic Disorder Ever Graded Lymphocyte Immune Globulin Kidney Failure Ever Graded

Lynparza Cancer 3 years Modified**If current treatment or reoccurrence -


LyricaNeuropathy (Diabetic


2 yearsModified*



Lysodren Cancer 3 yearsModified*


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

Matulane Cancer 3 yearsModified*



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 -


Megace ESAIDS / HIV

Cancer Ever

3 yearsNo coverageModified*



Megestrol, Megestrol AcetateAIDS / HIV

Cancer Ever

3 yearsNo coverageModified*



Mekinist Cancer 3 years Modified**If current treatment or reoccurrence -


Mektovi Cancer 3 years Modified**If current treatment or reoccurrence -







Mellaril Psychotic Disorder Ever Graded

MelphalanMelphalanHydrochloride



Memantine, Memantine HCL Alzheimer’s / Dementia Ever No coverageMepron AIDS / HIV Ever No coverage

Mercaptopurine Cancer 3 years Modified**If current treatment or reoccurrence -


Mesna Cancer 3 years Modified**If current treatment or reoccurrence -


Mesnex Cancer 3 years Modified**If current treatment or reoccurrence -


Mesoridazine Psychotic Disorder Ever Graded

MetaproterenolCOPD / Emphysema

AsthmaEver

GradedLevel

Metastron Cancer 3 years Modified**If current treatment or reoccurrence -


Methadone HCL Alcohol / Drug 2 years ModifiedMethadose Alcohol / Drug 2 years Modified

MethotrexateCancer

Rheumatoid Arthritis3 years

Modified*Level



MethyclothiazideCHF (Congestive


2 yearsModified

Level

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

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

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