master prescription drug list
TRANSCRIPT
MASTER PRESCRIPTION DRUG LIST North American – Liberty Bankers – Americo Eagle Premier
(USE CTR F TO SEARCH ALL THREE CARRIERS)
Eagle Premier ® Series
Prescription Drug Guide
2016 Edition For agent use only.
Not for public use.
13-178-12 (07/16)
Prescription Drug Guide
This Prescription Drug Guide is used in conjunction with Americo’s underwriting guidelines and does not reflect the full
underwriting standards of Americo or all prescription drugs considered by Americo. This Guide provides a list of com-mon
drugs, their uses, and eligible Eagle Premier Series products available to an applicant taking one of the listed drugs.
Americo products listed below under the Benefit Eligibility column are not a guarantee of policy issuance, and prescription
drug combinations may result in ineligibility. Further, any prescription drug used in combination with a re-lated or unrelated
medical condition could result in ineligibility. Each application is reviewed based on the circumstances and conditions
represented therein and may involve additional requirements. Both this Guide and the full underwriting guidelines used by
Americo are subject to change. Note: The brand name drug is in ALL CAPS and its generic equivalent is next to it in
lowercase letters. This guide allows you to search either by generic or brand name.
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
A/B OTIC Ear pain any Eagle Level
abacavir (ZIAGEN) HIV/AIDS any Eagle Guaranteed
abacavir/lamivudine (EPZICOM) HIV/AIDS any Eagle Guaranteed
ABILIFY (aripiprazole) Psychotic disorders 24 months Eagle Level; decline 40-49
ABSORBINE ARTHRITIS Topical arthritis pain treatment any Eagle Level
ABSTRAL (fentanyl) sublingual tablets Cancer pain 24 months Eagle Guaranteed
acamprosate (CAMPRAL) Alcohol dependency treatment 24 months Eagle Guaranteed
acarbose (PRECOSE) Diabetes any Eagle Level (with no diabetic complications)
ACCOLATE (zafirlukast) Asthma any Eagle Level
ACCUNEB (albuterol) Asthma any Eagle Level
ACCUPRIL (quinapril) Hypertension any Eagle Level
ACCUZYME (papain and urea) Dermatological treatment any Eagle Level
acebutolol HCl (SECTRAL) Hypertension any Eagle Level
acebutolol HCl (SECTRAL) Arrhythmia any Eagle Level
ACEON (perindopril) Hypertension any Eagle Level
ACEON (perindopril) Coronary artery disease 12 months Eagle Guaranteed
acetaminophen with codeine #3 (TYLENOL WITH Pain relief - narcotic any Eagle Level
CODEINE #3)
ACETASOL HC (acetic acid w/hydrocortisone) External ear infection any Eagle Level
acetazolamide (DIAMOX) Congestive heart failure any Eagle Guaranteed
acetazolamide (DIAMOX) Seizures any Eagle Level
acetazolamide (DIAMOX) Mountain sickness any Eagle Level
acetazolamide (DIAMOX) Glaucoma any Eagle Level
ACETIC ACID External ear infection any Eagle Level
acetic acid/aluminum acetate (DOMEBORO) External ear infection any Eagle Level
acetic acid/hydrocortisone (ACETASOL HC) External ear infection any Eagle Level
acetylcysteine (MUCOMYST) Emphysema any Eagle Guaranteed
acetylcysteine (MUCOMYST) Tuberculosis any Eagle Guaranteed
acetylcysteine (MUCOMYST) Pneumonia/bronchitis any Eagle Level
acetylcysteine (MUCOMYST) Cystic fibrosis any Eagle Guaranteed
ACLOVATE (alclometasone dipropionate) Dermatological treatment any Eagle Level
ACTIGALL (ursodiol) Gallstones any Eagle Level
ACTIGALL (ursodiol) Liver cirrhosis any Eagle Level
ACTIQ (fentanyl citrate) lozenge Cancer pain 24 months Eagle Guaranteed
ACTIVELLA (estradiol/norethindrone) Menopausal symptoms any Eagle Level
p. 2
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ACTONEL (risedronate) Osteoporosis any Eagle Level
ACTOPLUS MET (metformin and pioglitazone) Diabetes any Eagle Level (with no diabetic complications)
ACTOS (pioglitazone) Diabetes any Eagle Level (with no diabetic complications)
ACULAR LS Eye drops any Eagle Level
acyclovir (ZOVIRAX) Shingles/chickenpox/genital herpes any Eagle Level
ADALAT (nifedipine) Hypertension any Eagle Level
adalimumab (HUMIRA) Rheumatoid arthritis/juvenile
any Eagle Level psoriatic arthritis
adalimumab (HUMIRA) Crohn’s disease any Eagle Level
adalimumab (HUMIRA) Ankylosing spondylitis any Eagle Level
adalimumab (HUMIRA) Plaque psoriasis any Eagle Level
ADDERALL (dextroamphetamine/amphetamine) ADHD/narcolepsy any Eagle Level
adefovir (HEPSERA) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle
Guaranteed)
ADVAIR DISKUS (fluticasone propionate/salmeterol) Asthma any Eagle Level
ADVAIR DISKUS (fluticasone propionate/salmeterol) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
ADVICOR (niacin/lovastatin) Elevated cholesterol any Eagle Level
AEROBID (flunisolide) Asthma any Eagle Level
AFEDITAB (nifedipine) Hypertension any Eagle Level
AGGRENOX (aspirin/dipyridamole) Stroke/TIA 12 months Eagle Guaranteed
AGRYLIN (anagrelide HCl) Cancer 24 months Eagle Guaranteed
albuterol (ACCUNEB, PROAIR HFA, PROVENTIL, Asthma any Eagle Level
VENTOLIN)
albuterol/ipratropium (COMBIVENT, DUONEB) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
alclometasone dipropionate (ACLOVATE) Dermatological treatment any Eagle Level
ALDACTAZIDE (hydrochlorothiazide/spironolactone) Hypertension any Eagle Level
ALDACTAZIDE (hydrochlorothiazide/spironolactone) Liver cirrhosis any Eagle Guaranteed
ALDACTAZIDE (hydrochlorothiazide/spironolactone) Congestive heart failure any Eagle Guaranteed
ALDACTAZIDE (hydrochlorothiazide/spironolactone) Kidney disease any Eagle Guaranteed
ALDACTONE (spironolactone) Hyperaldosteronism/low potassium any Eagle Level
ALDACTONE (spironolactone) Hypertension any Eagle Level
ALDACTONE (spironolactone) Liver cirrhosis any Eagle Guaranteed
ALDACTONE (spironolactone) Congestive heart failure any Eagle Guaranteed
ALDACTONE (spironolactone) Kidney disease any Eagle Guaranteed
ALDARA (imiquimod) Dermatological treatment any Eagle Level
ALDOMET (methyldopa) Hypertension any Eagle Level
ALINIA Gastrointestinal infection any Eagle Level
aliskiren (TEKTURNA) Hypertension any Eagle Level
aliskiren/hydrochlorothiazide (TEKTURNA HCT) Hypertension any Eagle Level
ALLOPURINOL Gout any Eagle Level
ALLOPURINOL Cancer treatment-related uric acid
24 months Eagle Guaranteed elevation
ALPHAGAN (brimonidine tartrate) Glaucoma any Eagle Level
p. 3
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ALPRAZOLAM Anxiety/panic disorder any Eagle Level
ALTABAX Dermatological treatment any Eagle Level
ALTACE (ramipril) Hypertension any Eagle Level
ALTACE (ramipril) Congestive heart failure any Eagle Guaranteed
ALTOCOR (lovastatin) Elevated cholesterol any Eagle Level
ALTOPREV (lovastatin) Elevated cholesterol any Eagle Level
ALUPENT (metaproterenol sulfate) Asthma any Eagle Level
ALUPENT (metaproterenol sulfate) Emphysema any Eagle Guaranteed
amantadine HCl (SYMMETREL) Parkinson’s disease any Eagle Level
amantadine HCl (SYMMETREL) Drug-induced movement disorders any Eagle Level
AMARYL (glimepiride) Diabetes any Eagle Level (with no diabetic complications)
AMBIEN (zolpidem tartrate) Insomnia any Eagle Level
AMCINONIDE Dermatological treatment any Eagle Level
AMDRY-D Cough/cold/allergies any Eagle Level
amiloride (MIDAMOR) Congestive heart failure any Eagle Guaranteed
amiloride (MIDAMOR) Hypertension any Eagle Level
AMINOPHYLLINE Asthma any Eagle Level
AMINOPHYLLINE Emphysema/chronic obstructive
any Eagle Guaranteed pulmonary disease (COPD)
amiodarone (CORDARONE, PACERONE) Heart arrhythmia any Eagle Level
AMITIZA (lubiprostone) Constipation any Eagle Level
AMITRIPTYLINE HCL Depression 24 months Eagle Level
amlodipine (NORVASC) Hypertension any Eagle Level
amlodipine (NORVASC) Coronary artery disease 12 months Eagle Guaranteed
amlodipine/atorvastatin (CADUET ) Hypertension any Eagle Level
amlodipine/atorvastatin (CADUET ) Coronary artery disease 12 months Eagle Guaranteed
amlodipine/benazepril (LOTREL) Hypertension any Eagle Level
amlodipine/olmesartan (AZOR) Hypertension any Eagle Level
amlodipine/valsartan (EXFORGE) Hypertension any Eagle Level
ammonium lactate (LAC-HYDRIN) Dermatological treatment any Eagle Level
AMOXICILLIN Antibiotic any Eagle Level
amoxicillin/potassium clavulanate (AUGMENTIN) Antibiotic any Eagle Level
AMPHOTERICIN B Antifungal treatment any Eagle Level
AMPICILLIN Antibiotic any Eagle Level
ANAFRANIL (clomipramine HCl) Obsessive compulsive disorder any Eagle Level
anagrelide HCl (AGRYLIN) Cancer 24 months Eagle Guaranteed
ANAPLEX DMX Cough/cold/allergies any Eagle Level
anastrozole (ARIMIDEX) Cancer 24 months Eagle Guaranteed
ANDROGEL Testosterone replacement any Eagle Level
ANEMAGEN Iron supplementation any Eagle Level
ANIMI-3 Vitamin supplement any Eagle Level
ANTABUSE Alcohol dependency treatment 24 months Eagle Guaranteed
ANTARA (fenofibrate) Elevated cholesterol/triglycerides any Eagle Level
p. 4
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ANUCORT-HC Hemorrhoidal treatment any Eagle Level
APEXICON E Dermatological treatment any Eagle Level
APIDRA (insulin glulisine) Diabetes any Eagle Level (with no diabetic complications)
APLENZIN (bupropion) Depression any Eagle Level
aprepitant (EMEND) Nausea/vomiting prevention
any Eagle Level pre-SURGERY
aprepitant (EMEND) Nausea/vomiting prevention
24 months Eagle Guaranteed pre-CHEMOTHERAPY
APRESOLINE (hydralazine HCl) Hypertension any Eagle Level
ARAVA (leflunomide) Rheumatoid arthritis any Eagle Level
AREDIA (pamidronate) Cancer 24 months Eagle Guaranteed
AREDIA (pamidronate) Paget’s bone disease any Eagle Level
arformoterol inhalation (BROVANA) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
ARICEPT (donepezil) Alzheimer’s disease any Eagle Guaranteed
ARIMIDEX (anastrozole) Cancer 24 months Eagle Guaranteed
aripiprazole (ABILIFY) Psychotic disorders 24 months Eagle Level; decline 40-49
ARIXTRA (fondaparinux sodium) Presurgical PREVENTION of blood
any Eagle Level clot
ARIXTRA (fondaparinux sodium) Treatment of blood clot any Eagle Level
ARIXTRA (fondaparinux sodium) Treatment of pulmonary embolism
any Eagle Level (clot)
ARMOUR THYROID Thyroid replacement any Eagle Level
AROMASIN (exemestane) Cancer 24 months Eagle Guaranteed
ARTANE (trihexyphenidyl) Parkinson’s disease any Eagle Level
ARTHROTEC 75 Pain relief - anti-inflammatory any Eagle Level
ASACOL (mesalamine) Ulcerative colitis any Eagle Level
ASCOMP/CODEINE Tension headache any Eagle Level
ASMANEX Asthma any Eagle Level
ASPIRIN/CODEINE Pain relief any Eagle Level
aspirin/dipyridamole (AGGRENOX) Stroke/TIA 12 months Eagle Guaranteed
ASTELIN (azelastine) Nasal spray any Eagle Level
ATACAND (candesartan) Hypertension any Eagle Level
ATACAND (candesartan) Congestive heart failure any Eagle Guaranteed
ATACAND HCT (candesartan/hydrochlorothiazide) Hypertension any Eagle Level
atazanavir (REYATAZ) HIV-related anemia any Eagle Guaranteed
atenolol (TENORMIN) Hypertension any Eagle Level
atenolol (TENORMIN) Angina 12 months Eagle Guaranteed
atenolol (TENORMIN) Heart attack 12 months Eagle Guaranteed
atenolol/chlorthalidone (TENORETIC) Hypertension any Eagle Level
ATIVAN (lorazepam) Anxiety any Eagle Level
atorvastatin (LIPITOR) Elevated cholesterol any Eagle Level
ATRIPLA (efavirenz/emtricitabine/tenofovir disoproxil HIV/AIDS any Eagle Guaranteed
fumarate)
ATROPINE SULFATE Eye drops any Eagle Level
p. 5
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ATROVENT HFA (ipratropium bromide HFA) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)/emphysema
ATROVENT NASAL SPRAY (ipratropium bromide nasal Allergic and non-allergic nasal any Eagle Level
spray) symptoms
ATUSS DS Cough/cold/allergies any Eagle Level
AUGMENTED BETAMETHASONE DIPROPIONATE Dermatological treatment any Eagle Level
AUGMENTIN (amoxicillin/potassium clavulanate) Antibiotic any Eagle Level
AVALIDE (irbesartan/hydrochlorothiazide) Hypertension any Eagle Level
AVANDAMET (metformin/rosiglitazone) Diabetes any Eagle Level (with no diabetic complications)
AVANDARYL (glimepiride/rosiglitazone) Diabetes any Eagle Level (with no diabetic complications)
AVANDIA (rosiglitazone) Diabetes any Eagle Level (with no diabetic complications)
AVAPRO (irbesartan) Hypertension any Eagle Level
AVAPRO (irbesartan) Diabetic kidney disease any Eagle Guaranteed
AVELOX (moxifloxacin) Antibiotic any Eagle Level
AVINZA (morphine sulfate) Moderate to severe pain any Eagle Level
AVODART (dutasteride) Benign prostatic hypertrophy any Eagle Level
AVONEX (interferon beta-1a) Multiple sclerosis any Eagle Level
AXID (nizatidine) Ulcers/esophagitis any Eagle Level
AZASAN (azathioprine) Kidney transplant rejection
any Eagle Guaranteed prevention
AZASAN (azathioprine) Rheumatoid arthritis any Eagle Level
AZASITE Ophthalmic agent any Eagle Level
azathioprine (IMURAN, AZASAN) Kidney transplant rejection
any Eagle Guaranteed prevention
azathioprine (IMURAN, AZASAN) Rheumatoid arthritis any Eagle Level
azelastine (ASTELIN) Nasal spray any Eagle Level
AZELEX Dermatological treatment any Eagle Level
AZILECT (rasagiline) Parkinson’s disease any Eagle Level
AZITHROMYCIN Antibiotic any Eagle Level
AZMACORT (triamcinolone oral inhalation) Asthma any Eagle Level
AZOPT Ophthalmic agent any Eagle Level
AZOR (amlodipine/olmesartan) Hypertension any Eagle Level
BACITRACIN Dermatological treatment any Eagle Level
BACITRACIN/POLYMYXIN B Ophthalmic agent any Eagle Level
BACLOFEN Muscular sclerosis any Eagle Level
BACLOFEN Spasticity from spinal cord injury any Eagle Level
BACTROBAN Dermatological antibiotic any Eagle Level
BACTROBAN NASAL Nasal infection any Eagle Level
BARACLUDE (entecavir) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle
Guaranteed)
beclomethasone (QVAR) Asthma any Eagle Level
BECONASE AQ Nasal agent any Eagle Level
BELLADONNA ALKALOIDS/PHENOBARBITAL Ulcers any Eagle Level
benazepril HCl (LOTENSIN) Hypertension any Eagle Level
p. 6
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
BENICAR HCT (olmesartan) Hypertension any Eagle Level
BENTYL (dicyclomine) Irritable bowel syndrome any Eagle Level
BENZACLIN Dermatological treatment any Eagle Level
BENZONATATE Cough/cold/allergies any Eagle Level
benztropine mesylate (COGENTIN) Parkinson’s disease any Eagle Level
BEPREVE Ophthalmic agent any Eagle Level
BETAMETHASONE DIPROPIONATE Dermatological treatment any Eagle Level
BETAPACE (sotalol) Heart arrhythmia any Eagle Level
BETHANECHOL CHLORIDE Urinary spasm/retention any Eagle Level
BETIMOL Ophthalmic agent any Eagle Level
BETOPTIC-S Eye drops any Eagle Level
BIAXIN XL Antibiotic any Eagle Level
bicalutamide (CASODEX) Cancer 24 months Eagle Guaranteed
BICILLIN L-A Antibiotic any Eagle Level
BIDIL (isosorbide dinitrate and hydralazine Congestive heart failure any Eagle Guaranteed
hydrochloride)
BILTRICIDE Worm infection any Eagle Level
BIONECT Dermatological treatment any Eagle Level
BISACODYL EC Constipation any Eagle Level
BISMATROL Diarrhea any Eagle Level
BISOPROLOL FUMARATE Hypertension any Eagle Level
BISOPROLOL FUMARATE/HCTZ Hypertension any Eagle Level
BLEPHAMIDE Eye drops any Eagle Level
BONIVA (ibandronate) Osteoporosis any Eagle Level
BOTOX (onabotulinumtoxinA) Spasticity/multiple indications any Eagle Level
BRETHINE (terbutaline) Asthma/bronchitis any Eagle Level
BRETHINE (terbutaline) Emphysema any Eagle Guaranteed
BRICANYL (terbutaline) Asthma/bronchitis any Eagle Level
BRICANYL (terbutaline) Emphysema any Eagle Guaranteed
brimonidine tartrate (ALPHAGAN) Glaucoma any Eagle Level
BROMETANE DX Cough/cold/allergies any Eagle Level
BROVANA (arformoterol inhalation) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
BUDEPRION (bupropion) Depression 24 months Eagle Level
budesonide/formoterol (SYMBICORT) Asthma any Eagle Level
budesonide/formoterol (SYMBICORT) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
bumetanide (BUMEX) Congestive heart failure any Eagle Guaranteed
bumetanide (BUMEX) Liver disease any Eagle Guaranteed
bumetanide (BUMEX) Kidney disease any Eagle Guaranteed
BUMEX (bumetanide) Congestive heart failure any Eagle Guaranteed
BUMEX (bumetanide) Liver disease any Eagle Guaranteed
BUMEX (bumetanide) Kidney disease any Eagle Guaranteed
BUPROBAN (bupropion) Smoking cessation 12 months Smoking rates (Eagle Level)
p. 7
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
bupropion (APLENZIN, BUDEPRION, FORFIVO, Depression 24 months Eagle Level
WELLBUTRIN)
bupropion (BUPROBAN, ZYBAN) Smoking cessation 12 months Smoking rates (Eagle Level)
BUSPAR (buspirone HCl) Anxiety any Eagle Level
buspirone HCl (BUSPAR) Anxiety any Eagle Level
BUTALBITAL/ACETAMINOPHEN/CAFFEINE/ Tension headache any Eagle Level
CODEINE
BUTORPHANOL TARTRATE Pain relief any Eagle Level
BYETTA (exenatide) Diabetes any Eagle Level (with no diabetic complications)
BYSTOLIC (nebivolol) Hypertension any Eagle Level
CABERGOLINE Hyperprolactinemic disorders any Eagle Level
CADUET (amlodipine besylate, atorvastatin calcium) Hypertension any Eagle Level
CADUET (amlodipine besylate, atorvastatin calcium) Coronary artery disease 12 months Eagle Guaranteed
CALAMINE Dermatological treatment any Eagle Level
CALAN (verapamil) Hypertension any Eagle Level
CALAN (verapamil) Angina 12 months Eagle Guaranteed
CALAN (verapamil) Arrhythmia any Eagle Level
CALCIFOLIC-D Mineral/electrolyte replacement any Eagle Level
calcitonin (MIACALCIN) Osteoporosis any Eagle Level
calcitonin (MIACALCIN) Paget’s bone disease any Eagle Level
calcitriol (ROCALTROL) Calcium replacement in PRIMARY
any Eagle Level parathyroid disease
calcitriol (ROCALTROL) Kidney failure any Eagle Guaranteed
CALCIUM ACETATE Hyperphosphatemia in kidney failure any Eagle Guaranteed
CALCIUM CARBONATE Antacid any Eagle Level
CALCIUM/VITAMIN D Vitamin/mineral supplement any Eagle Level
CAL-NATE Vitamin supplement any Eagle Level
CAMPRAL (acamprosate) Alcohol dependency treatment 24 months Eagle Guaranteed
candesartan (ATACAND) Hypertension any Eagle Level
candesartan (ATACAND) Congestive heart failure any Eagle Guaranteed
candesartan hydrochlorothiazide (ATACAND HCT) Hypertension any Eagle Level
capecitabine (XELODA) Cancer 24 months Eagle Guaranteed
CAPOTEN (captopril) Hypertension any Eagle Level
CAPOTEN (captopril) Congestive heart failure any Eagle Guaranteed
CAPOTEN (captopril) Diabetic kidney disease any Eagle Guaranteed
CAPOZIDE (captopril/hydrochlorothiazide) Hypertension any Eagle Level
captopril (CAPOTEN) Hypertension any Eagle Level
captopril (CAPOTEN) Congestive heart failure any Eagle Guaranteed
captopril (CAPOTEN) Diabetic kidney disease any Eagle Guaranteed
captopril/hydrochlorothiazide (CAPOZIDE) Hypertension any Eagle Level
CARAC Dermatological treatment any Eagle Level
carbamazepine (CARBATROL, TEGRETOL) Epilepsy any Eagle Level
carbamazepine (CARBATROL, TEGRETOL) Facial nerve disorder any Eagle Level
CARBATROL (carbamazepine) Epilepsy any Eagle Level
p. 8
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
CARBATROL (carbamazepine) Facial nerve disorder any Eagle Level
CARBATUSS-CL Cough/cold/allergies any Eagle Level
carbidopa/levodopa (SINEMET) Parkinson’s disease any Eagle Level
CARDIZEM (diltiazem) Hypertension any Eagle Level
CARDIZEM (diltiazem) Angina 12 months Eagle Guaranteed
CARDOXIN (digoxin) Heart failure any Eagle Guaranteed
CARDURA (doxazosin mesylate) Benign prostatic hypertrophy any Eagle Level
CARDURA (doxazosin mesylate) Hypertension any Eagle Level
CARISOPRODOL Muscular pain any Eagle Level
CARISOPRODOL/ASPIRIN Muscular pain any Eagle Level
CARTIA XT (diltiazem) Hypertension any Eagle Level
CARTIA XT (diltiazem) Angina 12 months Eagle Guaranteed
carvedilol (COREG) Hypertension any Eagle Level
carvedilol (COREG) Congestive heart failure any Eagle Guaranteed
CASODEX (bicalutamide) Cancer 24 months Eagle Guaranteed
CATAFLAM (diclofenac) Pain relief - anti-inflammatory any Eagle Level
CATAPRES (clonidine HCl) Hypertension any Eagle Level
CAVERJECT (alprostadil) Erectile dysfunction any Eagle Level
CEDAX Antibiotic any Eagle Level
CEFACLOR Antibiotic any Eagle Level
CEFADROXIL Antibiotic any Eagle Level
CEFPODOXIME PROXETIL Antibiotic any Eagle Level
CEFTRIAXONE SODIUM Antibiotic any Eagle Level
CEFUROXIME AXETIL Antibiotic any Eagle Level
CEFZIL Antibiotic any Eagle Level
CELEBREX (celecoxib) Pain relief - anti-inflammatory any Eagle Level
celecoxib (CELEBREX) Pain relief - anti-inflammatory any Eagle Level
CELESTONE Multiple indications - corticosteroid any Eagle Level
CELEXA (citalopram hydrobromide) Depression any Eagle Level
CELLCEPT (mycophenolate) Organ transplant rejection
any Eagle Guaranteed prevention
CELLUVISC Eye drops any Eagle Level
CELONTIN (methsuximide) Seizures any Eagle Level
CENESTIN Menopausal symptoms any Eagle Level
CEPHADYN Pain relief - nonnarcotic any Eagle Level
CEPHALEXIN Antibiotic any Eagle Level
CEREFOLIN Vitamin any Eagle Level
CERON-DM Cough/cold/allergies any Eagle Level
CETAPHIL Dermatological treatment any Eagle Level
CHANTIX (varenicline) Smoking cessation 12 months smoking rates (Eagle Level)
CHERATUSSIN AC Cough/cold/allergies any Eagle Level
CHLORAL HYDRATE Insomnia any Eagle Level
chlordiazepoxide (LIBRIUM) Alcohol withdrawal 24 months Eagle Guaranteed
p. 9
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
chlordiazepoxide/amitriptyline (LIMBITROL) Depression/anxiety 24 months Eagle Level; 40-49 decline
chlordiazepoxide/clidinium (LIBRAX) Irritable bowel syndrome any Eagle Level
chlorhexidine gluconate (PERIDEX) Antiseptic rinse any Eagle Level
chloroquine phosphate Malaria any Eagle Level
chlorpheniramine/pseudoephedrine CR Cold/cough/allergies any Eagle Level
(DYNAHIST ER)
chlorpromazine HCl (THORAZINE) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49
chlorthalidone (HYDONE, HYGROTON, THALITONE) Hypertension any Eagle Level
chlorthalidone (HYDONE, HYGROTON, THALITONE) Congestive heart failure any Eagle Guaranteed
chlorthalidone (HYDONE, HYGROTON, THALITONE) Liver cirrhosis any Eagle Guaranteed
chlorthalidone (HYDONE, HYGROTON, THALITONE) Edema related to estrogen therapy any Eagle Level
chlorzoxazone (PARAFON FORTE DSC) Musculoskeletal pain any Eagle Level
cholestyramine (QUESTRAN) Elevated cholesterol any Eagle Level
CHOLINE MAGNESIUM TRISALICYLATE Pain relief - nonnarcotic any Eagle Level
CHORIONIC GONADOTROPIN Hormonal treatment any Eagle Level
CHROMAGEN Dietary supplement any Eagle Level
CIALIS (tadalafil) Erectile dysfunction any Eagle Level
CICLOPIROX OLAMINE Dermatological treatment any Eagle Level
cilostazol (PLETAL) Circulatory disease any Eagle Level
cimetidine (TAGAMET) Heartburn any Eagle Level
cinacalcet (SENSIPAR) Primary parathyroid disease any Eagle Level
cinacalcet (SENSIPAR) Parathyroid cancer 24 months Eagle Guaranteed
cinacalcet (SENSIPAR) Kidney disease any Eagle Guaranteed
CIPRO (ciprofloxacin) Antibiotic any Eagle Level
CIPRODEX External ear infection any Eagle Level
ciprofloxacin HCL (CIPRO) Antibiotic any Eagle Level
citalopram hydrobromide (CELEXA) Depression 24 months Eagle Level; decline 40-49
CITRACAL MAXIMUM Dietary supplement any Eagle Level
CLARINEX Cough/cold/allergies any Eagle Level
CLEMASTINE FUMARATE Antihistamine any Eagle Level
CLENIA FOAMING WASH Dermatological treatment any Eagle Level
CLEOCIN (clindamycin HCl) Antibiotic any Eagle Level
clindamycin HCl (CLEOCIN) Antibiotic any Eagle Level
CLINDAMYCIN PHOSPHATE Dermatological treatment any Eagle Level
CLINDESSE Bacterial vaginosis any Eagle Level
CLOBETASOL PROPIONATE Dermatological treatment any Eagle Level
CLODERM Dermatological treatment any Eagle Level
CLOMID (clomiphene citrate) Hormonal treatment any Eagle Level
clomiphene citrate (CLOMID) Hormonal treatment any Eagle Level
clomipramine HCl (ANAFRANIL) Obsessive compulsive disorder any Eagle Level
clonazepam (KLONOPIN) Seizures any Eagle Level
clonazepam (KLONOPIN) Panic disorder 24 months Eagle Level; decline 40-49
clonidine/chlorthalidone (CLORPRESS) Hypertension any Eagle Level
p. 10
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
clonidine HCl (CATAPRES) Hypertension any Eagle Level
clopidogrel (PLAVIX) Heart attack 12 months Eagle Guaranteed
clopidogrel (PLAVIX) Stroke 12 months Eagle Guaranteed
clorazepate dipotassium (TRANXENE) Anxiety disorder any Eagle Level
clorazepate dipotassium (TRANXENE) Seizures any Eagle Level
clorazepate dipotassium (TRANXENE) Alcohol withdrawal 24 months Eagle Guaranteed
CLORPRESS (clonidine/chlorthalidone) Hypertension any Eagle Level
clotrimazole (MYCELEX) Fungal infection any Eagle Level
CODAL-DH Cough/cold/allergies any Eagle Level
COGENTIN (benztropine mesylate) Parkinson’s disease any Eagle Level
colchicine (COLCRYS) Gout any Eagle Level
COLCRYS (colchicine) Gout any Eagle Level
colesevelam (WELCHOL) Elevated cholesterol any Eagle Level
colesevelam (WELCHOL) Diabetes any Eagle Level (with no diabetic complications)
COLESTID (colestipol) Elevated cholesterol any Eagle Level
colestipol (COLESTID) Elevated cholesterol any Eagle Level
COMBIGAN Glaucoma any Eagle Level
COMBIVENT (albuterol/ipratropium) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
COMBIVIR (lamivudine/zidovudine) HIV/AIDS any Eagle Guaranteed
COMPRO (prochlorperazine) Nausea/vomiting any Eagle Level
COMTAN (entacapone) Parkinson’s disease any Eagle Level
CONCERTA (methylphenidate hydrochloride) ADHD any Eagle Level
CONDYLOX Dermatological treatment any Eagle Level
COPAXONE (glatiramer) Multiple sclerosis any Eagle Level
COPEGUS (ribavirin) Hepatitis C 24 months Eagle Guaranteed
CORDARONE (amiodarone) Heart arrhythmia any Eagle Level
COREG (carvedilol) Hypertension any Eagle Level
COREG (carvedilol) Congestive heart failure any Eagle Guaranteed
CORGARD (nadolol) Hypertension any Eagle Level
CORGARD (nadolol) Angina 12 months Eagle Guaranteed
CORICIDIN HBP FLU Cough/cold/allergies any Eagle Level
CORZIDE (nadolol/bendroflumethiazide) Hypertension any Eagle Level
COSOPT Glaucoma any Eagle Level
COUMADIN (warfarin) Clot prevention after heart valve
12 months Eagle Guaranteed placement
COUMADIN (warfarin) Atrial fibrillation any Eagle Level
COVERA-HS (verapamil) Hypertension any Eagle Level
COVERA-HS (verapamil) Angina 12 months Eagle Level
COVERA-HS (verapamil) Arrhythmia any Eagle Level
COZAAR (losartan) Hypertension any Eagle Level
COZAAR (losartan) Diabetic Kidney Disease 24 months Eagle Guaranteed
p. 11
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
CREON (pancrelipase) Pancreatic enzyme - cystic fibrosis any Eagle Guaranteed
CREON (pancrelipase) Pancreatic enzyme - chronic
12 months Eagle Level; decline 40-49 pancreatitis
CREON (pancrelipase) Pancreatic enzyme - pancreatectomy 12 months Eagle Level; decline 40-49
CRESTOR (rosuvastatin) Elevated cholesterol any Eagle Level
CRESYLATE External ear infection any Eagle Level
CROMOLYN SODIUM Allergies any Eagle Level
CUBICIN Skin infections any Eagle Level
CYANOCOBALAMIN Vitamin supplement any Eagle Level
cyclobenzaprine (FLEXERIL) Muscle relaxant any Eagle Level
CYCLOPENTOLATE HCL Eye drops any Eagle Level
cyclophosphamide (CYTOXAN) Cancer 24 months Eagle Guaranteed
cyclophosphamide (CYTOXAN) Nephrotic syndrome (kidney
any Eagle Guaranteed disease)
cyclophosphamide (CYTOXAN) Juvenile rheumatoid arthritis vasculitis any Eagle Level
cyclosporine (GENGRAF) Organ transplant rejection
any Eagle Guaranteed prevention
CYMBALTA (duloxetine) Depression/anxiety 24 months Eagle Level; decline 40-49
CYMBALTA (duloxetine) Fibromyalgia/musculoskeletal pain any Eagle Level
CYMBALTA (duloxetine) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed
CYPROHEPTADINE HCL Antihistamine any Eagle Level
CYTOMEL (liothyronine) Thyroid replacement any Eagle Level
CYTOTEC (misoprostol) Ulcer any Eagle Level
CYTOXAN (cyclophosphamide) Cancer 24 months Eagle Guaranteed
CYTOXAN (cyclophosphamide) Nephrotic syndrome (kidney
any Eagle Guaranteed disease)
CYTOXAN (cyclophosphamide) Juvenile rheumatoid arthritis vasculitis any Eagle Level
CYTRA K CRYSTALS Urinary treatment/prevention of
any Eagle Level gout/kidney stones
DALMANE (flurazepam) Insomnia any Eagle Level
DAPSONE Leprosy/skin infections any Eagle Level
DARVON (propoxyphene) Pain relief - narcotic any Eagle Level
DEMADEX (torsemide) Hypertension any Eagle Level
DEMADEX (torsemide) Liver disease any Eagle Guaranteed
DEMADEX (torsemide) Congestive heart failure any Eagle Guaranteed
DEMADEX (torsemide) Kidney disease any Eagle Guaranteed
DEMSER (metyrosine) Pheochromocytomas any Eagle Level
DEPAKOTE (divalproex sodium) Bipolar 24 months Eagle Level; decline 40-49
DEPAKOTE (divalproex sodium) Epilepsy any Eagle Level
DEPAKOTE (divalproex sodium) Migraine any Eagle Level
DEPLIN Depression any Eagle Level
DEPO-MEDROL Multiple indications - corticosteroid any Eagle Level
DERMATOP Dermatological treatment any Eagle Level
DERMOTIC Ear drops any Eagle Level
p. 12
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
desipramine HCl (NORPRAMIN) Depression any Eagle Level
DESMOPRESSIN ACETATE Hormonal treatment any Eagle Level
DESONIDE Dermatological treatment any Eagle Level
DESOXIMETASONE Dermatological treatment any Eagle Level
DESYREL (trazodone) Depression any Eagle Level
DETROL LA Urinary antispasmodic any Eagle Level
DEXAMETHASONE Multiple indications - corticosteroid any Eagle Level
DEXAPHEN SA Cough/cold/allergies any Eagle Level
DEXEDRINE (dextroamphetamine) Narcolepsy any Eagle Level
DEXEDRINE (dextroamphetamine) ADHD any Eagle Level
dexmethylphenidate HCL (FOCALIN) ADHD/narcolepsy/obesity any Eagle Level
dextroamphetamine (DEXEDRINE) Narcolepsy any Eagle Level
dextroamphetamine (DEXEDRINE) ADHD any Eagle Level
dextroamphetamine/amphetamine (ADDERALL) ADHD/narcolepsy any Eagle Level
DIABETA (glyburide) Diabetes any Eagle Level (with no diabetic complications)
DIAMOX (acetazolamide) Congestive heart failure any Eagle Guaranteed
DIAMOX (acetazolamide) Seizures any Eagle Level
DIAMOX (acetazolamide) Mountain sickness any Eagle Level
DIAMOX (acetazolamide) Glaucoma any Eagle Level
diazepam (VALIUM) Anxiety disorder any Eagle Level
diazepam (VALIUM) Convulsive disorder/muscle spasms any Eagle Level
diazepam (VALIUM) Alcohol withdrawal 24 months Eagle Guaranteed
DIBENZYLINE Pheochromocytoma any Eagle Level
diclofenac (CATAFLAM) Pain relief - anti-inflammatory any Eagle Level
DICLOXACILLIN SODIUM Antibiotic any Eagle Level
dicyclomine (BENTYL) Irritable bowel syndrome any Eagle Level
diethylpropion (TENUATE) Obesity any Eagle Level
DIFFERIN Dermatological treatment any Eagle Level
DIFLORASONE DIACETATE Dermatological treatment any Eagle Level
diflunisal (DOLOBID) Pain relief - nonnarcotic any Eagle Level
DIGITEK (digoxin) Heart failure any Eagle Guaranteed
digoxin (DIGITEK, LANOXICAPS, LANOXIN, CAR- Heart failure any Eagle Guaranteed
DOXIN)
DILACOR (diltiazem) Hypertension any Eagle Level
DILACOR (diltiazem) Angina 12 months Eagle Guaranteed
DILANTIN (phenytoin) Seizures any Eagle Level
diltiazem (CARTIA XT, CARDIZEM, DILACOR, TIAZAC) Hypertension any Eagle Level
diltiazem (CARTIA XT, CARDIZEM, DILACOR, TIAZAC) Angina 12 months Eagle Guaranteed
DIOVAN (valsartan) Hypertension any Eagle Level
DIOVAN (valsartan) Congestive heart failure any Eagle Guaranteed
DIOVAN (valsartan) Treatment after heart attack 12 months Eagle Guaranteed
DIOVAN HCT (hydrochlorothiazide/valsartan) Hypertension any Eagle Level
DIPHENHYDRAMINE HCL Antihistamine any Eagle Level
p. 13
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
DIPHENOXYLATE/ATROPINE Diarrhea any Eagle Level
dipyridamole (PERSANTINE) Clot prevention after valve
12 months Eagle Guaranteed replacement
DITROPAN XL Urinary spasm any Eagle Level
divalproex sodium (DEPAKOTE) Bipolar 24 months Eagle Level; decline 40-49
divalproex sodium (DEPAKOTE) Epilepsy any Eagle Level
divalproex sodium (DEPAKOTE) Migraine any Eagle Level
docetaxel (TAXOTERE) Cancer 24 months Eagle Guaranteed
DOC-Q-LACE Constipation any Eagle Level
DOCUSATE CALCIUM Constipation any Eagle Level
dofetilide (TIKOSYN) Heart arrhythmia any Eagle Level
DOLOBID (diflunisal) Pain relief - nonnarcotic any Eagle Level
DOMEBORO (acetic acid/aluminum acetate) External ear infection any Eagle Level
DOMPERIDONE BP Parkinson’s disease any Eagle Level
DOMPERIDONE BP Nausea/vomiting any Eagle Level
DONATUSSIN Cough/cold/allergies any Eagle Level
donepezil (ARICEPT) Alzheimer’s disease any Eagle Guaranteed
DOVONEX Dermatological treatment any Eagle Level
doxazosin mesylate (CARDURA) Benign prostatic hypertrophy any Eagle Level
doxazosin mesylate (CARDURA) Hypertension any Eagle Level
doxepin HCl (SINEQUAN) Depression/anxiety any Eagle Level
doxercalciferol (HECTOROL) Parathyroidism due to chronic kidney
any Eagle Guaranteed disease
DOXYCYCLINE Antibiotic any Eagle Level
dronabinol (MARINOL) Appetitive stimulant in patients with
any Eagle Guaranteed AIDS
dronabinol (MARINOL) Nausea and vomiting related to
24 months Eagle Guaranteed chemotherapy
DUAC Dermatological treatment any Eagle Level
DUET DHA Vitamin supplement any Eagle Level
DUETACT (glimepiride/pioglitazone) Diabetes any Eagle Level (with no diabetic complications)
duloxetine (CYMBALTA) Depression/anxiety 24 months Eagle Level; decline 40-49
duloxetine (CYMBALTA) Fibromyalgia/musculoskeletal pain any Eagle Level
duloxetine (CYMBALTA) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed
DUONEB (albuterol/ipratropium) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
DURAFLU Cough/cold/allergies any Eagle Level
DURAGESIC (fentanyl) patch Continuous, persistent moderate to
any Eagle Level severe chronic pain
DURAGESIC (fentanyl) patch Cancer pain 24 months Eagle Guaranteed
DURAHIST D Cough/cold/allergies any Eagle Level
DURAPHEN FORTE Cough/cold/allergies any Eagle Level
DUREZOL Eye drops any Eagle Level
dutasteride (AVODART) Benign prostatic hypertrophy any Eagle Level
DYAZIDE (triamterene/hydrochlorothiazide) Hypertension any Eagle Level
p. 14
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
DYAZIDE (triamterene/hydrochlorothiazide) Edema any Eagle Level
DYNA HIST ER (chlorpheniramine/ Cold/cough/allergies any Eagle Level
pseudoephedrine CR)
DYNACIRC-CR (isradipine) Hypertension any Eagle Level
dyphylline/guaifenesin (DYPHYLLINE-GG) Asthma any Eagle Level
dyphylline/guaifenesin (DYPHYLLINE-GG) Emphysema/chronic bronchitis any Eagle Guaranteed
DYPHYLLINE-GG (dyphylline/guaifenesin) Asthma any Eagle Level
DYPHYLLINE-GG (dyphylline/guaifenesin) Emphysema/chronic bronchitis any Eagle Guaranteed
ECONAZOLE NITRATE Dermatological treatment any Eagle Level
ED A-HIST Cough/cold/allergies any Eagle Level
efavirenz (SUSTIVA) HIV/AIDS any Eagle Guaranteed
EFFEXOR (venlafaxine) Depression/anxiety any Eagle Level
ELDEPRYL (selegiline) Parkinson’s disease any Eagle Level
ELESTAT Eye drops any Eagle Level
ELIDEL Dermatological treatment any Eagle Level
ELMIRON Bladder pain any Eagle Level
EMEND (aprepitant) Nausea/vomiting prevention
any Eagle Level pre-surgery
EMEND (aprepitant) Nausea/vomiting prevention
24 months Eagle Guaranteed pre-chemotherapy
emtricitabine/tenofovir (TRUVADA) HIV/AIDS any Eagle Guaranteed
ENABLEX Urinary spasm any Eagle Level
enalapril (VASOTEC) Hypertension any Eagle Level
enalapril (VASOTEC) Congestive heart failure any Eagle Guaranteed
enalapril/hydrochlorothiazide (VASERETIC) Hypertension any Eagle Level
ENBREL (etanercept) Rheumatoid arthritis/psoriatic
any Eagle Level arthritis/ankylosing spondylitis
ENCORA Vitamin supplement any Eagle Level
ENDOMETRIN Hormonal treatment any Eagle Level
ENDURON (methyclothiazide) Hypertension any Eagle Level
ENDURON (methyclothiazide) Edema due to hormone or steroid
any Eagle Level therapy
ENDURON (methyclothiazide) Liver cirrhosis any Eagle Guaranteed
ENDURON (methyclothiazide) Congestive heart failure any Eagle Guaranteed
enoxaparin (LOVENOX) Deep vein thrombosis (clot) any Eagle Level
enoxaparin (LOVENOX) Unstable angina 12 months Eagle Guaranteed
enoxaparin (LOVENOX) Heart attack 12 months Eagle Guaranteed
entacapone (COMTAN) Parkinson’s disease any Eagle Level
entecavir (BARACLUDE) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle
Guaranteed)
ENTOCORT EC Crohn’s disease any Eagle Level
ENULOSE Constipation any Eagle Level
EPICREAM Dermatological treatment any Eagle Level
EPINEPHRINE HCL Asthma any Eagle Level
EPIPEN Allergic reaction any Eagle Level
p. 15
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
EPIVIR (lamivudine) HIV/AIDS any Eagle Guaranteed
eplerenone (INSPRA) Hypertension any Eagle Level
eplerenone (INSPRA) Congestive heart failure any Eagle Guaranteed
epoetin alfa (PROCRIT) Cancer-related anemia 24 months Eagle Guaranteed
epoetin alfa (PROCRIT) HIV-related anemia any Eagle Guaranteed
epoetin alfa (PROCRIT) Kidney disease-related anemia any Eagle Guaranteed
EPZICOM (abacavir/lamivudine) HIV/AIDS any Eagle Guaranteed
ERTACZO Dermatological treatment any Eagle Level
ERY-TAB Antibiotic any Eagle Level
ERYTHROCIN STEARATE Antibiotic any Eagle Level
escitalopram (LEXAPRO) Depression/anxiety 24 months Eagle Level; decline 40-49
esomeprazole (NEXIUM) GERD/ulcers any Eagle Level
ESTAZOLAM Insomnia any Eagle Level
ESTRADIOL Hormonal treatment any Eagle Level
estradiol/norethindrone (ACTIVELLA) Menopausal symptoms any Eagle Level
ESTRATEST H.S. Hormonal treatment any Eagle Level
ESTRIOL Hormonal treatment any Eagle Level
ESTROPIPATE Hormonal treatment any Eagle Level
eszopiclone (LUNESTA) Insomnia any Eagle Level
etanercept (ENBREL) Rheumatoid arthritis/psoriatic
any Eagle Level arthritis/ankylosing spondylitis
ETODOLAC Pain relief - anti-inflammatory any Eagle Level
etravirine (INTELENCE) HIV/AIDS any Eagle Guaranteed
EVISTA (raloxifene) Osteoporosis any Eagle Level
EVOXAC Dry mouth due to Sjögren’s
any Eagle Level syndrome
EXELDERM Dermatological treatment any Eagle Level
EXELON (rivastigmine transdermal) Alzheimer’s disease/dementia any Eagle Guaranteed
exemestane (AROMASIN) Cancer 24 months Eagle Guaranteed
exenatide (BYETTA) Diabetes any Eagle Level (with no diabetic complications)
EXFORGE (amlodipine/valsartan) Hypertension any Eagle Level
ezetimibe (ZETIA) Elevated cholesterol any Eagle Level
FACTIVE Antibiotic any Eagle Level
famciclovir (FAMVIR) Cold sores/shingles/herpes any Eagle Level
famciclovir (FAMVIR) Herpes in HIV-infected patients any Eagle Guaranteed
FAMOTIDINE Heartburn any Eagle Level
FAMVIR (famciclovir) Cold sores/shingles/herpes any Eagle Level
FAMVIR (famciclovir) Herpes in HIV-infected patients any Eagle Guaranteed
felbamate (FELBATOL) Epilepsy any Eagle Level
FELBATOL (felbamate) Epilepsy any Eagle Level
felodipine (PLENDIL) Hypertension any Eagle Level
FEMARA (letrozole) Breast cancer/cancer remission
24 months Eagle Guaranteed maintenance
FEMHRT 1/5 Hormonal treatment any Eagle Level
p. 16
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
fenofibrate (ANTARA) Elevated cholesterol/triglycerides any Eagle Level
fenofibrate (TRICOR) Elevated cholesterol/triglycerides any Eagle Level
FENOPROFEN CALCIUM Pain relief - anti-inflammatory any Eagle Level
fentanyl citrate (ACTIQ lozenge, ABSTRAL sublingual tablets, DURAGESIC patch, FENTORA tablet, IONSYS
Continuous, persistent moderate to any Eagle Level (inpatient hospital use only), LAZANDA nasal spray,
severe chronic pain ONSOLIS buccal soluble film, SUBSYS sublingual
spray)
fentanyl citrate (ACTIQ lozenge, ABSTRAL sublingual tablets, DURAGESIC patch, FENTORA tablet, IONSYS
(inpatient hospital use only), LAZANDA nasal spray, Cancer pain 24 months Eagle Guaranteed ONSOLIS buccal soluble film, SUBSYS sublingual
spray)
FENTORA (fentanyl) tablet Cancer pain 24 months Eagle Guaranteed
FERRALET 90 Iron supplementation any Eagle Level
FERREX 150 FORTE Iron supplementation any Eagle Level
FERROGELS FORTE Iron supplementation any Eagle Level
FERROUS FUMARATE 324 Iron supplementation any Eagle Level
FERROUS GLUCONATE Iron supplementation any Eagle Level
FERROUS SULFATE Iron supplementation any Eagle Level
FEXOFENADINE HCL Antihistamine any Eagle Level
filgrastim (NEUPOGEN) Cancer 24 months Eagle Guaranteed
FINACEA Dermatological treatment any Eagle Level
finasteride (PROPECIA, PROSCAR) Benign prostatic hypertrophy/male
any Eagle Level pattern baldness
FLAREX Eye drops any Eagle Level
FLAVOXATE HCL Urinary spasm any Eagle Level
flecainide (TAMBOCOR) Heart arrhythmia any Eagle Level
FLECTOR Dermatological treatment any Eagle Level
FLEXERIL (cyclobenzaprine) Muscle relaxant any Eagle Level
FLEXTRA-650 Pain relief - nonnarcotic any Eagle Level
FLOMAX (tamsulosin) Benign prostatic hypertrophy any Eagle Level
FLORICAL Calcium supplement any Eagle Level
FLOVENT (fluticasone) Asthma any Eagle Level
FLOXIN OTIC Ear infection any Eagle Level
FLUCONAZOLE Fungal infection any Eagle Level
FLUDROCORTISONE ACETATE Addison’s disease any Eagle Level
flumazenil (ROMAZICON) Drug overdose management 24 months Eagle Guaranteed
flunisolide (AEROBID) Asthma any Eagle Level
FLUOCINONIDE Dermatological treatment any Eagle Level
FLUOCINONIDE-E Dermatological treatment any Eagle Level
FLUOROMETHOLONE Eye drops any Eagle Level
fluoxetine (PROZAC) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49
fluoxetine/olanzapine (SYMBYAX) Depression/bipolar disorder 24 months Eagle Level; decline 40-49
fluphenazine (PROLIXIN) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49
flurazepam (DALMANE) Insomnia any Eagle Level
p. 17
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
FLURBIPROFEN SODIUM drops Eye drops any Eagle Level
FLURBIPROFEN tablet Rheumatoid arthritis/osteoarthritis any Eagle Level
fluticasone (FLOVENT) Asthma any Eagle Level
fluticasone propionate Allergies any Eagle Level
fluticasone propionate/salmeterol (ADVAIR DISKUS) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
fluticasone propionate/salmeterol (ADVAIR DISKUS) Asthma any Eagle Level
fluvastatin (LESCOL) Elevated cholesterol any Eagle Level
fluvoxamine (LUVOX) Obsessive compulsive disorder any Eagle Level
FOCALIN (dexmethylphenidate HCl) ADHD/narcolepsy/obesity any Eagle Level
FOLBEE Iron supplementation any Eagle Level
FOLBIC Vitamin supplement any Eagle Level
FOLGARD OS Vitamin supplement any Eagle Level
FOLITAB Vitamin supplement any Eagle Level
FOLTRIN Vitamin supplement any Eagle Level
fondaparinux sodium (ARIXTRA) Presurgical prevention of blood clot any Eagle Level
fondaparinux sodium (ARIXTRA) Treatment of blood clot any Eagle Level
fondaparinux sodium (ARIXTRA) reatment of pulmonary embolism
any Eagle Guaranteed (clot)
FORADIL AEROLIZER (formoterol) Asthma any Eagle Level
Chronic obstructive pulmonary FORADIL AEROLIZER (formoterol) disease (COPD)/emphysema/ any Eagle Guaranteed
chronic bronchitis
FORFIVO (bupropion) Depression any Eagle Level
formoterol (FORADIL AEROLIZER) Asthma any Eagle Level
Chronic obstructive pulmonary formoterol (FORADIL AEROLIZER) disease (COPD)/emphysema/ any Eagle Guaranteed
chronic bronchitis
FORTAMET (metformin) Diabetes any Eagle Level (with no diabetic complications)
FORTEO Osteoporosis any Eagle Level
FOSAMAX Osteoporosis any Eagle Level
fosinopril (MONOPRIL) Hypertension any Eagle Level
fosinopril (MONOPRIL) Congestive heart failure any Eagle Guaranteed
fosinopril/hydrochlorothiazide (MONOPRIL HCT) Hypertension any Eagle Level
FOSRENOL (lanthanum carbonate) Kidney disease any Eagle Guaranteed
FRESHKOTE Eye drops any Eagle Level
FROVA Migraine any Eagle Level
furosemide (LASIX) Hypertension any Eagle Level
furosemide (LASIX) Congestive heart failure any Eagle Guaranteed
furosemide (LASIX) Kidney disease any Eagle Guaranteed
furosemide (LASIX) Liver disease any Eagle Guaranteed
gabapentin (NEURONTIN) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed
gabapentin (NEURONTIN) Epilepsy any Eagle Level
GABITRIL (tiagabine) Seizures any Eagle Level
galantamine (RAZADYNE) Alzheimer’s disease any Eagle Guaranteed
p. 18
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
GAMMAGARD LIQUID Primary immunodeficiency any Eagle Guaranteed
GEMFIBROZIL Elevated triglycerides any Eagle Level
GENGRAF (cyclosporine) Transplant rejection any Eagle Guaranteed
GENTAMICIN SULFATE Antibiotic any Eagle Level
GEODON (ziprasidone) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
glatiramer (COPAXONE) Multiple sclerosis any Eagle Level
glimepiride (AMARYL) Diabetes any Eagle Level (with no diabetic complications)
glimepiride/pioglitazone (DUETACT) Diabetes any Eagle Level (with no diabetic complications)
glimepiride/rosiglitazone (AVANDARYL) Diabetes any Eagle Level (with no diabetic complications)
glipizide (GLUCOTROL) Diabetes any Eagle Level (with no diabetic complications)
glipizide/metformin (METAGLIP) Diabetes any Eagle Level (with no diabetic complications)
GLUCAGEN Diabetes - Hypoglycemia treatment any Eagle Level (with no diabetic complications)
GLUCOPHAGE (metformin) Diabetes any Eagle Level (with no diabetic complications)
GLUCOTROL (glipizide) Diabetes any Eagle Level (with no diabetic complications)
GLUCOVANCE (glyburide/metformin) Diabetes any Eagle Level (with no diabetic complications)
GLUMETZA (metformin) Diabetes any Eagle Level (with no diabetic complications)
glyburide (DIABETA, MICRONASE) Diabetes any Eagle Level (with no diabetic complications)
glyburide/metformin (GLUCOVANCE) Diabetes any Eagle Level (with no diabetic complications)
GLYCOLAX Constipation any Eagle Level
glycopyrrolate (ROBINUL) Ulcers any Eagle Level
GLYSET (miglitol) Diabetes any Eagle Level (with no diabetic complications)
golimumab (SIMPONI) Rheumatoid arthritis/psoriatic
any Eagle Level arthritis
golimumab (SIMPONI) Ankylosing spondylitis any Eagle Level
granisetron (KYTRIL) Nausea and vomiting, postoperative any Eagle Level
granisetron (KYTRIL) Nausea and vomiting,
24 months Eagle Guaranteed pre-chemotherapy
GRIFULVIN V Antifungal any Eagle Level
GRIS-PEG Antifungal any Eagle Level
GUAIFENEX DM Cough/cold/allergies any Eagle Level
guanfacine (INTUNIV, TENEX) Hypertension any Eagle Level
GUIADEX DM Cough/cold/allergies any Eagle Level
HALCION (triazolam) Insomnia any Eagle Level
HALDOL (haloperidol) Schizophrenia/psychosis 24 months Eagle Level; decline 40-49
HALDOL (haloperidol) Tourette’s disorder any Eagle Level
HALOBETASOL PROPIONATE Dermatological treatment any Eagle Level
haloperidol (HALDOL) Schizophrenia/psychosis 24 months Eagle Level; decline 40-49
haloperidol (HALDOL) Tourette’s disorder any Eagle Level
HECTOROL (doxercalciferol) Parathyroidism due to chronic kidney
any Eagle Guaranteed disease
HELIDAC Ulcers any Eagle Level
HEMATINIC Vitamin supplement any Eagle Level
HEMAX Vitamin supplement any Eagle Level
p. 19
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
HEPSERA (adefovir) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle
Guaranteed)
HISTA-VENT DA Cough/cold/allergies any Eagle Level
HISTINEX HC Cough/cold/allergies any Eagle Level
HUMALOG (insulin) Diabetes any Eagle Level (with no diabetic complications)
HUMIRA (adalimumab) Rheumatoid arthritis/juvenile
any Eagle Level psoriatic arthritis
HUMIRA (adalimumab) Crohn’s disease any Eagle Level
HUMIRA (adalimumab) Ankylosing spondylitis any Eagle Level
HUMIRA (adalimumab) Plaque psoriasis any Eagle Level
HUMULIN (insulin) Diabetes any Eagle Level (with no diabetic complications)
HYALGAN Osteoarthritis any Eagle Level
HYDONE (chlorthalidone) Hypertension any Eagle Level
HYDONE (chlorthalidone) Congestive heart failure any Eagle Guaranteed
HYDONE (chlorthalidone) Liver cirrhosis any Eagle Guaranteed
HYDONE (chlorthalidone) Edema related to estrogen therapy any Eagle Level
hydralazine (APRESOLINE) Hypertension any Eagle Level
HYDREA (hydroxyurea) Cancer 24 months Eagle Guaranteed
HYDREA (hydroxyurea) Essential thrombocytopenia any Eagle Level
hydrochlorothiazide Hypertension any Eagle Level
hydrochlorothiazide/losartan (HYZAAR) Hypertension any Eagle Level
hydrochlorothiazide/losartan (HYZAAR) Left ventricular hypertrophy 12 months Eagle Guaranteed
hydrochlorothiazide/moexipril (UNIRETIC) Hypertension any Eagle Level
hydrochlorothiazide/spironolactone (ALDACTAZIDE) Hypertension any Eagle Level
hydrochlorothiazide/spironolactone (ALDACTAZIDE) Liver cirrhosis any Eagle Guaranteed
hydrochlorothiazide/spironolactone (ALDACTAZIDE) Congestive heart failure any Eagle Guaranteed
hydrochlorothiazide/spironolactone (ALDACTAZIDE) Kidney disease any Eagle Guaranteed
hydrochlorothiazide/telmisartan (MICARDIS) Hypertension any Eagle Level
hydrochlorothiazide/valsartan (DIOVAN HCT) Hypertension any Eagle Level
HYDROCODONE BITARTRATE Cough/cold/allergies any Eagle Level
HYDROCODONE/ACETAMINOPHEN Pain relief - narcotic any Eagle Level
HYDROCODONE/GUAIFENESIN Cough syrup any Eagle Level
HYDROCODONE/HOMATROPINE Cough syrup any Eagle Level
HYDROCODONE/IBUPROFEN Pain relief - narcotic any Eagle Level
HYDROCORTISONE Dermatological treatment any Eagle Level
HYDRO-DP Cough/cold/allergies any Eagle Level
HYDROMORPHONE HCL Pain relief - narcotic any Eagle Level
HYDRON PSC Cough/cold/allergies any Eagle Level
HYDROQUINONE Dermatological treatment any Eagle Level
HYDRO-TUSSIN Cough syrup any Eagle Level
HYDROXYCHLOROQUINE SULFATE Malaria any Eagle Level
hydroxyurea (HYDREA) Cancer 24 months Eagle Guaranteed
hydroxyurea (HYDREA) Essential thrombocytopenia any Eagle Level
p. 20
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
HYDROXYZINE HCL Anxiety any Eagle Level
HYDROXYZINE HCL Itching due to allergies any Eagle Level
HYGROTON (chlorthalidone) Hypertension any Eagle Level
HYGROTON (chlorthalidone) Congestive heart failure any Eagle Guaranteed
HYGROTON (chlorthalidone) Liver cirrhosis any Eagle Guaranteed
HYGROTON (chlorthalidone) Edema related to estrogen therapy any Eagle Level
HYOSCYAMINE SULFATE ER Ulcers any Eagle Level
HYTRIN (terazosin) Benign prostatic hypertrophy any Eagle Level
HYZAAR (hydrochlorothiazide/losartan) Hypertension any Eagle Level
HYZAAR (hydrochlorothiazide/losartan) Left ventricular hypertrophy 12 months Eagle Guaranteed
ibandronate (BONIVA) Osteoporosis any Eagle Level
imipramine (TOFRANIL) Depression 24 months Eagle Level; decline 40-49
imiquimod (ALDARA) Dermatological treatment any Eagle Level
IMITREX (sumatriptan) Migraine any Eagle Level
IMURAN (azathioprine) Kidney transplant rejection
any Eagle Guaranteed prevention
IMURAN (azathioprine) Rheumatoid arthritis any Eagle Level
indapamide (LOZOL) Hypertension any Eagle Level
indapamide (LOZOL) Congestive heart failure any Eagle Guaranteed
INDERAL (propranolol) Hypertension any Eagle Level
INDERAL (propranolol) Migraine any Eagle Level
INDERAL (propranolol) Angina 12 months Eagle Guaranteed
INDERAL (propranolol) Hypertrophic subaortic stenosis
any Eagle Guaranteed (cardiomyopathy)
INDOCIN (indomethacin) Rheumatoid arthritis any Eagle Level
indomethacin (INDOCIN) Rheumatoid arthritis any Eagle Level
INSPRA (eplerenone) Hypertension any Eagle Level
INSPRA (eplerenone) Congestive heart failure any Eagle Guaranteed
insulin glulisine (APIDRA) Diabetes any Eagle Level (with no diabetic complications)
INTELENCE (etravirine) HIV/AIDS any Eagle Guaranteed
interferon alfa-2b (INTRON) Cancer 24 months Eagle Guaranteed
interferon alfa-2b (INTRON) Hepatitis C 24 months Eagle Guaranteed
interferon alfa-2b (INTRON) AIDS-related Kaposi’s sarcoma any Eagle Guaranteed
interferon alfa-2b (INTRON) Genital warts any Eagle Level
Interferon beta-1a (AVONEX, REBIF) Multiple sclerosis any Eagle Level
INTRON-A (interferon alfa-2b) Cancer 24 months Eagle Guaranteed
INTRON-A (interferon alfa-2b) Hepatitis C 24 months Eagle Guaranteed
INTRON-A (interferon alfa-2b) AIDS-related Kaposi’s sarcoma any Eagle Guaranteed
INTRON-A (interferon alfa-2b) Genital warts any Eagle Level
INTUNIV (guanfacine) Hypertension any Eagle Level
INVEGA (paliperidone) Schizophrenia 24 months Eagle Level; decline 40-49
IONSYS (fentanyl) HOSPITAL USE ONLY Continuous, persistent moderate to
any Eagle Level severe chronic pain
p. 21
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ipratropium bromide HFA (ATROVENT HFA) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)/emphysema
ipratropium bromide nasal spray (ATROVENT NASAL Allergic and non-allergic nasal any Eagle Level
SPRAY) symptoms
IQUIX Eye drops any Eagle Level
irbesartan (AVAPRO) Hypertension any Eagle Level
irbesartan (AVAPRO) Diabetic kidney disease any Eagle Guaranteed
irbesartan and hydrochlorothiazide (AVALIDE) Hypertension any Eagle Level
ISOMETHEPTENE/DICHLORALPHENAZONE/ ACET- Migraine any Eagle Level
AMINOPHEN
isoniazid (NYDRAZID) Tuberculosis any Eagle Guaranteed
ISOPTIN (verapamil) Hypertension any Eagle Level
ISOPTIN (verapamil) Angina 12 months Eagle Guaranteed
ISOPTIN (verapamil) Arrhythmia any Eagle Level
ISOPTO HOMATROPINE Eye drops any Eagle Level
ISORDIL (isosorbide) Angina 12 months Eagle Guaranteed
isosorbide (ISORDIL) Angina 12 months Eagle Guaranteed
isosorbide dinitrate and hydralazine hydrochloride Congestive heart failure any Eagle Guaranteed
(BIDIL)
isradipine (DYNACIRC-CR) Hypertension any Eagle Level
JALYN Benign prostatic hypertrophy any Eagle Level
JANUMET (metformin/sitagliptin) Diabetes any Eagle Level (with no diabetic complications)
JANUVIA (sitagliptin) Diabetes any Eagle Level (with no diabetic complications)
KALETRA (lopinavir/ritonavir) HIV/AIDS any Eagle Guaranteed
KAPIDEX Esophagitis/heartburn/GERD any Eagle Level
KENALOG-40 Multiple indications - corticosteroid any Eagle Level
KEPPRA (levetiracetam) Epilepsy any Eagle Level
KEROL Dermatological treatment any Eagle Level
KETOCONAZOLE Fungal infection any Eagle Level
KETOPROFEN Pain relief - anti-inflammatory any Eagle Level
KETOROLAC TROMETHAMINE Seasonal allergic symptoms any Eagle Level
KLARON Dermatological treatment any Eagle Level
KLONOPIN (clonazepam) Seizures any Eagle Level
KLONOPIN (clonazepam) Panic disorder 24 months Eagle Level; decline 40-49
KLOR-CON 10 Potassium supplementation any Eagle Level
KYTRIL (granisetron) Nausea and vomiting, postoperative any Eagle Level
KYTRIL (granisetron) Nausea and vomiting,
24 months Eagle Guaranteed pre-chemotherapy
labetalol (NORMODYNE, TRANDATE) Hypertension any Eagle Level
LAC-HYDRIN (ammonium lactate) Dermatological treatment any Eagle Level
LACTULOSE Constipation any Eagle Level
LAMICTAL (lamotrigine) Epilepsy any Eagle Level
LAMICTAL (lamotrigine) Bipolar disorder 24 months Eagle Level; decline 40-49
LAMISIL Fungal infection any Eagle Level
p. 22
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
lamivudine (EPIVIR) HIV/AIDS any Eagle Guaranteed
lamivudine/zidovudine (COMBIVIR) HIV/AIDS any Eagle Guaranteed
lamotrigine (LAMICTAL) Epilepsy any Eagle Level
lamotrigine (LAMICTAL) Bipolar disorder 24 months Eagle Level; decline 40-49
LANOXICAPS (digoxin) Heart failure any Eagle Guaranteed
LANOXIN (digoxin) Heart failure any Eagle Guaranteed
lansoprazole (PREVACID) Ulcers any Eagle Level
lanthanum carbonate (FOSRENOL) Kidney disease any Eagle Guaranteed
LANTUS (insulin) Diabetes any Eagle Level (with no diabetic complications)
LASIX (furosemide) Hypertension any Eagle Level
LASIX (furosemide) Congestive heart failure any Eagle Guaranteed
LASIX (furosemide) Kidney disease any Eagle Guaranteed
LASIX (furosemide) Liver disease any Eagle Guaranteed
LAZANDA (fentanyl) nasal spray Cancer pain 24 months Eagle Guaranteed
leflunomide (ARAVA) Rheumatoid arthritis any Eagle Level
lenalidomide (REVLIMID) Cancer 24 months Eagle Guaranteed
LESCOL (fluvastatin) Elevated cholesterol any Eagle Level
letrozole (FEMARA) Breast cancer/cancer remission
24 months Eagle Guaranteed maintenance
LEUCOVORIN CALCIUM Cancer 24 months Eagle Guaranteed
LEVAQUIN Antibiotic any Eagle Level
LEVEMIR FLEXPEN (insulin) Diabetes any Eagle Level (with no diabetic complications)
levetiracetam (KEPPRA) Epilepsy any Eagle Level
LEVITRA Erectile dysfunction any Eagle Level
LEVOBUNOLOL HCL Eye drops any Eagle Level
LEXAPRO (escitalopram) Depression/anxiety 24 months Eagle Level; decline 40-49
LIBRAX (chlordiazepoxide/clidinium) Irritable bowel syndrome any Eagle Level
LIBRIUM (chlordiazepoxide HCl) Alcohol withdrawal 24 months Eagle Guaranteed
LIDODERM Dermatological treatment any Eagle Level
LIMBITROL (chlordiazepoxide/amitriptyline) Depression/anxiety 24 months Eagle Level; decline 40-49
LIMBREL Osteoarthritis any Eagle Level
LINCOCIN Antibiotic any Eagle Level
liothyronine (CYTOMEL) Thyroid replacement any Eagle Level
LIPITOR (atorvastatin) Elevated cholesterol any Eagle Level
LIQUITEARS Eye drops any Eagle Level
liraglutide (VICTOZA) Diabetes any Eagle Level (with no diabetic complications)
lisinopril (PRINIVIL, ZESTRIL) Hypertension any Eagle Level
lisinopril (PRINIVIL, ZESTRIL) Congestive heart failure any Eagle Guaranteed
lisinopril (PRINIVIL, ZESTRIL) Heart attack 12 months Eagle Guaranteed
lisinopril/hydrochlorothiazide (PRINZIDE, Hypertension any Eagle Level
ZESTORETIC)
LITHIUM CARBONATE Bipolar disorder any Eagle Level; decline 40-49
LOCOID LIPOCREAM Dermatological treatment any Eagle Level
p. 23
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
LODRANE 24D Cough/cold/allergies any Eagle Level
LOPERAMIDE HCL Diarrhea any Eagle Level
lopinavir/ritonavir (KALETRA) HIV/AIDS any Eagle Guaranteed
LOPRESSOR (metoprolol) Hypertension any Eagle Level
LOPRESSOR (metoprolol) Angina 12 months Eagle Guaranteed
LOPRESSOR (metoprolol) Congestive heart failure any Eagle Guaranteed
LORATADINE Antihistamine any Eagle Level
lorazepam (ATIVAN) Anxiety any Eagle Level
losartan (COZAAR) Hypertension any Eagle Level
losartan (COZAAR) Diabetic Kidney Disease 24 months Eagle Guaranteed
LOTEMAX Eye drops any Eagle Level
LOTENSIN (benazepril HCl) Hypertension any Eagle Level
LOTREL (amlodipine/benazepril) Hypertension any Eagle Level
LOTRONEX Irritable bowel syndrome any Eagle Level
lovastatin (ALTOPREV, MEVACOR, ALTOCOR) Elevated cholesterol any Eagle Level
LOVAZA (omega-3-acid ethyl esters) Elevated triglycerides any Eagle Level
LOVENOX (enoxaparin) Deep vein thrombosis (clot) any Eagle Level
LOVENOX (enoxaparin) Unstable angina 12 months Eagle Guaranteed
LOVENOX (enoxaparin) Heart attack 12 months Eagle Guaranteed
LOXAPINE SUCCINATE Schizophrenia 24 months Eagle Level; decline 40-49
LOZOL (indapamide) Hypertension any Eagle Level
LOZOL (indapamide) Congestive heart failure any Eagle Guaranteed
lubiprostone (AMITIZA) Constipation any Eagle Level
LUMIGAN Eye drops any Eagle Level
LUNESTA (eszopiclone) Insomnia any Eagle Level
LUPRON DEPOT Cancer 24 months Eagle Guaranteed
LUVOX (fluvoxamine) Obsessive compulsive disorder any Eagle Level
LUXIQ Dermatological treatment any Eagle Level
LYRICA (pregabalin) Neuropathic pain - diabetic/
24 months Eagle Guaranteed postherpetic
LYRICA (pregabalin) Seizures any Eagle Level
LYRICA (pregabalin) Fibromyalgia any Eagle Level
MAGNESIUM SULFATE Convulsion any Eagle Level
MAGNESIUM SULFATE Magnesium deficiency any Eagle Level
MALARONE Malaria any Eagle Level
MAPAP Pain relief - nonnarcotic any Eagle Level
MAPAP PM Insomnia any Eagle Level
MAPAP SINUS MAXIMUM STRENGTH Cough/cold/allergies any Eagle Level
MARINOL (dronabinol) Appetite stimulant in patients with
any Eagle Guaranteed AIDS
MARINOL (dronabinol) Nausea and vomiting related to
24 months Eagle Guaranteed chemotherapy
MARPLAN Depression any Eagle Level
MAVIK (trandolapril) Hypertension any Eagle Level
p. 24
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
MAVIK (trandolapril) Congestive heart failure any Eagle Guaranteed
MAXAIR AUTOHALER (pirbuterol inhaler) Asthma any Eagle Level
MAXALT Migraine any Eagle Level
MAXARON FORTE Iron supplementation any Eagle Level
MAXIDEX Eye drops any Eagle Level
MAXZIDE (triamterene/hydrochlorothiazide) Hypertension any Eagle Level
MAXZIDE (triamterene/hydrochlorothiazide) Edema any Eagle Level
MEBENDAZOLE Worm infection any Eagle Level
MECLIZINE HCL Nausea any Eagle Level
MEFLOQUINE HCL Malaria any Eagle Level
MEGACE ES (megestrol) liquid Appetite stimulant in patients with
any Eagle Guaranteed AIDS
MEGACE ES (megestrol) liquid Cancer-related weight loss 24 months Eagle Guaranteed
MEGACE ES (megestrol) tablets Breast or uterine cancer palliative
24 months Eagle Guaranteed therapy
megestrol (MEGACE) liquid Appetite stimulant in patients with
any Eagle Guaranteed AIDS
megestrol (MEGACE) liquid Cancer-related weight loss 24 months Eagle Guaranteed
megestrol (MEGACE) tablets Breast or uterine cancer palliative
24 months Eagle Guaranteed therapy
memantine (NAMENDA) Alzheimer’s disease any Eagle Guaranteed
MENEST (esterified estrogen) Menopausal symptoms any Eagle Level
MENEST (esterified estrogen) Breast and prostatic cancer 24 months Eagle Guaranteed
MENTAX Dermatological treatment any Eagle Level
MEPERIDINE HCL Moderate to severe pain - narcotic any Eagle Level
MEPHYTON Coagulation disorder any Eagle Level
MEPROZINE Moderate to severe pain - narcotic any Eagle Level
mercaptopurine (PURINETHOL) Cancer 24 months Eagle Guaranteed
mesalamine (ASACOL) Ulcerative colitis any Eagle Level
mesalamine (ROWASA) Ulcerative colitis/proctitis any Eagle Level
METAGLIP (glipizide/metformin) Diabetes any Eagle Level
METANX Diabetic neuropathy 24 months Eagle Guaranteed
metaproterenol sulfate (ALUPENT) Asthma any Eagle Level
metaproterenol sulfate (ALUPENT) Emphysema any Eagle Guaranteed
metformin (FORTAMET, GLUCOPHAGE, Diabetes any Eagle Level (with no diabetic complications)
GLUMETZA, RIOMET)
metformin/pioglitazone (ACTOPLUS MET) Diabetes any Eagle Level (with no diabetic complications)
metformin/repaglinide (PRANDIMET) Diabetes any Eagle Level (with no diabetic complications)
metformin/rosiglitazone (AVANDAMET) Diabetes any Eagle Level (with no diabetic complications)
metformin/sitagliptin (JANUMET) Diabetes any Eagle Level (with no diabetic complications)
methadone HCl (DISKETS, DOLOPHINE, Moderate to severe pain - narcotic any Eagle Level
METHADOSE)
methadone HCl (DISKETS, DOLOPHINE, Opiate addiction 24 months Eagle Guaranteed
METHADOSE)
METHAZOLAMIDE Glaucoma any Eagle Level
p. 25
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
METHENAMINE HIPPURATE Urinary tract infection any Eagle Level
METHERGINE Obstetric care any Eagle Level
METHIMAZOLE Thyroid any Eagle Level
methocarbamol (ROBAXIN) Muscle relaxer any Eagle Level
methotrexate (RHEUMATREX DOSE PACK, TREXALL) Rheumatoid arthritis any Eagle Level
methotrexate (RHEUMATREX DOSE PACK, TREXALL) Psoriasis, severe any Eagle Level
methotrexate (RHEUMATREX DOSE PACK, TREXALL) Cancer 24 months Eagle Guaranteed
methsuximide (CELONTIN) Seizures any Eagle Level
methyclothiazide (ENDURON) Hypertension any Eagle Level
methyclothiazide (ENDURON) Edema due to hormone or steroid
any Eagle Level therapy
methyclothiazide (ENDURON) Liver cirrhosis any Eagle Guaranteed
methyclothiazide (ENDURON) Congestive heart failure any Eagle Guaranteed
methyldopa (ALDOMET) Hypertension any Eagle Level
methylphenidate hydrochloride (CONCERTA) ADHD any Eagle Level
methylprednisolone Multiple indications - corticosteroid any Eagle Level
methyltestosterone (TESTRED) Males: hormonal treatment any Eagle Level
methyltestosterone (TESTRED) Females: Inoperable breast cancer 24 months Eagle Guaranteed
METIPRANOLOL Eye drops any Eagle Level
metoclopramide HCl (REGLAN) GERD any Eagle Level
metoclopramide HCl (REGLAN) Diabetic gastroparesis (delayed
any Eagle Level digestion)
metoclopramide HCl (REGLAN) Nausea and vomiting related to
24 months Eagle Guaranteed chemotherapy
metolazone (ZAROXOLYN) Hypertension any Eagle Level
metolazone (ZAROXOLYN) Congestive heart failure any Eagle Guaranteed
metolazone (ZAROXOLYN) Kidney disease any Eagle Guaranteed
metoprolol (LOPRESSOR, TOPROL-XL) Hypertension any Eagle Level
metoprolol (LOPRESSOR, TOPROL-XL) Angina 12 months Eagle Guaranteed
metoprolol (LOPRESSOR, TOPROL-XL) Congestive heart failure any Eagle Guaranteed
METROGEL Dermatological treatment any Eagle Level
METRONIDAZOLE Antibiotic any Eagle Level
metyrosine (DEMSER) Pheochromocytomas any Eagle Level
MEVACOR (lovastatin) Elevated cholesterol any Eagle Level
mexiletine (MEXITIL) Heart arrhythmia any Eagle Level
MEXITIL (mexiletine) Heart arrhythmia any Eagle Level
MIACALCIN (calcitonin) Osteoporosis any Eagle Level
MIACALCIN (calcitonin) Paget’s bone disease any Eagle Level
MI-ACID Antacid any Eagle Level
MICARDIS (hydrochlorothiazide/telmisartan) Hypertension any Eagle Level
MICRONASE (glyburide) Diabetes any Eagle Level (with no diabetic complications)
MIDAMOR (amiloride HCl) Hypertension any Eagle Level
MIDAMOR (amiloride HCl) Congestive heart failure any Eagle Guaranteed
MIDODRINE HCL Low blood pressure any Eagle Level
p. 26
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
miglitol (GLYSET) Diabetes any Eagle Level (with no diabetic complications)
MIGRANAL Migraine any Eagle Level
MIGRATEN Migraine any Eagle Level
milnacipran (SAVELLA) Fibromyalgia any Eagle Level
MIMYX Dermatological treatment any Eagle Level
MINIPRESS (prazosin) Hypertension any Eagle Level
MINOCYCLINE HCL Antibiotic any Eagle Level
MINOXIDIL Hypertension any Eagle Level
MINOXIDIL Hair regrowth treatment any Eagle Level
MINTOX PLUS Antacid any Eagle Level
MIRAPEX (pramipexole) Restless legs syndrome any Eagle Level
MIRAPEX (pramipexole) Parkinson’s disease any Eagle Level
mirtazapine (REMERON) Depression any Eagle Level
misoprostol (CYTOTEC) Ulcers any Eagle Level
MOBIC Pain relief - anti-inflammatory any Eagle Level
MOBISYL Dermatological treatment any Eagle Level
modafinil (PROVIGIL) Narcolepsy (improves excessive
any Eagle Level sleepiness)
moexipril (UNIVASC) Hypertension any Eagle Level
MOMETASONE FUROATE Dermatological treatment any Eagle Level
MONOPRIL (fosinopril) Hypertension any Eagle Level
MONOPRIL (fosinopril) Congestive heart failure any Eagle Guaranteed
MONOPRIL HCT (fosinopril/hydrochlorothiazide) Hypertension any Eagle Level
montelukast (SINGULAIR) Allergies/asthma any Eagle Level
morphine sulfate (AVINZA) Moderate to severe pain - narcotic any Eagle Level
MOVIPREP Constipation any Eagle Level
moxifloxacin (AVELOX) Antibiotic any Eagle Level
MST 600 Pain relief - nonnarcotic any Eagle Level
MUCOMYST (acetylcysteine) Emphysema any Eagle Guaranteed
MUCOMYST (acetylcysteine) Tuberculosis any Eagle Guaranteed
MUCOMYST (acetylcysteine) Pneumonia/bronchitis any Eagle Level
MUCOMYST (acetylcysteine) Cystic fibrosis any Eagle Guaranteed
MULTAQ Heart arrhythmia any Eagle Level
MULTIRET FOLIC-500 Vitamin supplement any Eagle Level
MUPIROCIN Dermatological treatment any Eagle Level
MYCELEX (clotrimazole) Fungal infection any Eagle Level
mycophenolate (CELLCEPT) Transplant rejection any Eagle Guaranteed
mycophenolic acid (MYFORTIC) Organ transplant rejection any Eagle Guaranteed
MYFORTIC (mycophenolic acid) Organ transplant rejection any Eagle Guaranteed
nabumetone (RELAFEN) Rheumatoid arthritis/osteoarthritis any Eagle Level
nadolol (CORGARD) Hypertension any Eagle Level
nadolol (CORGARD) Angina 12 months Eagle Guaranteed
nadolol/bendroflumethiazide (CORZIDE) Hypertension any Eagle Level
p. 27
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
NAFCILLIN SODIUM Antibiotic any Eagle Level
NAFTIN Dermatological treatment any Eagle Level
NALDEX Cough/cold/allergies any Eagle Level
naloxone (NARCAN) Opiate overdose 24 months Eagle Guaranteed
naltrexone (REVIA) Alcohol dependence 24 months Eagle Guaranteed
naltrexone (VIVITROL) Alcohol dependence/opiate
24 months Eagle Guaranteed dependence
NAMENDA (memantine) Alzheimer’s disease any Eagle Guaranteed
NAPROXEN Pain relief - anti-inflammatory any Eagle Level
NARCAN (naloxone) Opiate overdose 24 months Eagle Guaranteed
NASACORT AQ Allergy symptoms any Eagle Level
NASAREL Allergy symptoms any Eagle Level
NASONEX Allergy symptoms any Eagle Level
NATAFORT Vitamin supplement any Eagle Level
NATALCARE GLOSSTABS Vitamin supplement any Eagle Level
NATATAB RX Vitamin supplement any Eagle Level
nateglinide (STARLIX) Diabetes any Eagle Level (with no diabetic complications)
nebivolol (BYSTOLIC) Hypertension any Eagle Level
NEEVO DHA Vitamin supplement any Eagle Level
NEFAZODONE HCL Depression any Eagle Level
NEO AC Cough/cold/allergies any Eagle Level
NEOMYCIN/POLYMYXIN/BACITRACIN Eye drops any Eagle Level
NEOMYCIN/POLYMYXIN/DEXAMETHASONE Eye drops any Eagle Level
NEOMYCIN/POLYMYXIN/GRAMICIDIN Eye drops any Eagle Level
NEOMYCIN/POLYMYXIN/HYDROCORTISONE Eye drops any Eagle Level
NEOMYCIN SULFATE Topical antibiotic any Eagle Level
NERVO B-12 SL Vitamin supplement any Eagle Level
NEUPOGEN (filgrastim) Cancer 24 months Eagle Guaranteed
NEURONTIN (gabapentin) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed
NEURONTIN (gabapentin) Epilepsy any Eagle Level
NEUTRA-PHOS Mineral/electrolyte supplement any Eagle Level
NEVANAC Eye drops any Eagle Level
NEXAVAR (sorafenib) Cancer 24 months Eagle Guaranteed
NEXIUM (esomeprazole) GERD/ulcers any Eagle Level
niacin (NIASPAN) Elevated cholesterol any Eagle Level
niacin/lovastatin (ADVICOR) Elevated cholesterol any Eagle Level
NIACOR Vitamin supplement/elevated
any Eagle Level cholesterol
NIASPAN (niacin) Elevated cholesterol any Eagle Level
NICORETTE STARTER KIT Smoking cessation 12 months Smoker rates (Eagle Level)
NICOTINE Smoking cessation 12 months Smoker rates (Eagle Level)
NIFEDICAL (nifedipine) Hypertension any Eagle Level
nifedipine (ADALAT, PROCARDIA, NIFEDICAL, Hypertension any Eagle Level
AFEDITAB)
p. 28
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
NIFEREX Iron supplementation any Eagle Level
nisoldipine (Sular) Hypertension any Eagle Level
NITROFURANTOIN Urinary tract antibiotic any Eagle Level
nitroglycerine (NITRO-TIME, NITROLINGUAL, Angina 12 months Eagle Guaranteed
NITROMIST, NITROSTAT, NITROQUICK
NITROLINGUAL (nitroglycerin) Angina 12 months Eagle Guaranteed
NITROMIST (nitroglycerin) Angina 12 months Eagle Guaranteed
NITROQUICK (nitroglycerin) Angina 12 months Eagle Guaranteed
NITROSTAT (nitroglycerin) Angina 12 months Eagle Guaranteed
NITRO-TIME (nitroglycerin) Angina 12 months Eagle Guaranteed
nizatidine (AXID) Ulcers/esophagitis any Eagle Level
NOHIST-EXT Antihistamine any Eagle Level
NOREL SR Cough/cold/allergies any Eagle Level
NORETHINDRONE ACETATE Hormonal treatment any Eagle Level
NORFLEX (orphenadrine) Muscle relaxer any Eagle Level
NORMODYNE (labetalol) Hypertension any Eagle Level
NOROXIN Antibiotic any Eagle Level
NORPRAMIN (desipramine HCl) Depression any Eagle Level
NORTRIPTYLINE HCL Depression any Eagle Level
NORVASC (amlodipine) Hypertension any Eagle Level
NORVASC (amlodipine) Coronary artery disease 12 months Eagle Guaranteed
NORVIR (ritonavir) HIV/AIDS any Eagle Guaranteed
NOVACORT Dermatological treatment any Eagle Level
NOVOLOG (insulin) Diabetes any Eagle Level (with no diabetic complications)
NUCYNTA Moderate to severe pain - narcotic any Eagle Level
NUTROPIN AQ PEN Hormonal treatment any Eagle Level
NUVIGIL Narcolepsy (improves excessive
any Eagle Level sleepiness)
NYDRAZID (isoniazid) Tuberculosis any Eagle Guaranteed
NYSTATIN Fungal infection any Eagle Level
NYSTATIN/TRIAMCINOLONE Dermatological treatment any Eagle Level
NYSTOP Dermatological treatment any Eagle Level
OFLOXACIN Eye drops any Eagle Level
olanzapine (ZYPREXA) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
olmesartan (BENICAR HCT) Hypertension any Eagle Level
OLUX-E Dermatological treatment any Eagle Level
omega-3-acid ethyl esters (LOVAZA) Elevated triglycerides any Eagle Level
omeprazole (PRILOSEC) Ulcers/GERD/esophagitis any Eagle Level
omeprazole/sodium bicarbonate (ZEGERID) Ulcers/GERD/esophagitis any Eagle Level
OMNARIS Allergies any Eagle Level
OMNICEF Antibiotic any Eagle Level
onabotulinumtoxinA (BOTOX) Spasticity/multiple indications any Eagle Level
ondansetron (ZOFRAN) Nausea/vomiting related to
24 months Eagle Guaranteed chemotherapy
p. 29
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ONGLYZA (saxagliptin) Diabetes any Eagle Level (with no diabetic complications)
ONSOLIS (fentanyl) buccal soluble film Cancer pain 24 months Eagle Guaranteed
OPANA ER Moderate to severe pain - narcotic any Eagle Level
OPTI-CLEAR Eye drops any Eagle Level
OPTIVAR Eye drops any Eagle Level
ORACEA Dermatological treatment any Eagle Level
ORAP Tourette’s disorder any Eagle Level
orphenadrine (NORFLEX) Muscle relaxer any Eagle Level
OVIDE Dermatological treatment any Eagle Level
OXAPROZIN Pain relief - anti-inflammatory any Eagle Level
oxazepam (SERAX) Anxiety any Eagle Level
oxcarbazepine (TRILEPTAL) Seizures any Eagle Level
OXISTAT Dermatological treatment any Eagle Level
OXSORALEN ULTRA Psoriasis, severe any Eagle Level
OXYCODONE Moderate to severe pain - narcotic any Eagle Level
OXYTROL Urinary spasm any Eagle Level
OYSCO 500 Mineral/electrolyte supplement any Eagle Level
OYST-CAL Mineral/electrolyte supplement any Eagle Level
PACERONE (amiodarone) Heart arrhythmia any Eagle Level
paliperidone (INVEGA) Schizophrenia 24 months Eagle Level; decline 40-49
pamidronate (AREDIA) Cancer 24 months Eagle Guaranteed
pamidronate (AREDIA) Paget’s bone disease any Eagle Level
PAMINE FORTE Ulcer any Eagle Level
pancrelipase (CREON) Pancreatic enzyme - cystic fibrosis any Eagle Guaranteed
pancrelipase (CREON) Pancreatic enzyme - chronic
12 months Eagle Level; decline 40-49 pancreatitis
pancrelipase (CREON) Pancreatic enzyme - pancreatectomy 12 months Eagle Level; decline 40-49
PANLOR SS Moderate to severe pain - narcotic any Eagle Level
pantoprazole (PROTONIX) GERD/ulcers any Eagle Level
papain and urea (ACCUZYME) Dermatological treatment any Eagle Level
PARAFON FORTE DSC (chlorzoxazone) Musculoskeletal pain any Eagle Level
PAREGORIC Diarrhea any Eagle Level
paricalcitol (ZEMPLAR) Kidney disease any Eagle Guaranteed
paroxetine (PAXIL, PEXEVA) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49
PATANASE Allergies any Eagle Level
PATANOL Eye drops any Eagle Level
PAXIL (paroxetine) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49
PEDIOX-S Antihistamine any Eagle Level
PEGASYS (peginterferon alfa-2a) Hepatitis B and C 24 months Eagle Guaranteed
PEG-INTRON Hepatitis C 24 months Eagle Guaranteed
PENICILLIN V POTASSIUM Antibiotic any Eagle Level
PENLAC NAIL LACQUER Dermatological treatment any Eagle Level
PENTAZOCINE/ACETAMINOPHEN Pain relief - narcotic any Eagle Level
p. 30
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
PENTAZOCINE/NALOXONE HCL Moderate to severe pain - narcotic any Eagle Level
pentoxifylline (PENTOXIL, TRENTAL) Circulation disorder any Eagle Level
PENTOXIL (pentoxifylline) Circulation disorder any Eagle Level
PERIDEX (chlorhexidine gluconate) Antiseptic rinse any Eagle Level
perindopril (ACEON) Hypertension any Eagle Level
perindopril (ACEON) Coronary artery disease 12 months Eagle Guaranteed
PERMETHRIN Dermatological treatment any Eagle Level
PERPHENAZINE Schizophrenia 24 months Eagle Level; decline 40-49
PERPHENAZINE Severe nausea/vomiting any Eagle Level
PERPHENAZINE/AMITRIPTYLINE Depression/anxiety any Eagle Level
PERSANTINE (dipyridamole) Clot prevention after valve
12 months Eagle Guaranteed replacement
PEXEVA (paroxetine) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49
PHENAVENT LA Cough/cold/allergies any Eagle Level
PHENAZOPYRIDINE HCL Urinary spasm any Eagle Level
PHENDIMETRAZINE TARTRATE Obesity any Eagle Level
PHENOBARBITAL Sedative/seizures any Eagle Level
PHENTERMINE HCL ADHD/narcolepsy/obesity any Eagle Level
phenytoin (DILANTIN) Seizures any Eagle Level
PHENYTOIN SODIUM EXTENDED Seizures any Eagle Level
P-HIST Cough/cold/allergies any Eagle Level
PHOSPHA 250 NEUTRAL Mineral/electrolyte supplement any Eagle Level
PILOCARPINE HCL (Ophthalmic) Eye drops any Eagle Level
PILOCARPINE HCL (Oral) Dry mouth any Eagle Level
PILOCARPINE HCL (Oral) Dry mouth due to cancer radiation
24 months Eagle Guaranteed treatment
PINDOLOL Hypertension any Eagle Level
pioglitazone (ACTOS) Diabetes any Eagle Level (with no diabetic complications)
pirbuterol inhaler (MAXAIR AUTOHALER) Asthma any Eagle Level
PIROXICAM Pain relief - anti-inflammatory any Eagle Level
PLAVIX (clopidogrel) Heart attack 12 months Eagle Guaranteed
PLAVIX (clopidogrel) Stroke 12 months Eagle Guaranteed
PLENDIL (felodipine) Hypertension any Eagle Level
PLETAL (cilostazol) Circulatory disease any Eagle Level
POLY HIST FORTE Cough/cold/allergies any Eagle Level
POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE Eye drops any Eagle Level
pramipexole (MIRAPEX) Restless legs syndrome any Eagle Level
pramipexole (MIRAPEX) Parkinson’s disease any Eagle Level
pramlintide (SYMLIN) Diabetes any Eagle Level (with no diabetic complications)
PRAMOSONE Dermatological treatment any Eagle Level
PRANDIMET (metformin/repaglinide) Diabetes any Eagle Level (with no diabetic complications)
PRANDIN (repaglinide) Diabetes any Eagle Level (with no diabetic complications)
PRAVACHOL (pravastatin) Elevated cholesterol any Eagle Level
p. 31
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
pravastatin (PRAVACHOL) Elevated cholesterol any Eagle Level
prazosin (MINIPRESS) Hypertension any Eagle Level
PRECOSE (acarbose) Diabetes any Eagle Level (with no diabetic complications)
PREDNISOLONE Multiple indications - corticosteroid any Eagle Level
PREDNISOLONE ACETATE Eye drops any Eagle Level
PREDNISONE Multiple indications - corticosteroid any Eagle Level
pregabalin (LYRICA) Neuropathic pain - diabetic/
24 months Eagle Guaranteed postherpetic
pregabalin (LYRICA) Seizures any Eagle Level
pregabalin (LYRICA) Fibromyalgia any Eagle Level
PREMARIN Hormonal treatment any Eagle Level
PREMPRO Hormonal treatment any Eagle Level
PRENATAL 19 Vitamin supplement any Eagle Level
PRENATAL PLUS Vitamin supplement any Eagle Level
PREVACID (lansoprazole) Ulcers any Eagle Level
PREVPAC Ulcers any Eagle Level
PRILOSEC (omeprazole) Ulcers/GERD/esophagitis any Eagle Level
PRIMACARE ONE Vitamin supplement any Eagle Level
PRIMIDONE Epilepsy any Eagle Level
PRINIVIL (lisinopril) Hypertension any Eagle Level
PRINIVIL (lisinopril) Congestive heart failure any Eagle Guaranteed
PRINIVIL (lisinopril) Heart attack 12 months Eagle Guaranteed
PRINZIDE (lisinopril/hydrochlorothiazide) Hypertension any Eagle Level
PRISTIQ Depression any Eagle Level
PROAIR HFA (albuterol) Asthma any Eagle Level
PROBENECID Gout any Eagle Level
PROCARDIA (nifedipine) Hypertension any Eagle Level
prochlorperazine (COMPRO) Nausea/vomiting any Eagle Level
PROCHLORPERAZINE MALEATE Nausea/vomiting, severe any Eagle Level (unless coupled w/cancer)
PROCHLORPERAZINE MALEATE Schizophrenia/anxiety 24 months Eagle Level; decline 40-49
PROCRIT (epoetin alfa) Cancer-related anemia 24 months Eagle Guaranteed
PROCRIT (epoetin alfa) HIV-related anemia any Eagle Guaranteed
PROCRIT (epoetin alfa) Kidney disease-related anemia any Eagle Guaranteed
PROCTOFOAM HC Hemorrhoids any Eagle Level
PROCTOSOL HC Hemorrhoids any Eagle Level
PROGRAF (tacrolimus) Organ transplant rejection any Eagle Guaranteed
PROLIXIN (fluphenazine) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49
PROMETHAZINE Cough/cold/allergies any Eagle Level
PROMETHAZINE HCL Antihistamine any Eagle Level
PROMETRIUM Hormonal treatment any Eagle Level
PROPAFENONE HCL Heart arrhythmia any Eagle Level
PROPANTHELINE BROMIDE Ulcers any Eagle Level
PROPECIA (finasteride) Male pattern baldness any Eagle Level
p. 32
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
propoxyphene (DARVON) Pain relief - narcotic any Eagle Level
propoxyphene-N/acetaminophen Pain relief - narcotic any Eagle Level
propranolol (INDERAL) Hypertension any Eagle Level
propranolol (INDERAL) Migraine any Eagle Level
propranolol (INDERAL) Angina 12 months Eagle Guaranteed
propranolol (INDERAL) Hypertrophic subaortic stenosis
any Eagle Guaranteed (cardiomyopathy)
PROPYLTHIOURACIL Thyroid any Eagle Level
PROSCAR (finasteride) Benign prostatic hypertrophy any Eagle Level
PROSED/DS Urinary antibiotic any Eagle Level
PROTONIX (pantoprazole) GERD/ulcers any Eagle Level
PROTOPIC Dermatological treatment any Eagle Level
PROVENTIL (albuterol) Asthma any Eagle Level
PROVIGIL (modafinil) Narcolepsy (improves excessive
any Eagle Level sleepiness)
PROZAC (fluoxetine) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49
PRUDOXIN Dermatological treatment any Eagle Level
PSEUDOEPHEDRINE/GUAIFENESIN/ DEXTRO- Cough/cold/allergies any Eagle Level
METHORPHAN
PSEUDOVENT 400 Cough/cold/allergies any Eagle Level
PURINETHOL (mercaptopurine) Cancer 24 months Eagle Guaranteed
PYLERA Ulcers any Eagle Level
PYRIDOSTIGMINE BROMIDE Myasthenia gravis any Eagle Level
QDALL AR Antihistamine any Eagle Level
QUALAQUIN Malaria any Eagle Level
QUESTRAN (cholestyramine) Elevated cholesterol any Eagle Level
quetiapine (SEROQUEL) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
quinapril (ACCUPRIL) Hypertension any Eagle Level
quinapril/hydrochlorothiazide (QUINARETIC) Hypertension any Eagle Level
QUINARETIC (quinapril/hydrochlorothiazide) Hypertension any Eagle Level
QUINIDINE SULFATE Heart arrhythmia any Eagle Level
QUINIDINE SULFATE Malaria any Eagle Level
QVAR (beclomethasone) Asthma any Eagle Level
raloxifene (EVISTA) Osteoporosis any Eagle Level
ramelteon (ROZEREM) Insomnia any Eagle Level
ramipril (ALTACE) Hypertension any Eagle Level
ramipril (ALTACE) Congestive heart failure any Eagle Guaranteed
RANEXA (ranolazine) Angina 12 months Eagle Guaranteed
RANITIDINE HCL Heartburn/indigestion any Eagle Level
ranolazine (RANEXA) Angina 12 months Eagle Guaranteed
RAPAFLO Benign prostatic hypertrophy any Eagle Level
RAPAMUNE (sirolimus) Organ transplant rejection
any Eagle Guaranteed prevention
rasagiline (AZILECT) Parkinson’s disease any Eagle Level
p. 33
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
RAZADYNE (galantamine) Alzheimer’s disease any Eagle Guaranteed
RE 10 WASH Dermatological treatment any Eagle Level
REBIF (interferon beta-1a) Multiple sclerosis any Eagle Level
RECLAST (zoledronic acid) Osteoporosis any Eagle Level
REGLAN (metoclopramide) GERD any Eagle Level
REGLAN (metoclopramide) Diabetic gastroparesis (delayed
24 months Eagle Guaranteed digestion)
REGLAN (metoclopramide) Nausea and vomiting related to
24 months Eagle Guaranteed chemotherapy
REGRANEX Dermatological treatment any Eagle Level
RELAFEN (nabumetone) Rheumatoid arthritis/osteoarthritis any Eagle Level
RELISTOR Constipation any Eagle Level
RELPAX Migraine any Eagle Level
REMERON (mirtazapine) Depression 24 months Eagle Level; decline 40-49
RENACIDIN Kidney stones any Eagle Level
RENAGEL (sevelamer) Kidney disease any Eagle Guaranteed
RENAL Vitamin supplement any Eagle Level
RENVELA (sevelamer) Kidney disease any Eagle Guaranteed
repaglinide (PRANDIN) Diabetes any Eagle Level (with no diabetic complications)
REPLIVA 21/7 Iron supplementation any Eagle Level
REQUIP (ropinirole) Restless legs syndrome any Eagle Level
REQUIP (ropinirole) Parkinson’s disease any Eagle Level
RESTASIS Eye drops any Eagle Level
RESTORIL (temazepam) Insomnia any Eagle Level
RETIN-A MICRO Dermatological treatment any Eagle Level
RETROVIR (zidovudine) HIV/AIDS any Eagle Guaranteed
REVIA (naltrexone) Alcohol dependence 24 months Eagle Guaranteed
REVLIMID (lenalidomide) Cancer 24 months Eagle Guaranteed
REYATAZ (atazanavir) HIV-related anemia any Eagle Guaranteed
RHINOCORT AQUA Nasal spray any Eagle Level
ribavirin (COPEGUS) Hepatitis C 24 months Eagle Guaranteed
RIFAMPIN Tuberculosis any Eagle Guaranteed
RIMANTADINE HCL Influenza any Eagle Level
RINNOVI NAIL SYSTEM Dermatological treatment any Eagle Level
RIOMET (metformin) Diabetes any Eagle Level (with no diabetic complications)
risedronate (ACTONEL) Osteoporosis any Eagle Level
RISPERDAL (risperidone) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
risperidone (RISPERDAL) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
ritonavir (NORVIR) HIV/AIDS any Eagle Guaranteed
rivastigmine transdermal (EXELON) Alzheimer’s disease/dementia any Eagle Guaranteed
ROBAXIN (methocarbamol) Muscle relaxer any Eagle Level
ROBINUL (glycopyrrolate) Ulcers any Eagle Level
ROCALTROL (calcitriol) Calcium replacement in PRIMARY
any Eagle Level parathyroid disease
p. 34
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
ROCALTROL (calcitriol) Kidney failure; SECONDARY para-
any Eagle Guaranteed thyroid disease
ROMAZICON (flumazenil) Drug overdose management 24 months Eagle Guaranteed
ropinirole (REQUIP) Restless legs syndrome any Eagle Level
ropinirole (REQUIP) Parkinson’s disease any Eagle Level
ROSAC Dermatological treatment any Eagle Level
rosiglitazone (AVANDIA) Diabetes any Eagle Level (with no diabetic complications)
rosuvastatin (CRESTOR) Elevated cholesterol any Eagle Level
ROWASA (mesalamine) Ulcerative colitis/proctitis any Eagle Level
ROZEREM (ramelteon) Insomnia any Eagle Level
R-TANNA Cough/cold/allergies any Eagle Level
SALKERA Dermatological treatment any Eagle Level
salmeterol (SEREVENT) Asthma any Eagle Level
salmeterol (SEREVENT) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
SALSALATE Pain relief - nonnarcotic any Eagle Level
SANCTURA XR Overactive bladder any Eagle Level
SANTYL Dermatological treatment any Eagle Level
SAVELLA (milnacipran) Fibromyalgia any Eagle Level
saxagliptin (ONGLYZA) Diabetes any Eagle Level (with no diabetic complications)
SECTRAL (acebutolol HCl) Hypertension any Eagle Level
SECTRAL (acebutolol HCl) Arrhythmia any Eagle Level
selegiline (ELDEPRYL, ZELAPAR) Parkinson’s disease any Eagle Level
SELENIUM SULFIDE Dermatological treatment any Eagle Level
SENNA Constipation any Eagle Level
SENNA S Constipation any Eagle Level
SENSIPAR (cinacalcet) Primary parathyroid disease any Eagle Level
SENSIPAR (cinacalcet) Parathyroid cancer 24 months Eagle Guaranteed
SENSIPAR (cinacalcet) Kidney disease any Eagle Guaranteed
SERAX (oxazepam) Anxiety any Eagle Level
SEREVENT DISKUS (salmeterol) Asthma any Eagle Level
SEREVENT DISKUS (salmeterol) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
SEROQUEL (quetiapine) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
sertraline (ZOLOFT) Depression any Eagle Level
sevelamer (RENAGEL, RENVELA) Kidney disease any Eagle Guaranteed
SILVER SULFADIAZINE Dermatological treatment any Eagle Level
SIMCOR (simvastatin/niacin) Elevated cholesterol any Eagle Level
SIMPONI (golimumab) Rheumatoid arthritis/psoriatic
any Eagle Level arthritis
SIMPONI (golimumab) Ankylosing spondylitis any Eagle Level
simvastatin (ZOCOR) Elevated cholesterol any Eagle Level
simvastatin/niacin (SIMCOR) Elevated cholesterol any Eagle Level
SINEMET (carbidopa/levodopa) Parkinson’s disease any Eagle Level
p. 35
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
SINEQUAN (doxepin HCl) Depression/anxiety any Eagle Level
SINGULAIR (montelukast) Allergies/asthma any Eagle Level
sirolimus (RAPAMUNE) Organ transplant rejection
any Eagle Guaranteed prevention
sitagliptin (JANUVIA) Diabetes any Eagle Level (with no diabetic complications)
SKELAXIN Muscle relaxer any Eagle Level
SODIUM SULFACETAMIDE Eye drops any Eagle Level
SOLARAZE Dermatological treatment any Eagle Level
SOLTAMOX (tamoxifen) Breast cancer/cancer remission
24 months Eagle Guaranteed maintenance
SONATA (zaleplon) Insomnia any Eagle Level
sorafenib (NEXAVAR) Cancer 24 months Eagle Guaranteed
SORBITOL Constipation any Eagle Level
SORBUTUSS Cough/cold/allergies any Eagle Level
SORIATANE Dermatological treatment any Eagle Level
SORIATANE CK Dermatological treatment any Eagle Level
SORINE (sotalol) Heart arrhythmia any Eagle Level
sotalol (BETAPACE, SORINE) Heart arrhythmia any Eagle Level
SPECTRACEF Antibiotic any Eagle Level
SPIRIVA (tiotropium) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
spironolactone (ALDACTONE) Hyperaldosteronism/low potassium any Eagle Level
spironolactone (ALDACTONE) Hypertension any Eagle Level
spironolactone (ALDACTONE) Liver cirrhosis any Eagle Guaranteed
spironolactone (ALDACTONE) Congestive heart failure any Eagle Guaranteed
spironolactone (ALDACTONE) Kidney disease any Eagle Guaranteed
STALEVO 100 Parkinson’s disease any Eagle Level
STARLIX (nateglinide) Diabetes any Eagle Level (with no diabetic complications)
STRATTERA ADHD any Eagle Level
STROMECTOL Worm infection any Eagle Level
STROVITE ADVANCE Vitamin supplement any Eagle Level
SUBOXONE Opiate dependency 24 months Eagle Guaranteed
SUBSYS (fentanyl) sublingual spray Cancer pain 24 months Eagle Guaranteed
SUBUTEX Opiate dependency 24 months Eagle Guaranteed
SUCRALFATE Ulcers any Eagle Level
SULAR (nisoldipine) Hypertension any Eagle Level
SULFAMETHOXAZOLE/TRIMETHOPRIM DS Antibiotic any Eagle Level
SULFASALAZINE Ulcerative colitis any Eagle Level
SULINDAC Pain relief - anti-inflammatory any Eagle Level
sumatriptan (IMITREX) Migraine any Eagle Level
SUSTIVA (efavirenz) HIV/AIDS any Eagle Guaranteed
SYMBICORT (budesonide/formoterol) Asthma any Eagle Level
SYMBICORT (budesonide/formoterol) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
p. 36
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
SYMBYAX (fluoxetine/olanzapine) Depression/bipolar disorder any Eagle Level
SYMLIN (pramlintide) Diabetes any Eagle Level (with no diabetic complications)
SYMMETREL (amantadine HCl) Parkinson’s disease any Eagle Level
SYMMETREL (amantadine HCl) Drug-induced movement disorders any Eagle Level
SYNTHROID Thyroid any Eagle Level
SYNVISC Osteoarthritis any Eagle Level
SYSTANE Eye drops any Eagle Level
TACLONEX Dermatological treatment any Eagle Level
tacrolimus (PROGRAF) Organ transplant rejection any Eagle Guaranteed
tadalafil (CIALIS) Erectile dysfunction any Eagle Level
TAGAMET (cimetidine) Heartburn any Eagle Level
TAMBOCOR (flecainide) Heart arrhythmia any Eagle Level
TAMIFLU Influenza any Eagle Level
tamoxifen (SOLTAMOX) Breast cancer/cancer remission
24 months Eagle Guaranteed maintenance
tamsulosin (FLOMAX) Benign prostatic hypertrophy any Eagle Level
TANDEM Iron supplementation any Eagle Level
TARKA (trandolapril/verapamil) Hypertension any Eagle Level
TAXOTERE (docetaxel) Cancer 24 months Eagle Guaranteed
TEBAMIDE Nausea/vomiting any Eagle Level
TEGRETOL (carbamazepine) Epilepsy any Eagle Level
TEGRETOL (carbamazepine) Facial nerve disorder any Eagle Level
TEKTURNA (aliskiren) Hypertension any Eagle Level
TEKTURNA HCT (aliskiren/hydrochlorothiazide) Hypertension any Eagle Level
temazepam (RESTORIL) Insomnia any Eagle Level
TENEX (guanfacine) Hypertension any Eagle Level
tenofovir (VIREAD) Hepatitis B 24 months Eagle Guaranteed
tenofovir (VIREAD) HIV/AIDS any Eagle Guaranteed
TENORETIC (atenolol/chlorthalidone) Hypertension any Eagle Level
TENORMIN (atenolol) Hypertension any Eagle Level
TENORMIN (atenolol) Angina 12 months Eagle Guaranteed
TENORMIN (atenolol) Heart attack 12 months Eagle Guaranteed
TENUATE (diethylpropion) Obesity any Eagle Level (refer build chart)
terazosin (HYTRIN) Benign prostatic hypertrophy any Eagle Level
terbutaline (BRETHINE, BRICANYL) Asthma/bronchitis any Eagle Level
terbutaline (BRETHINE, BRICANYL) Emphysema any Eagle Guaranteed
TERCONAZOLE Fungal infection any Eagle Level
TESTOSTERONE CYPIONATE Hormonal treatment any Eagle Level
TESTOSTERONE PROPIONATE Hormonal treatment any Eagle Level
TESTRED (methyltestosterone) Males: hormonal treatment any Eagle Level
TESTRED (methyltestosterone) Females: Inoperable breast cancer 24 months Eagle Guaranteed
TETRACAINE HCL Eye drops any Eagle Level
TETRACYCLINE HCL Antibiotic any Eagle Level
p. 37
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
THALITONE (chlorthalidone) Hypertension any Eagle Level
THALITONE (chlorthalidone) Congestive heart failure any Eagle Guaranteed
THALITONE (chlorthalidone) Liver cirrhosis any Eagle Guaranteed
THALITONE (chlorthalidone) Edema related to estrogen therapy any Eagle Level
THALOMID Cancer 24 months Eagle Guaranteed
THEOPHYLLINE Asthma any Eagle Level
THEOPHYLLINE Emphysema any Eagle Guaranteed
THIAMINE HCL Vitamin supplement any Eagle Level
THIORIDAZINE HCL Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49
THIOTHIXENE Schizophrenia 24 months Eagle Level; decline 40-49
THORAZINE (chlorpromazine HCl) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49
tiagabine (GABITRIL) Seizures any Eagle Level
TIAZAC (diltiazem) Hypertension any Eagle Level
TIAZAC (diltiazem) Angina 12 months Eagle Guaranteed
TICLID (ticlopidine) Stroke 12 months Eagle Guaranteed
TICLID (ticlopidine) Clot prevention after heart stent
12 months Eagle Guaranteed placement
ticlopidine (TICLID) Stroke 12 months Eagle Guaranteed
ticlopidine (TICLID) Clot prevention after heart stent
12 months Eagle Guaranteed placement
TIKOSYN (dofetilide) Heart arrhythmia any Eagle Level
TIMOLOL MALEATE OPHTHALMIC GEL FORMING Eye drops any Eagle Level
TINDAMAX Antibiotic any Eagle Level
tiotropium (SPIRIVA) Chronic obstructive pulmonary
any Eagle Guaranteed disease (COPD)
TIZANIDINE HCL Muscle relaxer any Eagle Level
TOBI Antibiotic any Eagle Level
TOBRADEX Eye drops any Eagle Level
TOBRAMYCIN SULFATE Eye drops any Eagle Level
TOFRANIL (imipramine) Depression any Eagle Level
TOLNAFTATE Dermatological treatment any Eagle Level
TOPAMAX (topiramate) Epilepsy any Eagle Level
TOPAMAX (topiramate) Migraine any Eagle Level
topiramate (TOPAMAX) Epilepsy any Eagle Level
topiramate (TOPAMAX) Migraine any Eagle Level
TOPROL-XL (metoprolol) Hypertension any Eagle Level
TOPROL-XL (metoprolol) Angina 12 months Eagle Guaranteed
TOPROL-XL (metoprolol) Congestive heart failure any Eagle Guaranteed
torsemide (DEMADEX) Hypertension any Eagle Level
torsemide (DEMADEX) Liver disease any Eagle Guaranteed
torsemide (DEMADEX) Congestive heart failure any Eagle Guaranteed
torsemide (DEMADEX) Kidney disease any Eagle Guaranteed
TOVIAZ Overactive bladder any Eagle Level
TRAMADOL HCL Moderate to severe pain - narcotic any Eagle Level
p. 38
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
TRANDATE (labetalol) Hypertension any Eagle Level
trandolapril (MAVIK) Hypertension any Eagle Level
trandolapril (MAVIK) Congestive heart failure any Eagle Guaranteed
trandolapril/verapamil (TARKA) Hypertension any Eagle Level
TRANSDERM-SCOP Nausea/vomiting any Eagle Level
TRANXENE (clorazepate dipotassium) Anxiety disorder any Eagle Level
TRANXENE (clorazepate dipotassium) Seizures any Eagle Level
TRANXENE (clorazepate dipotassium) Alcohol withdrawal 24 months Eagle Guaranteed
TRAVATAN Eye drops any Eagle Level
trazodone (DESYREL) Depression any Eagle Level
TRENTAL (pentoxifylline) Circulation disorder any Eagle Level
TRETINOIN Dermatological treatment any Eagle Level
TREXIMET Migraine any Eagle Level
TRIAMCINOLONE ACETONIDE Dermatological treatment any Eagle Level
triamcinolone oral inhalation (AZMACORT) Asthma any Eagle Level
triamterene/hydrochlorothiazide (DYAZIDE, MAXZIDE) Hypertension any Eagle Level
triamterene/hydrochlorothiazide (DYAZIDE, MAXZIDE) Edema any Eagle Level
triazolam (HALCION) Insomnia any Eagle Level
TRICOR (fenofibrate) Elevated cholesterol/triglycerides any Eagle Level
TRIFLUOPERAZINE HCL Schizophrenia/anxiety 24 months Eagle Level; decline 40-49
TRIFLURIDINE Eye drops any Eagle Level
trihexyphenidyl (ARTANE) Parkinson’s disease any Eagle Level
TRILEPTAL (oxcarbazepine) Seizures any Eagle Level
TRILIPIX Elevated cholesterol/triglycerides any Eagle Level
TRI-LUMA Dermatological treatment any Eagle Level
TRILYTE Constipation any Eagle Level
TRIMETHOBENZAMIDE HCL Nausea/vomiting any Eagle Level
TRIMETHOPRIM Antibiotic any Eagle Level
TRIPLE ANTIBIOTIC Dermatological treatment any Eagle Level
TRIXAICIN HP Dermatological treatment any Eagle Level
TROPICAMIDE Eye drops any Eagle Level
TRUSOPT Eye drops any Eagle Level
TRUVADA (emtricitabine/tenofovir) HIV/AIDS any Eagle Guaranteed
TUSNEL-HC Cough/cold/allergies any Eagle Level
TUSSI-12D Cough/cold/allergies any Eagle Level
TUSSIONEX PENNKINETIC EXTENDED RELEASE Cough/cold/allergies any Eagle Level
TYGACIL Antibiotic any Eagle Level
TYLENOL WITH CODEINE #3 (acetaminophen with Pain relief - narcotic any Eagle Level
codeine #3)
UDAMIN SP Vitamin supplement any Eagle Level
ULORIC Gout any Eagle Level
ULTRACET Pain relief - narcotic any Eagle Level
UMECTA PD Dermatological treatment any Eagle Level
p. 39
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
UNIRETIC (hydrochlorothiazide/moexipril) Hypertension any Eagle Level
UNIVASC (moexipril) Hypertension any Eagle Level
UREA Dermatological treatment any Eagle Level
URISED Urinary antibiotic any Eagle Level
UROQID #2 Urinary antibiotic any Eagle Level
UROXATRAL Benign prostatic hypertrophy any Eagle Level
URSO (ursodiol) Gallstones any Eagle Level
URSO (ursodiol) Liver cirrhosis any Eagle Guaranteed
ursodiol (ACTIGALL, URSO) Gallstones any Eagle Level
ursodiol (ACTIGALL, URSO) Liver cirrhosis any Eagle Guaranteed
UTA Urinary antibiotic any Eagle Level
VALCYTE (valganciclovir) Cytomegalovirus-AIDS any Eagle Guaranteed
VALCYTE (valganciclovir) Cytomegalovirus-organ transplant any Eagle Guaranteed
valganciclovir (VALCYTE) Cytomegalovirus-AIDS any Eagle Guaranteed
valganciclovir (VALCYTE) Cytomegalovirus-organ transplant any Eagle Guaranteed
VALIUM (diazepam) Anxiety disorder any Eagle Level
VALIUM (diazepam) Convulsive disorder/muscle spasms any Eagle Level
VALIUM (diazepam) Alcohol withdrawal 24 months Eagle Guaranteed
VALPROIC ACID Seizures any Eagle Level
valsartan (DIOVAN) Hypertension any Eagle Level
valsartan (DIOVAN) Congestive heart failure any Eagle Guaranteed
valsartan (DIOVAN) Treatment after heart attack 12 months Eagle Guaranteed
VALTREX Cold sores/herpes/chickenpox any Eagle Level
VALTURNA Hypertension any Eagle Level
VANCOCIN HCL Antibiotic any Eagle Level
VANIQA Dermatological treatment any Eagle Level
varenicline (CHANTIX) Smoking cessation 12 months smoking rates (Eagle Guaranteed)
VASERETIC (enalapril/hydrochlorothiazide) Hypertension any Eagle Level
VASOTEC (enalapril) Hypertension any Eagle Level
VASOTEC (enalapril) Congestive heart failure any Eagle Guaranteed
VAZOTAN Cough/cold/allergies any Eagle Level
VAZOTUSS HC Cough/cold/allergies any Eagle Level
venlafaxine (EFFEXOR) Depression/anxiety any Eagle Level
VENTOLIN (albuterol) Asthma any Eagle Level
VERAMYST Nasal allergy symptoms any Eagle Level
verapamil (CALAN, COVERA-HS, ISOPTIN, VERELAN) Hypertension any Eagle Level
verapamil (CALAN, COVERA-HS, ISOPTIN, VERELAN) Angina 12 months Eagle Guaranteed
verapamil (CALAN, COVERA-HS, ISOPTIN, VERELAN) Arrhythmia any Eagle Level
VERELAN (verapamil) Hypertension any Eagle Level
VERELAN (verapamil) Angina 12 months Eagle Guaranteed
VERELAN (verapamil) Arrhythmia any Eagle Level
VERTIGOHEEL Vertigo any Eagle Level
VESICARE Overactive bladder any Eagle Level
p. 40
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
VFEND Fungal infection any Eagle Level
VIAGRA Erectile dysfunction any Eagle Level
VICKS NYQUIL Cough/cold/allergies any Eagle Level
VICTOZA (liraglutide) Diabetes any Eagle Level (with no diabetic complications)
VIGAMOX Eye drops any Eagle Level
VIMOVO Pain relief- anti-inflammatory any Eagle Level
VIREAD (tenofovir) Hepatitis B 24 months Eagle Guaranteed
VIREAD (tenofovir) HIV/AIDS any Eagle Guaranteed
VIVITROL (naltrexone) Alcohol dependence/opiate
24 months Eagle Guaranteed dependence
VYTORIN Elevated cholesterol any Eagle Level
VYVANSE ADHD any Eagle Level
warfarin (COUMADIN) Clot prevention after heart valve
12 months Eagle Guaranteed placement
warfarin (COUMADIN) Atrial fibrillation any Eagle Level
WELCHOL (colesevelam) Elevated cholesterol any Eagle Level
WELCHOL (colesevelam) Diabetes any Eagle Level (with no diabetic complications)
WELLBUTRIN (bupropion) Depression any Eagle Level
XALATAN Eye drops any Eagle Level
XELODA (capecitabine) Cancer 24 months Eagle Guaranteed
XENADERM Dermatological treatment any Eagle Level
XENICAL Obesity any Eagle Level
XERAC AC Dermatological treatment any Eagle Level
XIBROM Eye drops any Eagle Level
XIFAXAN Antibiotic any Eagle Level
XOPENEX Asthma any Eagle Level
XPECT-AT Cough/cold/allergies any Eagle Level
XYZAL Antihistamine any Eagle Level
ZADITOR Eye drops any Eagle Level
zafirlukast (ACCOLATE) Asthma any Eagle Level
zaleplon (SONATA) Insomnia any Eagle Level
ZAROXOLYN (metolazone) Hypertension any Eagle Level
ZAROXOLYN (metolazone) Congestive heart failure any Eagle Guaranteed
ZAROXOLYN (metolazone) Kidney disease any Eagle Guaranteed
ZEGERID (omeprazole/sodium bicarbonate) Ulcers/GERD/esophagitis any Eagle Level
ZELAPAR (selegiline) Parkinson’s disease any Eagle Level
ZEMPLAR (paricalcitol) Kidney disease any Eagle Guaranteed
ZESTORETIC (lisinopril/hydrochlorothiazide) Hypertension any Eagle Level
ZESTRIL (lisinopril) Hypertension any Eagle Level
ZESTRIL (lisinopril) Congestive heart failure any Eagle Guaranteed
ZESTRIL (lisinopril) Heart attack 12 months Eagle Guaranteed
ZETIA (ezetimibe) Elevated cholesterol any Eagle Level
ZIAGEN (abacavir) HIV/AIDS any Eagle Guaranteed
p. 41
Prescription Drug Guide
Drug Name Drug Indication Rx Fill
Benefit Eligibility or Drug Category Within
zidovudine (RETROVIR) HIV/AIDS any Eagle Guaranteed
ZINC SULFATE Mineral supplementation any Eagle Level
ziprasidone (GEODON) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49
ZOCOR (simvastatin) Elevated cholesterol any Eagle Level
ZOFRAN (ondansetron) Nausea/vomiting related to
24 months Eagle Guaranteed chemotherapy
zoledronic acid (RECLAST, ZOMETA) Osteoporosis any Eagle Level
ZOLOFT (sertraline) Depression any Eagle Level
zolpidem tartrate (AMBIEN) Insomnia any Eagle Level
ZOMETA (zoledronic acid) Osteoporosis any Eagle Level
ZOMIG Migraine any Eagle Level
ZONEGRAN (zonisamide) Epilepsy any Eagle Level
zonisamide (ZONEGRAN) Epilepsy any Eagle Level
ZOTANE HC External ear infection any Eagle Level
ZOVIRAX Herpes any Eagle Level
ZOVIRAX (acyclovir) Shingles/chickenpox/genital herpes any Eagle Level
ZYBAN (bupropion) Smoking cessation 12 months Eagle Level
ZYLET Eye drops any Eagle Level
ZYMAR Eye drops any Eagle Level
ZYPREXA (olanzapine) Schizophrenia/bipolar disorder any Eagle Level
ZYRTEC Antihistamine any Eagle Level
ZYRTEC-D Cough/cold/allergies any Eagle Level
ZYVOX Antibiotic any Eagle Level
p. 42
Field Prescription Drug Guide
The following Guide is designed to assist you when writing a SIMPL Preferred,
SIMPL Standard or Modified Whole Life application. It discloses the most
widely used prescriptions and usage. It is not uncommon for applicants to be
on medication or multiple medications and this is an underwriting
consideration.
Prescribed medications “obtained or increased in the last 2 years” are used in the underwriting process for SIMPL Preferred, SIMPL Standard OR MWL.
PLEASE NOTE:
When multiple Rxs are used for one disorder it may be a sign that the disease/illness may be at
an uninsurable stage and this can be reason for a decline. Please call or check with Underwriter. LBL/CLICO may investigate any medication (or combination of) which may suggest treatment for
a condition that may be life threatening.
If you see an unlisted drug or have any questions, please call our Underwriting Department at
1-800-731-4300 prior to submitting the application. BPH = Benign prostate hypertrophy HTN = Hypertension or High Blood Pressure CHF = Congestive Heart Failure MS = Multiple Sclerosis COPD = Chronic Obstructive RA = Rheumatoid Arthritis
Pulmonary Disease RLS = Restless Leg Syndrome • (dot) = “Yes” approved for plan SIMPL SIMPL
List of Medications PREF. STD. MWL Medical Condition Underwriting Decision
3TC HIV treatment
Abarelix Prostate cancer
Accupril • • • HTN/CHF/Renal failure Yes if for HTN only
Aggrenox • • Circulatory disorders/Stroke/TIA Stroke/TIA MWL only
Akineton • • Parkinson's Disease
Aldactone • • • HTN/CHF/Renal Failure prevention Yes if for HTN only
Aldesleukin Cancer treatment
Alglucerase Gaucher's genetic disease
Altace • • • HTN/CHF/Kidney Failure prevention Yes if for HTN only
Altretamine Cancer treatment
Amantadine Severe Parkinson's Disease
Ambrisentan Pulmonary HTN/CHF
Amicar • • Anemia/Cirrhosis SIMPL Std if Cirrhosis only
Amiodarone • CHF/Irregular heart beat
LBL-FPDG-05-02-2016 1
SIMPL SIMPL
List of Medications PREF. STD. MWL Medical Condition Underwriting Decision
Amlodipine Besylate • • • HTN/CHF/Kidney Failure prevention Yes if for HTN only
Anakinra • Rheumatoid Arthritis
Anastrozole • Cancer treatment Yes Testosterone only
Aplenzin • • • Major Depression/Depression
Aromasin • Breast cancer
Arimidex • Breast cancer
Aricept Dementia, Alzheimer’s Dementia
Atenolol • • • HTN/Migraines
Atripla AIDS, HIV treatment
Avinza • Moderate to Severe pain
Avastin Chemotherapy for cancer treatment
Avonex Multiple Sclerosis (MS)
Azasan Anti-rejection for organ transplant
Azathioprine Anti-rejection for organ transplant
AZT HIV/AIDS treatment
Baclofen • Anti-spasmodic/MS/Nerve Damage
Benztropine • Severe Parkinson's Disease
Betaseron Multiple Sclerosis (MS)
Bicalutamide Cancer treatment
BiDil • Angina/Heart Disease
Bocerevir • Hepatitis C
Bumetanide CHF/Kidney disease
Bumex CHF/Kidney disease
Buprenex • Moderate to severe chronic pain
Buprenorphine • Moderate to severe chronic pain
Butrans • Moderate to severe chronic pain
Byetta • • • Diabetes Only if controlled
Caduet • • • HTN/CHF/Kidney Failure prevention Yes if for HTN only
Calcitriol Kidney Dialysis
Captopril • • • HTN/CHF Yes if for HTN only
Carbidopa Parkinson's Disease
Carboplatin Cancer
Cardizem • • • HTN/Angina/Abnormal Heart Rhythms Yes if for HTN only
Carvedilol • • • Heart failure/Hypertension Yes if for HTN only
Cellcept Anti-rejection for organ transplant
Certolizumab pegol • Crohn’s/Rheumatoid,Psoriatic Arthritis
Cilostazol • Claudication/Clogged arteries
Cimzia • Crohn’s/Rheumatoid,Psoriatic Arthritis
Cognex Dementia/Alzheimer's Dementia
Combivent • COPD/Emphysema
Copaxone Multiple Sclerosis (MS)
Cordarone CHF/ Heart failure
Coreg • • • Heart failure/Hypertension Yes if for HTN only
Coumadin • • Blood thinner If for Stroke MWL only
Cozaar • • • HTN
Creon • Pancreatic insufficiency
Cyclosporine Autoimmune disorders
Cymbalta • • • Depression
LBL-FPDG-05-02-2016 2
SIMPL SIMPL
List of Medications PREF. STD. MWL Medical Condition Underwriting Decision
DALIResp • Severe Respiratory disorder(s)
Digoxin • • Irregular heart beat
Dilaudid • Moderate to severe pain
Diltiazem • • • HTN/Angina/Cardiac Yes if for HTN only
Dimethyl fumarate Multiple Sclerosis/Brain Lesions
Disulfiram Alcoholism
Donepezil Alzheimer's dementia
Dopamine • Circulatory problems
Dopar • Severe Parkinson's Disease
Dronabinol Cancer, AIDS treatment Dronedarone • Anti-arrhythmic
Droperidol • Tranquilizer, sedative, anti-nausea
Droxia Leukemia/Cancer/Sickle Cell Anemia
Dynacirc CR • • • HTN/High Blood Pressure
Effient • CAD/stent - angioplasty history If current use only MWL
Enalapril • • • HTN/Hypertension/CHF Yes if for HTN only
Eldepryl • Severe Parkinson's Disease
Entresto Chronic heart failure
Eliquis • Blood thinner
Enbrel • Arthritis/Ankylosing Spondylitis
Emcyt Cancer
Entacapone Severe Parkinson’s Disease
Enzalutamide Cancer
Erbitux Cancer treatment
Ergoloid Dementia
Erythropoietin • Anemia of Renal or Kidney origin
Etanercept • Arthritis/Ankylosing Spondylitis
Etopophos Cancer
Eulexin Cancer
Evzio Narcotic overdose
Exelon Dementia
Exemestane • Breast cancer
Extavia Multiple Sclerosis (MS)
Femara Cancer
Fentanyl • Severe Pain
Fentanyl Patch • Severe Pain
Flecainide • Arrhythmias/Abnormal Heart Rhythms No CHF,Cardiomyopathy
Fluphenazine • Psychotic Disorders
Formoterol • COPD
Furosemide • • • Fluid/HTN/CHF Yes if for HTN only
Gabapentin • • • Pain/Neuropathy SMP Pref or Std < 900 mg
Galantamine Alzheimer's dementia
Glatiramer Multiple Sclerosis (MS)
Gleevec Cancer
Goserelin Cancer
Gilenya Multiple Sclerosis (MS)
HCTZ • • • Fluid/HTN/CHF/Kidney failure Yes if for HTN only
LBL-FPDG-05-02-2016 3
SIMPL SIMPL
List of Medications PREF. STD. MWL Medical Condition Underwriting Decision
Hectoral Kidney Disorder
Hexalen Cancer
Hydergine Alzheimer's dementia
Hydrea • Leukemia (CLL)
Hydromorphone • Moderate to severe pain
Hydroxychloroquine • Autoimmune disorders
Hydroxyurea • Leukemia (CLL)
Humira • Rheumatoid
Idarubicin Leukemia
Ifosfamide Cancer
Imatinib Cancer
Imdur • Angina/Heart disease
Imuran Organ transplant/blood disorders
Incivek • • Hepatitis C
Inderal • • • Tremor/HTN/Angina Yes if for HTN only
Insulin • • • Diabetes Only if controlled
Interferon • Cancer, HIV/AIDS, Hepatitis C Yes if Hepatitis C only
Isosorbide • Angina/Heart disease
Jakafi Organ transplant/blood disorders
Kemadrin • Severe Parkinson's Disease
Kineret • Rheumatoid Arthritis
Lamivudine HIV/AIDS treatment
Lanoxin • Heart/A Fib If used for CHF, decline
Lantus • • • Diabetes Only if controlled
Larodopa • Severe Parkinson's Disease
Lasix • • • Fluid/HTN/CHF Yes if for HTN only
Letrozole • Cancer/Breast Cancer
Levodopa • Severe Parkinson's Disease
Lisinopril • • • HTN/Heart Yes if for HTN only
Lloperidone • Schizophrenia
Lopressor • • • HTN/Heart Yes if for HTN only
Lopinavir HIV/AIDS treatment
Lupron • Cancer
Megace • Cancer/HIV/AIDS treatment MWL only if for appetite
Megestrol • Cancer/HIV/AIDS treatment MWL only if for appetite
Memantine Alzheimer's dementia
Mercaptopurine Leukemia
Mesna Cancer
Methadone Severe pain/Drug addiction
Methotrexate • • Cancer/MS/Rheumatoid Arthritis (RA) MWL if for Cancer
Metoprolol • • • HTN/Angina/Heart Yes if for HTN only
Mitomycin Cancer
Modafinil • • • Daytime sleepiness/Narcolepsy/OSA
Morphine • Moderate to Severe pain
Mycophenolate Anti-rejection Organ transplant
Multaq • Anti-arrhythmic
Naloxone Narcotic overdose
LBL-FPDG-05-02-2016 4
SIMPL SIMPL
List of Medications PREF. STD. MWL Medical Condition Underwriting Decision
Naltrexone Drug Addiction
Namenda Alzheimer's dementia
Narcan Narcotic overdose
Neurontin • • • Pain/Neuropathy SMP if < 900 mg daily
Nifedipine • • • HTN/Angina/Heart SMP PREF for HTN only
Nitrobid • Angina/chest pains/Heart
Nitroglycerine • Angina/chest pains/Heart
Nitroquick • Angina/chest pains/Heart
Nivolumab Advanced Cancer
Norfloxacin • • • Infections
Norvir HIV/AIDS treatment
Nucynta • • • Pain/Neuropathy
Nuvigil • • • Narcolepsy, Excessive sleepiness
Octreotide • Cancer treatment
Olysio • • Hepatitis C
Opdivo Advanced Cancer
Oxycontin • Severe pain
Paclitaxel Cancer
Parlodel Severe Parkinson's Disease
Permex • Severe Parkinson's Disease
Plaquenil • Autoimmune disorders, Lupus
Plavix • Blood thinner
Pradaxa • Blood thinner
Pramipexole • RLS/Mild Parkinson's Disease
Prasugrel • CAD/stent - angioplasty history If current use only MWL
Procrit • Kidney Disorder
Procylidine • Severe Parkinson's Disease
Prograf Organ transplant rejection
Provigil • • • Excessive sleepiness/Narcolepsy/OSA
Ranexa • Chronic Angina
Ranolazine • Chronic Angina
Rasagiline • Severe Parkinson's Disease
Renagel Kidney Dialysis
Remeron • • • Depression/Tremors/Panic disorder
Remicade • Rheumatoid
Reminyl Alzheimer's/Dementia
Requip • • • Parkinson's/Restless Leg Syndrome SMPL Pref./Std if RLS only
Ribavirin • • Hepatitis C
Rifaximin Liver Failure
Ritonavir HIV/AIDS treatment
Rivastigmine Alzheimer's/Dementia
Ropinirole • • • RLS/Parkinson's Disease
Ruxolitinib Organ transplant/blood disorders
Sandostatin • Cancer treatment
Selegiline • • • RLS/Dementia SMP Pref./STD If RLS only
Simeprevir • • Hepatitis C
Sinemet Parkinson’s Disease
LBL-FPDG-05-02-2016 5
SIMPL SIMPL
List of Medications PREF. STD. MWL Medical Condition Underwriting Decision
Spiriva • COPD/Emphysema
Spironolactone • • • Fluid/HTN/CHF Yes if for HTN only
Szofosburvir • • Hepatitis C
Solvadi • • Hepatitis C
Stalevo • Severe Parkinson's Disease
Stribild HIV/AIDS treatment
Suboxone Drug and Alcohol treatment
Sunitinib Malate Advanced Renal Cancer & GIST
Sutent Advanced Renal Cancer & GIST Symmetrel • • Parkinson's Disease
Tacrolimus Organ transplant rejection
Tamoxifen • Breast cancer
Taiazac • • • HTN/Angina Yes if for HTN only
Tapentadol • • • Pain/Neuropathy
Tecfidera Multiple Sclerosis/Brain Lesions
Telaprevir • • Hepatitis C
Tenofovir HIV treatment
Tizanidine • MS/Spinal cord disorders No, if for MS
Thorazine • Psychotic Disorders
Tolcapone • • Parkinson's Disease
Toprol • • • HTN/Angina/Heart Yes if for HTN only
Torsemide CHF/Kidney or Liver Disease
Toremifene Cancer
Triamterene • • • Fluid/HTN/CHF Yes if for HTN only
Trifluoperazone • Psychotic Disorders
Trihexyphenidyl • • Parkinson's Disease
Vasotec • • • HTN/Angina/CHF SMPL for HTN only
Viread HIV treatment
Vicodin • Chronic Pain
Victrelis • Hepatitis C
Warfarin • Blood thinner
Xarelto • Blood thinner
Xifaxan Brain function loss
Xtandi Cancer
ZDV HIV treatment
Zenpep • Pancreatic insufficiency
Zidovudine HIV treatment
Zoladex Cancer
Zometa Cancer/Multiple Myeloma
LifeVue Whole Life
Field Underwriting Guide Introduction: This product has three underwriting classes; Level Death Benefit, Graded Death Benefit and Decline. There are a series
of knock-out questions that will be asked upfront by the agent to determine the applicant’s product eligibility. If knock-out
requirements are met, the applicant will then answer a series of risk questions that are confirmed with an MIB check and
Prescription (Rx) Database check during the decision process. The decision is then reported to the agent and applicant.
Prescription (Rx) Database: The Rx scoring is based on medical conditions rather than directly on the drugs or therapeutic categories. Scoring cut
offs for each underwriting class are established both for the highest single condition score and for all conditions found
combined on a weighted basis. **A combination of medications could result in a higher score**.
Class Max Max Risk Tolerance Smoking Criteria Notes Single Combined
Score Score
No distinct classes
Allow 2 conditions scoring 299 or one No equiv to
299 and two lower scoring conditions
Level DB 299
479
but may play role in
"yes" on Part C conditions selection
Anything worse than above but not
No equiv to
HIV or terminal illness. Allows up to Graded DB 300
599
No distinct classes
two 300 scores plus a 299 but not
"yes" on Part A
three 300 scores
Worse than above
Decline 998 none none
999 score limited to MIB conditions
When und
such as HIV code needing underwriting referral rather than particular class or
RTU
none
none
referral, not a
none
decline action. class, is desired
Prescription Drugs Scored 299 & 300: This Prescription Drug Guide is used in conjunction with North American’s Underwriting guidelines and does not reflect all
prescription drugs considered by North American. This guide provides a list of common drugs scored at 299 and 300 that
combined and/or alone can eliminate an applicant from receiving a Level and/or Graded Death Benefit. Any prescription
drug used in combination with a related or unrelated prescription drug could result in a decline. Both this guide and the
full underwriting guidelines used by North American are subject to change.
The Prescriptions listed below have a “linked condition” that is associated with the medication. This may not be the only
condition that is treated by this prescription drug.
Scores at 299 if applicant is taking 3 or more severe uncontrolled hypertension medications.
Scores as 25 by itself.
• Scores at 299 if prescription information indicates chronic use. Scores lower than 299 otherwise.
*** Scores 300 if prescribed within last 24 months and 299 if 25 months or longer.
Label Name Linked Condition
Scor
e
ABILIFY Schizophrenia 300
ACETYLCYSTEINE Acetaminophen Toxicity 299
ACITRETIN Severe Recalcitrant Psoriasis 299
AGGRENOX Prevention of Cerebral Thrombosis 300
AMANTADINE Dementia associated with Parkinson's Disease 300
AMIODARONE Ventricular Fibrillation 300
AMLODIPINE BESYLATE Severe Uncontrolled Hypertension 299*
AMLODIPINE-BENAZEPRIL Severe Uncontrolled Hypertension 299*
AMPHETAMINE SALTS Narcolepsy Syndrome 299
AMPYRA ER Walking Impairment due to Multiple Sclerosis 300
AMRIX ER Muscle Spasticity of Spinal Origin 299
ANASTROZOLE Hormone Receptor Positive Breast Cancer 300***
ANDRODERM Male Hypogonadism 299
ANDROGEL Male Hypogonadism 299
ARANESP Anemia in Chronic Kidney Disease 300
ARICEPT Diffuse Lewy Body Disease 300
ARIMIDEX Hormone Receptor Positive Breast Cancer 299
ARIPIPRAZOLE Schizophrenia 300
AROMASIN Advanced Breast Cancer Progression Post-Antiestrogen Therapy 300
ASACOL EC Ulcerative Colitis 299
ASACOL HD Ulcerative Colitis 299
ASPIRIN EC Myocardial Infarction Prevention 300
ATENOLOL Severe Uncontrolled Hypertension 299*
ATENOLOL-CHLORTHALIDONE Severe Uncontrolled Hypertension 299*
ATROVENT HFA INHALER Prevention of Bronchospasms with Emphysema 300
AUBAGIO Multiple Sclerosis 299
AVINZA Pain, severe, long 299**
AXIRON Male Hypogonadism 299
AZATHIOPRINE Prevention of Kidney Transplant Rejection 300
AZILECT Idiopathic Parkinsonism 300
BACLOFEN Muscle Spasticity of Spinal Origin 299
BENAZEPRIL HCL Severe Uncontrolled Hypertension 299*
BENICAR Severe Uncontrolled Hypertension 299*
BENICAR HCT Severe Uncontrolled Hypertension 299*
BENZTROPINE Extrapyramidal Disease 300
BETASERON Multiple Sclerosis 299
BETHANECHOL Urinary Retention 299
BIDIL Chronic Heart Failure 300
BISOPROLOL-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*
BRILINTA Myocardial Reinfarction Prevention 299
BUDESONIDE EC Crohn's Disease 299
BUPRENORPHINE-NALOXONE Opioid Dependence 300
BUPROPION SR Smoking Cessation 299
BUTRANS Pain, severe, long 299**
BYSTOLIC Severe Uncontrolled Hypertension 299*
CARBAMAZEPINE Manic Bipolar Disorder 299
CARBIDOPA-LEVO ER Parkinsonism 300
CARISOPRODOL Muscle Spasticity of Spinal Origin 299
CARTIA XT Severe Uncontrolled Hypertension 299*
CARVEDILOL Chronic Heart Failure 300
CHLORPROMAZINE Schizophrenia 300
CILOSTAZOL Intermittent Claudication 300
CLONIDINE Severe Uncontrolled Hypertension 299*
CLOPIDOGREL Myocardial Reinfarction Prevention 300***
CLOZAPINE Treatment-Resistant Schizophrenia 300
COMBIVENT INHALER Chronic Obstructive Pulmonary Disease with Bronchospasms 300
COPAXONE Multiple Sclerosis 299
COREG CR Chronic Heart Failure 300
COZAAR Severe Uncontrolled Hypertension 299*
CREON DR Pancreatic Insufficiency 300
CVS ASPIRIN EC Myocardial Infarction Prevention 300
CYCLOBENZAPRINE Muscle Spasticity of Spinal Origin 299
DALIRESP Prevention of Bronchospasm with Chronic Bronchitis 300
D-AMPHETAMINE ER Narcolepsy Syndrome 299
DEPO-TESTOSTERONE Male Hypogonadism 299
DEXAMETHASONE Autoimmune Disease 300
DEXTROAMPHETAMINE Narcolepsy Syndrome 299
DIGITEK Chronic Heart Failure 300
DIGOX Chronic Heart Failure 300
DILANTIN Epilepsy 299
DILAUDID Pain, severe, long 299**
DILT XR Severe Uncontrolled Hypertension 299*
DILTIAZEM Severe Uncontrolled Hypertension 299*
DIOVAN Severe Uncontrolled Hypertension 299*
DIVALPROEX SOD ER Manic Bipolar Disorder 299
DONEPEZIL HCL Diffuse Lewy Body Disease 300
DOXAZOSIN MESYLATE Severe Uncontrolled Hypertension 299*
EFFIENT Myocardial Reinfarction Prevention 299
ELIQUIS Thromboembolism with Chronic Atrial Fibrillation 300
EMBEDA ER Chronic Pain 299**
EMEND Prevention of Cancer Chemotherapy-Induced Nausea and Vomiting 299
ENBREL Rheumatoid Arthritis 299
ENOXAPARIN Thromboembolic Disorder 300
EPLERENONE Chronic Heart Failure Following Myocardial Infarction 300
EXALGO ER Pain, severe, long 299**
EXELON Dementia associated with Parkinson's Disease 300
EXFORGE Severe Uncontrolled Hypertension 299*
FENTANYL Pain, severe, long 299**
FLECAINIDE ACETATE Cardioversion of Atrial Fibrillation 299
FLUDROCORTISONE Adrenogenital Disorder 299
FLUPHENAZINE Schizophrenia 300
FORTESTA Male Hypogonadism 299
GILENYA Multiple Sclerosis 299
HALOPERIDOL Schizophrenia 300
HARVON Chronic Hepatitis C - Genotype 1 300
HEPARIN SODIUM Acute ST Elevation Myocardial Infarction 299
HM ASPIRIN Myocardial Reinfarction Prevention 299
HUMALOG Type 1 Diabetes Mellitus 299
HUMALOG MIX Type 1 Diabetes Mellitus 299
HUMIRA Crohn's Disease 299
HUMULIN Type 1 Diabetes Mellitus 299
HYDRALAZINE Severe Uncontrolled Hypertension 299*
HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*
HYDROCODONE-ACETAMINOPHEN Pain, severe, long 299**
HYDROMORPHONE Pain, severe, long 299**
HYDROXYCHLOROQUINE Systemic Lupus Erythematosus 299
HYZAAR Severe Uncontrolled Hypertension 299*
INCIVEK Chronic Hepatitis C - Genotype 1 299
INNOPRAN XL Severe Uncontrolled Hypertension 299*
IPRATROPIUM BR Prevention of Bronchospasms with Emphysema 300
ISOSORBIDE Chronic Angina Pectoris 299
KRISTALOSE Hepatic Encephalopathy 300
LABETALOL HCL Severe Uncontrolled Hypertension 299*
LAMICTAL Bipolar Disorder in Remission 299
LAMOTRIGINE Bipolar Disorder in Remission 299
LANTUS Type 1 Diabetes Mellitus 299
LEFLUNOMIDE Rheumatoid Arthritis 299
LETROZOLE Ovarian Carcinoma 300
LEVEMIR Type 1 Diabetes Mellitus 299
LISINOPRIL Severe Uncontrolled Hypertension 299*
LITHIUM CARBONATE Bipolar Disorder 299
LITHIUM CARBONATE ER Bipolar Disorder 299
LORCET Pain, severe, long 299**
LOSARTAN POTASSIUM Severe Uncontrolled Hypertension 299*
LOSARTAN-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*
LOTREL Severe Uncontrolled Hypertension 299*
MEGESTROL Hormone Receptor Positive Breast Cancer 300
MEPERIDINE Pain, severe, long 299**
MEPERITAB Pain, severe, long 299**
MESALAMINE Ulcerative Colitis 299
METHADONE HCL Pain, severe, long 299**
METHOCARBAMOL Muscle Spasticity of Spinal Origin 299
METHOTREXATE 2.5 MG TABLET Rheumatoid Arthritis 299
METHOTREXATE 250 MG/10 ML VIAL Osteosarcoma of Bone 300
METHYLDOPA Severe Uncontrolled Hypertension 299*
METHYLIN Narcolepsy Syndrome 299
METHYLPHENIDATE Narcolepsy Syndrome 299
METHYLPREDNISOLONE Autoimmune Disease 300
METOCLOPRAMIDE Diabetic Gastroparesis 299
METOLAZONE Severe Uncontrolled Hypertension 299*
METOPROLOL Severe Uncontrolled Hypertension 299*
MICARDIS Severe Uncontrolled Hypertension 299*
MINOXIDIL Severe Uncontrolled Hypertension 299*
MIRAPEX Dementia associated with Parkinson's Disease 300
MODAFINIL Narcolepsy Syndrome 299
MORPHINE Pain, severe, long 299**
MULTAQ Prevention of Recurrent Atrial Fibrillation 299
NALTREXONE Alcoholism 299
NAMENDA Moderate to Severe Alzheimer's Type Dementia 300
NEUPRO Dementia associated with Parkinson's Disease 300
NIFEDICAL XL Severe Uncontrolled Hypertension 299*
NIFEDIPINE ER Severe Uncontrolled Hypertension 299*
NITROGLYCERIN 0.4 MG TABLET SL Angina 300***
NITROQUICK 0.4 MG TABLET SL Angina 300***
NITROSTAT 0.4 MG TABLET SL Angina 300***
NOVOLIN Type 1 Diabetes Mellitus 299
NOVOLOG Type 1 Diabetes Mellitus 299
NUEDEXTA Pseudobulbar Affect 299
NUVIGIL Sleepiness Due To Obstructive Sleep Apnea 299
OLANZAPINE Mixed Bipolar I Disorder 299
OPANA Pain, severe, long 299**
OXYBUTYNIN Neurogenic Bladder 299
OXYCODONE Pain, severe, long 299**
OXYCONTIN Chronic Pain 299**
OXYMORPHONE Chronic Pain 299**
OYSTER SHELL CALCIUM-VIT D TAB Hypocalcemia Prevention 299
PACERONE Ventricular Fibrillation 300
PANCREAZE DR Pancreatic Insufficiency 299
PCCA LIPODERM BASE Severe Uncontrolled Hypertension 299*
PEGINTRON REDIPEN Chronic Hepatitis C - Genotype 1 299
PERFOROMIST Prevention of Bronchospasm with Chronic Bronchitis 299
PERPHENAZINE Schizophrenia 300
PHENOBARBITAL Seizure Disorder 299
PHENYTOIN Epilepsy 299
PILOCARPINE HCL Xerostomia Secondary to Sjogren's Syndrome 299
PLAQUENIL Systemic Lupus Erythematosus 299
PLAVIX Myocardial Reinfarction Prevention 300
PRAMIPEXOLE Dementia associated with Parkinson's Disease 300
PRAZOSIN Severe Uncontrolled Hypertension 299*
PREDNISOLONE AC 1% EYE DROP Severe Ocular Inflammation 299
PREDNISONE Autoimmune Disease 300***
PROPANTHELINE Urinary Incontinence 299
PROPRANOLOL Severe Uncontrolled Hypertension 299*
PROVIGIL Narcolepsy Syndrome 299
PYRIDOSTIGMINE BR Myasthenia Gravis 299
QUETIAPINE FUMARATE Mixed Bipolar I Disorder 299
QUINAPRIL Severe Uncontrolled Hypertension 299*
QUINIDINE SULF ER Cardioversion of Atrial Fibrillation 299
ASPIRIN EC Myocardial Infarction Prevention 300
RANEXA ER Chronic Angina Pectoris 299
REGRANEX Diabetic Neuropathic Ulcer of Lower Extremities 300
RELION NOVOLIN Type 1 Diabetes Mellitus 299
RENVELA Renal Osteodystrophy with Hyperphosphatemia 300
REQUIP Dementia associated with Parkinson's Disease 300
RIBASPHERE RIBAPAK Chronic Hepatitis C - Genotype 1 299
RIFAMPIN Acute Tuberculosis 300***
RISPERIDONE Mixed Bipolar I Disorder 299
ROPINIROLE HCL Dementia associated with Parkinson's Disease 300
ROXICODONE Pain, severe, long 299**
RYZOLT ER Chronic Pain 299**
SANTYL OINTMENT Severe Burns 299
SAPHRIS Mixed Bipolar I Disorder 299
SENSIPAR Hyperparathyroidism Secondary to Chronic Renal Failure with Dialysis 300
SEREVENT DISKUS Bronchospasm Prevention with COPD 300
SEROQUEL Mixed Bipolar I Disorder 299
SIMPONI Rheumatoid Arthritis 299
SKELAXIN Muscle Spasticity of Spinal Origin 299
SM CALCIUM Hypocalcemia Prevention 299
SORIATANE Severe Recalcitrant Psoriasis 299
SOTALOL Life-Threatening Ventricular Tachycardia 300
SPIRIVA Bronchospasm Prevention with COPD 300
SPIRONOLACTONE Severe Uncontrolled Hypertension 299*
SULFASALAZINE Ulcerative Colitis 299
SULFAZINE EC Ulcerative Colitis 299
SYMBYAX Depression associated with Manic Depressive Disorder 299
TAMOXIFEN Hormone Receptor Positive Breast Cancer 300***
TECFIDERA DR Multiple Sclerosis 299
TEGRETOL Manic Bipolar Disorder 299
TEKTURNA Severe Uncontrolled Hypertension 299*
TEKTURNA HCT Severe Uncontrolled Hypertension 299*
TERAZOSIN Severe Uncontrolled Hypertension 299*
TESTIM Male Hypogonadism 299
TESTOSTERONE Male Hypogonadism 299
THEOPHYLLINE ER Chronic Obstructive Pulmonary Disease with Bronchospasms 300
TOPAMAX Simple-Partial Epilepsy 299
TOPIRAMATE Simple-Partial Epilepsy 299
TOPROL XL Severe Uncontrolled Hypertension 299*
TRIAMTERENE-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*
TRIHEXYPHENIDYL Idiopathic Parkinsonism 300
TROKENDI XR Simple-Partial Epilepsy 299
TRUVADA HIV Infection 900
TUDORZA PRESSAIR Bronchospasm Prevention with COPD 300
VALPROIC ACID Bipolar Disorder 299
VALSARTAN Severe Uncontrolled Hypertension 299*
VALSARTAN-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*
VANCOMYCIN HCL Pseudomembranous Enterocolitis 299
VERAPAMIL Severe Uncontrolled Hypertension 299*
VYVANSE Binge Eating Disorder 300
WARFARIN Thromboembolic Disorder 300
XARELTO Thromboembolism with Chronic Atrial Fibrillation 300
XELJANZ Rheumatoid Arthritis 299
ZYPREXA Mixed Bipolar I Disorder 299
Build Chart: Our build chart is a unisex chart which applies to males and females. Any height/weight combination that is outside
of the published guidelines is not eligible for level death benefit.
Weight Limits - LBS
Height
Minimum
Maximum
4' 8" 74 198
4' 9" 77 205
4'10" 79 212
4'11" 82 220
5' 0" 85 227
5' 1" 88 235
5' 2" 91 243
5' 3" 94 251
5' 4" 97 259
5' 5" 100 267
5' 6" 103 275
5' 7" 106 284
5' 8" 109 292
5' 9" 112 301
5'10" 115 310
5'11" 119 319
6' 0" 122 328
6' 1" 126 337
6' 2" 129 346
6' 3" 133 356
6' 4" 136 365
6' 5" 140 375
6' 6" 143 386
6' 7" 147 395
6' 8" 151 405
6' 9" 154 415
Medical Conditions Not Considered:
Terminal Illness HIV, AIDS, AIDS related complex (ARC) Individual confined to nursing facility, assisted living facility, hospice or psychiatric facility, or have a felony or misdemeanor.