Mass Mutual Underwriting Guide - New York Long Term Care ...

General GuidelinesOur goal in underwriting is to issue your LTCi business in a timely manner.Underwriting long term care insurance requires attention to an applicant’s:• current functional and cognitive ability• current medical conditions including medicationsAn important component of successful long term care sales is thoroughfield underwriting. Please review the following guidelines.Eligible issue ages 18-84 based on age nearest birthday.*We consider applicants age nearest 85, but only prior to their 85thbirthday. Some state restrictions may apply.FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.1

Premium Rate ClassesSignatureCare offers three premium rate classes that you may quote:Ultra Preferred, Select Preferred and Preferred. Underwriting decisionswill depend on the multiplicity and severity of the medical conditionsalong with other factors. The final underwriting determination will bebased on the information that was reviewed for the applicant. It iscritical that you quote the appropriate rate class and in the event yourclient qualifies for a better rate than quoted, we will contact you todetermine whether to issue with a lower rate or increased benefits.MassMutual Financial Group LTCi underwriting has the full authority toissue coverage, modify coverage, or deny coverage based on bothmedical and non medical factors irrespective of the suggestedguidelines that are outlined in the Field Underwriting Guide.Quoting:It is recommended to check each medical condition reported by theclient in the Field Underwriting Guide and not to quote the ultrapreferredrate if two or more ultra preferred conditions are disclosedsince certain conditions may represent greater risk. Since your clientmay be disappointed with a premium higher than you originally quoted,it is critical that you quote the appropriate rate class.The following premium rate classes are offered:• Ultra Preferred (85%)• Select Preferred (100%)• Preferred (125%)2FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

The following is a list of the classifications defined and some generalguidelines for determining qualification:ULTRA PREFERRED (ALL MUST APPLY)For very healthy non-smoking applicants.• Non-cigarette smoker for the last 12 months(other tobacco use acceptable)• Weight is within Ultra Preferred range on Height/Weight Chart• Consultation with a physician in the last 24 months• Applicants with no medical history or considered to be undertreatment for a mild medical impairment• No current treatment for a serious condition (such as heart orcirculatory disorder, diabetes, rheumatoid arthritis or cancer)• Applicants may be receiving regular treatment of a preventativenature only, for example:• Medication such as thyroid replacement, hormonalsupplements, digestive aids, or analgesics and antiinflammatorymedications that are used on an as neededbasis are acceptable.• High blood pressure that is kept in the normal range (140/90to 120/80) with medication is acceptable, but cannot be incombination with other heart disorders.SELECT PREFERRED (ONE OR MORE OF THE FOLLOWING APPLY)For individuals that are currently being treated for minimal to moderatemedical impairments or in combination but are considered to be stableand under adequate control.• Cigarette Smoker with no other significant medical history andotherwise in good health• Weight is within the Select Preferred range on Height/Weight Chart• Medical history of cardiac or circulatory disorder, diabetes,rheumatoid arthritis, or cancer with excellent prognosisFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.3

• Under regular treatment with prescription medications listed inthe Prescription Drug Guide for Conditions Not Eligible for UltraPreferred Rates.• No medical consultation within the last 24 monthsPREFERRED (ONE OR MORE OF THE FOLLOWING APPLY)For applicants with moderate to significant medical impairments due tohealth history, weight problems, smoking status or some combination ofthese factors but whose medical problems are well controlled andwhose overall health status is stable• Under treatment for moderate to significant chronic healthcondition which requires close medical supervision (such asrheumatoid arthritis, ulcerative colitis, or emphysema)• History of a combination of moderate to significant medicalimpairments (such as heart and lung disease, or rheumatoidarthritis with coronary artery disease)• Weight is within the Preferred range on Height/Weight ChartAdditional Rate Classes used for Limited Benefit Offer Only: Thereare two additional rate classes available and will be offered to thoseapplicants who have a combination of medical conditions that pose ahigher, but not immediate risk, of utilization of long term care services.This is done at the underwriter’s discretion and only after allunderwriting requirements have been reviewed. Your underwriterwill call to discuss the offer.Postpone: The medical condition has a specified stability period andmay be considered at a later date.Uninsurable: The medical condition is not acceptable.Previously Declined CasesIn general, individuals who have been previously declined for long termcare coverage are unlikely to qualify for coverage. Should an application besubmitted for an individual who has been declined previously, it is requiredthat a copy of the declination letter that provides the specific reason orreasons for the decline decision be submitted with the application.4FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Height/Weight ChartThe height and weight charts are used for the purpose of assessingwhether a person has an increased risk of morbidity. The followingcharts set forth MassMutual’s guidelines for Males and for Females.Anyone outside the parameters listed on the following tables isconsidered a high risk for use of Long Term Care services and will beconsidered for coverage on an individual basis.MALE BUILD CHART (WEIGHT IS IN POUNDS)Height Ultra Preferred Select Preferred Preferred5’0 92-186 187-214 215-2355’1 94-190 191-217 218-2395’2 96-194 195-222 223-2445’3 99-201 202-227 228-2505’4 102-206 207-232 233-2555’5 104-209 210-238 239-2625’6 107-217 218-244 245-2685’7 110-222 223-250 251-2755’8 113-229 230-257 258-2835’9 116-234 235-264 265-2905’10 119-240 241-271 272-2985’11 122-246 247-278 279-3066’0 125-254 255-288 289-3176’1 128-259 260-292 293-3216’2 129-267 268-299 300-3296’3 135-274 275-307 308-3386’4 139-282 283-315 316-3476’5 143-288 289-323 324-3556’6 147-297 298-331 332-3646’7 151-306 307-339 340-3736’8 155-314 315-347 348-382FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.5

FEMALE BUILD CHART (WEIGHT IS IN POUNDS)Height Ultra Preferred Select Preferred Preferred4’8 78-157 158-191 192-2104’9 79-160 161-195 196-2154’10 80-163 164-199 200-2194’11 82-166 167-203 204-2235’0 84-170 171-208 209-2295’1 86-174 175-213 214-2345’2 88-178 179-218 219-2405’3 90-184 185-223 224-2455’4 92-186 187-229 230-2525’5 94-192 193-234 235-2575’6 97-197 198-239 240-2635’7 99-201 202-245 246-2705’8 102-207 208-251 252-2765’9 105-212 213-257 258-2835’10 108-218 219-264 265-2905’11 111-225 226-272 273-2996’0 115-232 233-282 283-3106’1 118-240 241-292 293-3216’2 121-247 248-300 301-3306’3 124-254 255-309 310-3406’4 127-260 261-318 319-3506FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Medical Condition GuidelinesAAbscess – A localized collection of pus in any part of the body.• resolved or 6 months after surgery . . . . . . . . .ULTRA PREFERRED• brain or abdominal• present or surgery within 6 months . . . . . . . .POSTPONEAcoustic Neuroma – A benign tumor that may develop in the hearingand balance nerves in the inner ear.• surgically removed . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAddison’s Disease – A severe hormonal deficiency of the adrenal gland.• well controlled on medication . . . . . . . . . . . .SELECT PREFERREDAdhesions• post surgery, full recovery . . . . . . . . . . . . . . . .ULTRA PREFERREDADL (Activities of Daily Living) Deficits• any mental or physical limitation in performing theactivities of daily living . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAdult Day Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAIDS (Acquired Immunodeficiency Syndrome) . . . . .UNINSURABLEAlcoholism – A disease marked by excessive consumption of anddependence on alcoholic drinks.• recovered more than 5 years, in good health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• recovered more than 3 years, in good health . . . . . . .PREFERRED• within 3 years or with relapses . . . . . . . . . . . . . . .UNINSURABLEAllergies and Hay Fever . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.7

Alzheimer's Disease – The deterioration of intellectual functions.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAmaurosis Fugax – A temporary, partial, or complete loss of vision.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAmnesia – Memory loss, sometimes including the memory ofpersonal identity• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAmputation – To cut off or remove usually through surgery a projectingbody part.• due to trauma or congenital, independent,no ADL limitations . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• due to disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAmyotrophic Lateral Sclerosis (Lou Gehrig’s Disease) –The degeneration of muscular activity within the brain and thespinal cord.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAnemia – A deficiency of red blood cells in the blood.• mild . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• moderate . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• severe or with complications or defined as Aplastic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAneurysm – Abnormal expansion of a blood vessel.• abdominal or thoracic, 1 year after surgerywith good recovery . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• cerebral, with or without surgery . . . . . . . . . . . . . .UNINSURABLE• present or surgery within 1 year . . . . . . . . . . . . . . . . . .POSTPONE8FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Angina Pectoris – Severe pain and constriction in region of the heart.• controlled on medications . . . . . . . . . . . . . . . .SELECT PREFERRED• occasional episodes, or with historyof myocardial infarction . . . . . . . . . . . . . . . . .SELECT PREFERRED• with current (or within past 12 months)cigarette smoking . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAngioplasty, Cardiac – Repair of a blood vessel with a balloon orthrough a surgical procedure.• after 6 months, with or without medication . .SELECT PREFERRED• with stent, after 6 months, with orwithout medication . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with history of myocardial infarction . . . . . . .SELECT PREFERRED• with current cigarette smoking, ongoing heart failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAnkylosing Spondylitis – Chronic inflammation of the spine andsacroiliac joints.• mild . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• moderate . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with narcotic use or physical limitations . . . . . . . .UNINSURABLEAnxiety Disorder – A state of apprehension, uneasiness, and fear.• situational with occasional medication . . . . . .ULTRA PREFERRED• moderate with regular ormultiple medications . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with hospitalization past 5 yearsor with functional impairment . . . . . . . . . . . . . . . .UNINSURABLEAplastic Anemia• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.9

Arnold-Chiari Malformation – A genetic disorder occurring in thelower portion of the brain in the cerebellum or brainstem. Ultimatelyaffects balance, fine motor coordination, and unsteadiness in gait.• Type 1 only, surgically repaired,after 5 years, no residuals . . . . . . . . . . . . . . .SELECT PREFERRED• present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEArrhythmias (other than Atrial Fibrillation) – Irregular heartbeat.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDArteriovenous Malformations (AVM) – An abnormal collection ofblood vessels.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEArteritis – Inflammation of an artery.• currently being treated . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONE• off therapy more than 1 year, in remission . .SELECT PREFERREDArthritis (Degenerative or Osteoarthritis) – The breakdown anddeterioration of cartilage in the joints.• mild, asymptomatic, no treatment oroccasional medication . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• moderate, with routine NSAID orjoint injections . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• significant, taking multiple medications,no physical limitations . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• with physical limitations, multiple jointreplacements or surgery anticipated . . . . . . . . . . .UNINSURABLE10FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Arthritis (Rheumatoid) – A chronic systemic disease marked byinflammatory changes in the joints.• mild, controlled with non-steroidal medications,no deformities . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• moderate to severe, requiringmultiple medications . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE• with physical limitations or surgery anticipated . .UNINSURABLEArthroscopy – Examination of or joint surgery using an arthroscope.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDAsbestosis – A respiratory disease caused by inhaling asbestos fibersthat can lead to breathing problems and heart failure.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAssisted Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAsthma – A disease of the respiratory system characterized by difficultyof breathing.• mild, seasonal, infrequent attacks withshort term medication use . . . . . . . . . . . . . . . .ULTRA PREFERRED• moderate, controlled with medications(no steroids) . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• severe, requiring multiple medications or steroids . . .PREFERRED• with current (or within past 12 months)cigarette smoking . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAtrial Fibrillation – A severe, chaotic irregular heartbeat, which couldlead to heart failure or strokes.• new onset, < 6 months . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONE• history of, successful cardioversion,normal sinus rhythm . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• currently on anticoagulation medication . . . . . . . . . . .PREFERRED• described as chronic, intermittent,or with multiple cardioversions . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.11

Attention Deficit Disorder (ADD) and Attention DeficitHyperactivity Disorder (ADHD) – A persistent pattern of inattentionand hyperactivity-impulsivity that occurs more frequently or severelythan is typical.• stable, well controlled on single medication . .ULTRA PREFERRED• stable on more than 1 medication . . . . . . . . .SELECT PREFERREDAutoimmune Disorders – A person’s immune system begins to attackits own body, creating antibodies against its own tissue.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAvascular Necrosis – A disease resulting from loss of blood supply tothe bones causing death of bone tissue and bone collapse.B• mild, surgically corrected, . . . . . . . . . . . . . . . SELECT PREFERREDBack Pain• mild, intermittent medication, nounderlying disease process . . . . . . . . . . . . . . .ULTRA PREFERRED• due to herniated disc (unoperated) orspinal disorder . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• surgery anticipated . . . . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONEBarrett’s Esophagus – A condition of the esophagus in which thenormal tissue changes into abnormal tissue caused by recurrent refluxof gastric juices.• biopsy done within the last 2 yearswith favorable results . . . . . . . . . . . . . . . . . . .SELECT PREFERREDBasal Cell Skin Cancer• completely excised . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDBell’s Palsy – Temporary paralysis of the facial muscles• history of, complete recovery . . . . . . . . . . . . . .ULTRA PREFERRED12FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Benign Prostatic Hypertrophy (BPH) – An enlargement of theprostate.• PSA’s normal, controlled with medication,no surgery anticipated . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• with surgery and full recovery . . . . . . . . . . . . .ULTRA PREFERREDBiliary Cirrhosis – A liver disease that slowly destroys the bile ducts inthe liver.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEBi-Polar Disorder – A mood disorder characterized by mood swingsfrom mania (exaggerated feeling of well-being) to depression• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEBladder Infection – Urinary• history of infection, complete recovery . . . . . .ULTRA PREFERRED• chronic infections, without incontinence . . . .SELECT PREFERREDBladder Prolapse (Cystocele) – The dropping or sagging of a women’sbladder due to the weakness of the bladder.• surgically repaired . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDBlood Pressure, Elevated – A higher than normal blood pressure.(check list for cardiac medications)• mild and no other cardiac condition . . . . . . . . .ULTRA PREFERRED• in combination with othercardiac condition . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• poor medication compliance or not controlled . . . .UNINSURABLEBrain Tumor – Abnormal growth in or on the brain• after 5 years following removal,benign, no residuals . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• all others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEBreast Disorders – Any type of lump, swelling, cyst or mass that canbe felt in the breast tissue.• fibrocystic disease . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.13

Bronchiectasis – A chronic expansion and destruction of the bronchiof the lungs, with secondary infection.• asymptomatic, non-cigarette smoker, minimum 1 year sincediagnosis, normal pulmonary function tests . . . . . . . .PREFERRED• chronic, with hospitalizations . . . . . . . . . . . . . . . . .UNINSURABLEBronchitis – Acute or chronic inflammation of the bronchial tube.• acute attack, nonsmoker . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• multiple attacks, smoker . . . . . . . . . . . . . . . . .SELECT PREFERRED• chronic, nonsmoker . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• chronic, with current (or within past 12 months)cigarette smoking . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEBuerger’s Disease (Thromboangiitis Obliterans) – A chronic,recurring, inflammatory, vascular disease of the peripheral arteriesand veins.• current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE• full recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• chronic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEBypass Surgery (Heart) – A surgery that reroutes the blood supply bybypassing blocked arteries.C• after 6 months, with good results . . . . . . . . .SELECT PREFERRED• with history of myocardial infarction . . . . . . .SELECT PREFERRED• with current (or within past 12 months)cigarette smoking . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECancer – An uncontrolled growth of abnormal cells which havemutated from normal tissue.BladderEarly Stage 0 (in situ), 2 year fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED14FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Early Stages (A, B1, B2), 2 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDEarly stages (A, B1, B2), 5 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDAll other stages, over 2 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERREDAny invasion of regional lymphatics, metastasis,or recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEBreastEarly Stage 0, 1, 2, over 2 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDEarly Stage 0,1,2, over 5 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDStages III, IV over 2 years from last treatment . . . . . . . .PREFERREDStages III, IV, over 5 years from last treatment .SELECT PREFERREDAny invasion of regional lymphatics, metastasis,or recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEColonStages 0, I (Dukes A) 2 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDStages 0, I (Dukes A) 5 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDStages IIA, IIB (Dukes B), IIIA (Dukes C) 2 yearsfrom last treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERREDStages IIA, IIB (Dukes B), IIIA (Dukes C) 5 yearsfrom last treatment . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDAny invasion of regional lymphatics, metastasis,or recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.15

EsophagusStage 0 (in situ), 5 years from last treatment . . . . . . . . .PREFERREDAny invasion of regional lymphatics,metastasis, or recurrence . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEKidneyStage I, II, 2 years from last treatment . . . . . . .SELECT PREFERREDStage I, II, 5 years from last treatment . . . . . . . .ULTRA PREFERREDAll other stages, over 2 years from last treatment . . . . .PREFERREDAny invasion of regional lymphatics,metastasis, or recurrence . . . . . . . . . . . . . . . . . . . . . .UNINSURABLELiverAll stages within 5 years . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEAll stages 5 years from last treatment . . . . . . . . . . . . . .PREFERREDLungAll stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLELymphomaStages I, II, 10 years from last treatment . . . . . . . . . . . .PREFERREDMelanomaStage 0 (in situ), 1 year from last treatment . . . .ULTRA PREFERREDStages IA, IB, IIA, IIB, 2 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDStages IA, IB, IIA, IIB, 5 years fromlast treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDStage IIIA, 2 years from last treatment . . . . . . . . . . . . . .PREFERREDStage IIIA, 5 years from last treatment . . . . . . .SELECT PREFERREDAny invasion of regional lymphatics,metastasis, or recurrence . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.16

OvarianStages IA, IB, IC, 2 years from last treatment . .SELECT PREFERREDStages IA, IB, IC, 5 years from last treatment . . .ULTRA PREFERREDStage IIA, 2 years from last treatment . . . . . . . . . . . . . .PREFERREDStage IIA, 5 years from last treatment . . . . . . . .SELECT PREFERREDAny invasion of regional lymphatics,metastasis, or recurrence . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEProstateGrade 1, 2 years from last treatment . . . . . . . . .SELECT PREFERREDGrade 1, 5 years from last treatment . . . . . . . . . .ULTRA PREFERREDGrade 2-3, 2 years from last treatment . . . . . . . . . . . . . .PREFERREDGrade 2-3, 5 years from last treatment . . . . . . ..SELECT PREFERREDAny invasion of regional lymphatics, metastasis,Or recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECane Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECardiomyopathy – A disease that damages the heart muscle so that itloses its ability to pump blood and can cause irregular heartbeats.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECarotid Artery Disease – A constriction or narrowing of the arteriesthat supply the blood flow to the neck and brain.• nonsmoker, asymptomatic or corrected by endarterectomy, nohistory of TIA or stroke . . . . . . . . . . . . . . . . . .SELECT PREFERRED• nonsmoker, asymptomatic, with otherheart or circulatory disorder . . . . . . . . . . . . . . . . . . . . .PREFERRED• severe; symptomatic or cigarette smoker . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.17

Carpal Tunnel Syndrome – A painful and progressive condition causedby compression of the median nerve.• successful surgery, no residuals . . . . . . . . . . . .ULTRA PREFERRED• surgery anticipated, with functional limits . . . . . . . . . .POSTPONECataracts – A clouding of the lens or the eye, which obstructs thepassage of light.• recovered after surgery . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• present but not requiring surgery,no visual impairment . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• surgery scheduled or anticipated . . . . . . . . . . . . . . . . .POSTPONECatheter (current use; indwelling) A tubular medical device forinsertion into canals, vessels, or passageways to permit injection orwithdrawal of fluids.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECerebral Palsy – A disorder of movement and gait caused by braindamage.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECerebral Vascular Accident (CVA) – The blood supply to a part of thebrain is interrupted by an ischemic stroke or by a hemorrhagic stroke.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECharcot-Marie-Tooth Disease – A hereditary progressiveneuromuscular disorder that primarily affects the feet, leg, and hands.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECholecystitis, Cholelithiasis (see Gallbladder) – A suddeninflammation of the gallbladder that causes severe pain.Chronic Fatigue Syndrome – A prolonged persistent fatigue that canbe incapacitating and/or debilitating.• mild, controlled with medication, not affectingfunctional ability . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED18FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

• severe, with functional limitations;use of steroids or narcotics . . . . . . . . . . . . . . . . . .UNINSURABLEChronic Obstructive Pulmonary Disease (COPD) – A severe diseaseof the lungs that obstructs the airways.• nonsmoker, controlled with 1-2 medications/inhalers, nohospitalizations . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• nonsmoker, controlled with 1-2 medications, occasional steroiduse, no hospitalizations . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• with current (or within past 12 months) cigarette smoking,oxygen use, hospitalizations, daily steroid use, with heartor circulatory disorders . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECirrhosis, Liver – The gradual loss of liver function due to cell damageand internal scarring.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECognitive Impairment – The inability to mentally function normally,reduction in memory, thinking, and learning.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEColitis – A chronic, episodic, inflammatory disease of the large intestineand rectum characterized by bloody diarrhea.• controlled with medication . . . . . . . . . . . . . . .SELECT PREFERRED• occasional flares, treated with steroids,normal weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• recurrent flares, hospitalizations, weight loss,chronic steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECollagen Vascular Disease – Any disorder affecting the connectivetissue, with rheumatic symptoms including muscle stiffness, soreness,and pain in the joints.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEColostomy – An opening of a portion of the colon through theabdominal wall.• 2 years after surgery, no complications . . . . .SELECT PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.19

Confusion• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECongestive Heart Failure (CHF) – The heart’s inability to maintainsufficient cardiac output to meet the body’s needs.• controlled with medications for 1 year, singleevent, ejection fraction >45% . . . . . . . . . . . . . . . . . . .PREFERRED• chronic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEConnective Tissue Disease (see Collagen Vascular Disease)Coronary Artery Disease – A condition that reduces the blood flowthrough the coronary arteries to the heart muscle.• with angina or positive cardiac test . . . . . . . .SELECT PREFERRED• with history of myocardialinfarction or angioplasty . . . . . . . . . . . . . . . . .SELECT PREFERRED• with current (or within past 12 months)cigarette smoking, or multiple heart attacks . . . . .UNINSURABLECREST Syndrome (see Scleroderma)Crohn’s Disease – Inflammation and ulceration of the small intestine.• controlled with medication . . . . . . . . . . . . . . .SELECT PREFERRED• occasional flares, treated with steroids,normal weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• recurrent flares, hospitalizations, weight loss,chronic steroids . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECushing’s Syndrome (due to Pituitary, Adrenal or Ectopic Tumors)– A hormonal disorder resulting from the overproduction ofcorticosteroid by the adrenal gland.• corrected by surgery, no complications or secondarydisorders such as high blood pressure, osteoporosisor diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE20FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

CVA (see Stroke)Cystic Fibrosis – An inherited disease characterized by chronic lunginfections and an inability to absorb fats or other nutrients from foods.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLECystitis – Inflammation of the urinary bladder.D• acute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDDegenerative Joint Disease (see Arthritis)Dementia – A cognitive deficit including memory impairment.• all forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDemyelinating Disease – Causing or characterized by the loss ordestruction of myelin (the sheath around nerve fibers), such asmultiple sclerosis.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDepression – A mental disorder marked by sadness, inactivity, difficultywith thinking and concentration, feelings of helplessness andworthlessness.• mild, situational or treated with occasional, regular, or multiplemedication . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• chronic with multiple medications, hospitalizationsUNINSURABLEDermatomyositis – An autoimmune disorder in which the muscles andskin become inflamed, causing weakness of the muscles and a skin rash.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDiabetes Mellitus, Insulin Dependent – A chronic disease ofcarbohydrate metabolism in which the body makes little or no insulin,requiring daily injections of insulin to sustain life.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDiabetes Mellitus, Non-Insulin Dependent (diet or oralmedications) – A chronic disease of carbohydrate metabolism, markedby high blood sugar and sugar in urine, resulting from inadequateFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.21

production or use of insulin.• newly diagnosed or change in medications < 1 year . .POSTPONE• diet or oral medication control . . . . . . . . . . . .SELECT PREFERRED• diet or medication control, overweight, . . . . . . . . . . . .PREFERRED• poor control or with other serious health conditions, diabeticcomplications, cigarette smoker or smoker within past12 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDialysis, Kidney – A procedure to remove the waste products from theblood and excess fluid from the body as a treatment for kidney failure.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDiverticulitis, Diverticulosis (see Irritable Bowel Syndrome) –Diverticulitis is inflammation and perforation of a diverticulum (anabnormal pouch or sac of the intestine), Diverticulosis is a conditionwhere small sacs of the inner lining of the intestine are present.Down’s Syndrome – A chromosome abnormality resulting in moderateto severe mental retardation and other abnormalities• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEDrug Dependency or Abuse• after 5 years, complete abstinenceincluding alcohol . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• after 3 years, complete abstinenceincluding alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• within 3 years or with relapses . . . . . . . . . . . . . . .UNINSURABLEDuodenal Ulcer – A peptic ulcer situated in the small intestines.• history of, occasional medication . . . . . . . . . . .ULTRA PREFERRED• chronic, frequent flare ups and/or bleeding . .SELECT PREFERRED• surgery anticipated or scheduled . . . . . . . . . . . . . . . . .POSTPONEDupuytren’s Contracture – A painless thickening and contracture oftissue beneath the skin on the palm of the hand.22• present or surgically corrected, no functionalFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Elimitations or other disease present . . . . . . . .ULTRA PREFERRED• surgery anticipated or scheduled . . . . . . . . . . . . . . . . .POSTPONEEmphysema (see Chronic Obstructive Pulmonary Disease)Endarterectomy (see Carotid Artery Disease) – surgery to remove orbypass fatty deposits or blockage in an artery.Endocarditis – Inflammation of the inner lining of the heart.• fully recovered > 6 months, 1 episode,no residuals . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT REFERRED• recurrent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEEpilepsy (Seizures) – Transient neurological abnormalities caused byabnormal electric activity in the brain.• controlled on medication,seizure free > 12 months . . . . . . . . . . . . . . . . .SELECT PREFERRED• seizure within 1 year; poorcontrol or cause unknown . . . . . . . . . . . . . . . . . . . .UNINSURABLEEpstein-Barr Syndrome – A herpes virus that causes infectiousmononucleosis.• 6 months after full recovery, no residuals . . . .ULTRA PREFERRED• current evaluation or work up . . . . . . . . . . . . . . . . . . . .POSTPONEEsophageal Varices – Twisted, expanded areas in the esophagealveins resulting from portal hypertension caused by advanced liverdisease.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEEsophagitis – Inflammation of the esophagus.• mild, well controlled by diet or medication . . .ULTRA PREFERRED• recurrent or with bleeding . . . . . . . . . . . . . . .SELECT PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.23

FFalls• multiple (3) with or without injury in past 5 years .UNINSURABLEFatty Liver – Accumulation of excess fat in the liver cells. Some causesare obesity, high triglycerides and alcohol use.• liver function tests normal, stable . . . . . . . . .SELECT PREFERRED• abnormal liver function tests or relatedto alcohol intake . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFibrocystic Breast Disease – A benign breast lump characterized bycysts and thickening of the milk glands.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDFibromyalgia – A chronic disorder of the muscles and related softtissue including ligaments and tendons, characterized by muscle pain,fatigue, and sleep disturbances.• mild, controlled with minimal medication,no limitations . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with chronic fatigue, weakness, functional limitations;use of steroids or narcotics . . . . . . . . . . . . . . . . . .UNINSURABLEFractures• arm, due to trauma, no functional impairment,full recovery . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• leg, due to trauma, no functional impairment,full recovery . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• pelvis, due to trauma,no functional impairment . . . . . . . . . . . . . . . .SELECT PREFERRED• Vertebral, due to trauma,no functional limits . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• Vertebral, due to osteoporosis . . . . . . . . . . . . . . . .UNINSURABLE• Paget’s disease . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE24FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Fuch’s Corneal Dystrophy – A gradual deterioration of one layer oranother of the cornea, which causes clouding and blurred vision.G• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEGallbladder (Cholecystitis, Cholelithiasis) – A sudden inflammationof the gallbladder that causes severe pain.• medically managed . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• after 3 months surgery . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• pending or anticipated surgery . . . . . . . . . . . . . . . . . . .POSTPONEGastric Bypass Surgery (Stapling, Banding) – Surgery to promoteweight loss by reducing the size of the stomach and/or interrupting thedigestive process.• after 6 months, must use weight attime of surgery . . . . . . . . . . . . . . . . . . . . . . . . . .SEE BUILD CHART• after 24 months, use current weight . . . . . . . . . . . . . . . . . .CHARTGastroesophageal Reflux Disease (GERD) – Regurgitation of gastricjuices into the lower esophagus.• well controlled by diet or medication . . . . . . .ULTRA PREFERRED• recurrent symptoms or flare ups . . . . . . . . . . .SELECT PREFERREDGilbert’s Disease (confirmed diagnosis) – An inherited disorder thataffects the way bilirubin is processed by the liver.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDGlaucoma – A group of eye diseases that cause damage to the opticnerve which lead to blindness.• treated with eyes drops,no visual impairment . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• with progressive visual loss . . . . . . . . . . . . . . . . . .UNINSURABLEGoiter – An enlargement of the thyroid gland.• post surgery or post radioactive iodine treatment, benign,on thyroid replacement . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.25

Gout – Recurrent inflammation of the peripheral joints, which maybecome chronic and cause joint deformity.• controlled with medication, no flare up . . . . . .ULTRA PREFERRED• with recurrent flare ups, . . . . . . . . . . . . . . . . .SELECT PREFERREDGraves’ Disease – An autoimmune disease that causes over activity ofthe thyroid gland.• controlled by medication . . . . . . . . . . . . . . . . .ULTRA PREFERREDGuillian-Barre Syndrome – A disorder in which the body’s immunesystem attacks the peripheral nerves, which are outside the brain andspinal cord.H• full recovery after 12 months, no residuals or functionallimitations . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• full recovery with minimal residuals after 12 months, nofunctional limitations . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERREDHashimoto’s Thyroiditis – An inflammation of the thyroid gland, thatfrequently results in hypothyroidism (low thyroid).• controlled by thyroid replacement therapy . . .ULTRA PREFERREDHeadaches – Diffuse pain in different portions of the head, notconfined to any nerve distribution area.• occasional medication . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDHeart Attack – Insufficient blood supply to the heart muscle.• after 6 months, single attack, 1-2 medications, stable and fullyfunctional . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• after 12 months, second or multiple attacks, 1-2 medications,stable, fully functional . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• with chronic angina (chest pain) . . . . . . . . . . . . . . . . .PREFERRED• current cigarette smoker or smokerwithin past 12 months . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE26FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Heart Blocks – A condition in which the signal from the heart’s upperto lower chambers is impaired or doesn’t transmit.• left bundle branch block with normalstress test, echo . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• right bundle branch block with normalstress test, echo . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• First-degree AV Block, asymptomatic, treatment free,no underlying cardiac conditions . . . . . . . . . . .ULTRA PREFERRED• Second-degree AV Block, asymptomatic, no underlyingcardiac conditions . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• Third-degree AV Block, asymptomatic, medicallytreated or with successful pacemaker implant, withknown heart disease, after 12 months . . . . . . . . . . . .PREFERREDHeart Valve Disease with Replacement – A surgery used to repair orreplace diseased heart valves.• after 6 months . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• surgery scheduled or anticipated . . . . . . . . . . . . . . . . .POSTPONEHemochromatosis/Hemosiderosis – A disorder that causes the bodyto absorb excess iron, which accumulates in the liver, pancreas, heart,and in other organs.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHemophilia – An inherited disorder in which a person’s blood lacks acertain protein important in forming blood clots, leading to excessivebleeding.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHemorrhoids – A mass of dilated veins in swollen tissue at the marginof the anus or nearby within the rectum. Also known as piles.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.27

Hepatitis (A & B) – An inflammation of the liver caused by viruses,bacteria, parasites, and toxic reactions to drugs, alcohol, and chemicals.• hepatitis A, full recovery (3 months), normal liverfunction tests . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• hepatitis B, full recovery (12 months), normal liverfunction tests . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• described as active, chronic active, ordue to alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHepatitis C - The most serious hepatitis virus and the leading causeof chronic hepatitis, end stage liver disease, liver cancer and livertransplants in the US. The C virus is transmitted primarily by blood orblood products. Typically due to IV transfusion, past organ transplant,illegal drug use, or occupationally (health care workers who have hadaccidental needle sticks with infected blood).• acute infection, after 1 year, considered recovered(virus cleared), no virus detectable, no illegaldrug use history, normal liver biopsy andnormal liver function tests . . . . . . . . . . . . . . .SELECT PREFERRED• all others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHerniated Disc – A rupture of an intervertebral disc of the spine with aprotrusion of the disc’s core into the spinal canal.• post surgery with good recovery . . . . . . . . . . .ULTRA PREFERRED• present, no surgery planned . . . . . . . . . . . . . .SELECT PREFERRED• surgery anticipated or scheduled . . . . . . . . . . . . . . . . .POSTPONEHiatal Hernia – A portion of the stomach protrudes upward into thechest through an opening in the diaphragm.• with or without surgery, controlled bydiet or medication . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDHip Replacement (see Joint Replacement)28FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

HIV Positive• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHodgkin’s Lymphoma – A malignant growth of cells in thelymph system• after 10 years, complete remission . . . . . . . . . . . . . . .PREFERREDHome Care Service• within the last 12 months . . . . . . . . . . . . . . . . . . . . . . .POSTPONEHuntington’s Chorea – A genetic disease that involves thedegeneration of the basal ganglia of the brain.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHydrocephalus – A disorder characterized by an excessive amount ofcerebrospinal fluid under pressure within the skull.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEHypercholesterolemia (high cholesterol) . . . . . .ULTRA PREFERREDHyperglycemia – a condition in which an excessive amount of sugarcirculates in the blood.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDHyperparathyroidism – The over activity of the parathyroid glandsthat leads to an abnormally elevated level of calcium in the blood.• surgically corrected, normal calcium,no limitations . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• minimally elevated calcium levels, stable, closely monitored, norelated disorders such as high blood pressure, impaired renalfunction, or bone demineralization . . . . . . . . .SELECT PREFERREDHypertension (see Blood Pressure, elevated)Hyperthyroidism – The over activity of the thyroid gland which resultsin the over production of thyroid hormone.• controlled with medication . . . . . . . . . . . . . . . .ULTRA PREFERREDHypothyroidism – The under activity of the thyroid gland which resultsin the under production of thyroid hormone.FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.29

• controlled with medication . . . . . . . . . . . . . . . .ULTRA PREFERREDHysterectomy – the surgical removal of the uterus.I• after 3 months, no complicationsor malignancy . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDIleostomy (see Colostomy) – The creation of a surgical passagethrough the abdominal wall into the ileum.Incontinence, Bowel – The inability of the body to control theevacuative functions.• surgically corrected . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• all others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEIncontinence, Urinary – The inability of the body to control theevacuative functions.• stress or urge, treated with 1 medication . . . .ULTRA PREFERRED• treated with surgery, full recovery . . . . . . . . . .ULTRA PREFERRED• complete loss of control . . . . . . . . . . . . . . . . . . . . .UNINSURABLEIntestinal Obstruction – A partial or complete blockage of the bowelthat results in the failure of the intestinal contents to pass through.• surgically corrected after 12 months,no residuals . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• surgery anticipated or scheduled . . . . . . . . . . . . . . . . .POSTPONEIrritable Bowel Syndrome – A form of colitis, which is characterizedby constipation and diarrhea.• controlled with medication,no surgery anticipated . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• frequent flare ups and/or bleeding . . . . . . . . .SELECT PREFERREDITP (Idiopathic Thrombocytopenic Purpura) – A bleeding disorderthat is caused by too few platelets in the blood.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE30FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

JJoint Replacement (Knee or Hip) – The replacement of a joint.K• one or both joints, after 6 months,no functional limitations, . . . . . . . . . . . . . . . .SELECT PREFERRED• surgery anticipated or scheduled . . . . . . . . . . . . . . . . .POSTPONEKidney Dialysis (see Dialysis) – The build up of waste and toxins,which are not filtered out of the blood and start to accumulate inthe tissues.Kidney Failure – Failure of the kidney to perform its essential functions.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEKidney Infection – An infection of the kidney and the ducts that carryurine away from the kidney.• no current treatment, fully recovered . . . . . . . .ULTRA PREFERRED• currently under treatment,medically managed . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDKidney Stones (Nephrolithiasis) – renal calculi or nephrolithisis.Solid lump made up of crystals that separate from the urine.• no current treatment, resolved . . . . . . . . . . . . .ULTRA PREFERREDKidney Transplant – A surgical procedure to implant a healthy kidneyinto a patient with kidney failure.• 5 years after transplant, normal renal function tests,no complications . . . . . . . . . . . . . . . . . . . .PREFERRED (No HCBS)Knee Replacement (see Joint Replacement) – The replacement ofa kneeFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.31

LLabyrinthitis – An inflammation of the fluid filled chambers in the innerear that sense balance, resulting in vertigo.• well controlled with occasional medication . .ULTRA PREFERRED• well controlled on 1-2 medications . . . . . . . .SELECT PREFERREDLacunar Infarct (see Stroke) – An area of tissue in the brain thatundergoes death of cells following the cessation of blood supply,resulting from occlusion or stenosis of the supplying artery.Lambert-Eaton Syndrome (Myasthenia Syndrome) – A conditionmarked by neuropathy and weakness of the limbs.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLELeft bundle branch block (see Heart Blocks) – A defect in thehearts electrical conduction system.Leukemia (any type) – A group of bone marrow cancers in whichwhite blood cells divide uncontrollably, affecting the production ofnormal white blood cells, red blood cells and platelets.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLELiver Cyst• 1-2 cysts, no liver disease . . . . . . . . . . . . . . . .ULTRA PREFERRED• multiple cysts, no kidney or liver disease . . . .SELECT PREFERREDLou Gehrig’s Disease (see Amyotrophic Lateral Sclerosis) – Thedegeneration of muscular activity within the brain and the spinal cord.Lung Cancer (see Cancer)Lupus (Discoid) – A chronic disease of the skin characterized byremissions and exacerbation of a scaling, red, macular rash.• stable after 12 months, negative ANA . . . . . .ULTRA PREFERREDLupus Erythematosus (Systemic) – A chronic, inflammatory autoimmune disorder that may affect organ systems including the skin,joints, and internal organs.32• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Lyme’s Disease – A bacterium that is transmitted by a tick andcharacterized by skin changes, flu like symptoms and joint inflammation.• correct diagnosis, adequate treatment,no residual, after 3 months . . . . . . . . . . . . . . .ULTRA PREFERRED• correct diagnosis, adequate treatment,with residuals but full recovery . . . . . . . . . . .SELECT PREFERRED• questionable diagnosis or current treatment . . . . . . . .POSTPONELymphoma (see Cancer) – A form of cancer a malignant tumor of thelymphoid tissue.MMacular Degeneration – A deterioration of the central portion of theretina, affecting central vision and visualization of fine details.• no functional limits, successful adaptationto any visual loss . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• progressive visual loss, changes to lifestyleto accommodate vision loss . . . . . . . . . . . . . . . . . .UNINSURABLEMajor Depression – An emotional state characterized by feelings ofpersistent sadness, worthlessness, rejection, loss of hope, and loss ofinterest in usual activities.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEManic Depression (see Bipolar)Marfan’s Syndrome – An inheritable disorder of connective tissue thataffects the skeletal system, cardiovascular system, eyes, and skin.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMedicaid Recipient• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMelanoma (see Cancer) – A malignant skin tumor containingdark pigment.FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.33

Memory Loss/Problems – A loss of the ability to memorizeinformation or recall information stored in the brain.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMeniere’s Disease – An inner ear disorder, usually accompanied byvarying degrees of hearing loss, ringing in the ears, and dizziness.• adequately diagnosed by MRI, controlled with occasionalmedication, after 6 months . . . . . . . . . . . . . . .ULTRA PREFERRED• diagnosis made by symptoms only, not diagnosed by MRI, regularmedication, after 6 months . . . . . . . . . . . . . . .SELECT PREFERRED• uncontrolled with ongoing symptoms . . . . . . . . . .UNINSURABLEMenopausal Symptoms (Pre/Post)• adequately diagnosed, controlled with 1 depression medication inlieu of hormone replacement therapy . . . . . . .ULTRA PREFERREDMental Retardation – A condition characterized by impairedintellectual function which interferes with the ability to cope in everydayactivities.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMigraine Headaches – A severe, sometimes incapacitating headache,which can be accompanied by visual changes or stomach disturbances.• uncomplicated, controlled withoccasional medication . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• described as complicated,uncontrolled orwith chronic pain and limitations . . . . . . . . . . . . . .UNINSURABLEMitral Valve Prolapse – A condition, in which the mitral valve in theheart is deformed, causing a degree of leakage and is characterized by aheart murmur and sometimes chest pain.• no symptoms, normal EKG, may or may nottake antibiotic for prophylactic reasons . . . . . .ULTRA PREFERRED• symptomatic or with other heart condition . .SELECT PREFERRED34FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Monoclonal Gammopathy – A disorder of the blood in which most ofthe protein produced is from one antibody instead of from many.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMultiple Myeloma – a malignancy of plasma cells derived from B-lymphocytes.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMultiple Sclerosis – A progressive disease of the central nervoussystem in which the protective covering of nerve fibers in the brain orspinal cord is destroyed.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMuscular Dystrophy – A slow, progressive disease characterized bydegeneration of muscle fibers.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMyasthenia Gravis – An autoimmune disorder in which the musclesbecome weak and tire easily.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEMyasthenia Syndrome (see Lambert-Eaton Syndrome)Myocardial Infarction (see Heart Attack) – Insufficient blood supplyto the heart muscle.Myocarditis – An inflammation of the heart muscle, which is due to aviral infection.N• acute, full recovery, not related to any otherhealth condition . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDNarcolepsy – A rare syndrome of recurrent attacks of sleep, suddenloss of muscle tone and sleep paralysis.• well controlled, no functional limitations . . . .SELECT PREFERRED• with disability or hospitalizations . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.35

Nephrectomy (removal of one kidney only)• after 6 months, normal labs andkidney tests . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• due to disease or unhealthy remaining kidney . . .UNINSURABLENephrolithiasis (see Kidney Stones)Nephrosclerosis – A kidney disorder in which the smallest arteries inthe kidneys are damaged.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLENeurofibromatosis – A genetic disorder of the nervous system thatcauses tumors to form on the nerves anywhere in the body at any time.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLENeurogenic Bladder – A urinary problem in which there is abnormalemptying of the bladder with subsequent retention or incontinence ofurine.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLENeuropathy – An abnormal and degenerative state of the nervoussystem or nerves.• mild, non progressive, no functional limitations . . . . .PREFERRED• Progressive symptoms OR Requires adaptive devices orassistance with Activities, OR History of Falls OR Balanceproblem when walking OR under current evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLENursing Home Confinement0• within the last year . . . . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONEObsessive compulsive disorder (OCD) – A disorder characterized byrepetitive thoughts and behaviors.• well controlled with goodongoing treatment . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED36FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Organ Transplant (except Kidney) – The replacement of a diseasedorgan with a healthy one.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEOrganic Brain Syndrome – A disturbance of mental functioning due toa physical cause as opposed to a psychological cause.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEOsteomyelitis – An acute or chronic bone infection caused by bacteria.• acute with complete recoveryafter 6 months . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• chronic or active or with functional limitations . . .UNINSURABLEOsteoporosis – A reduction of bone mass, causing bones to becomebrittle, fragile, and susceptible to fractures.• mild, on medication, no history of fracture . .SELECT PREFERRED• with fracture history . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEOxygen• current use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPPacemaker – An electrical device that can control the beating of theheart by a series of rhythmic electrical discharges.• no complications . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDPaget’s Disease – A disruption of normal bone formation causing theaffected bones to weaken, thicken, and become deformed.• if discovered on x-ray, no symptomsor fractures . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with fracture history . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• with severe joint deformity or pain . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.37

Panic Disorder – Panic disorder is characterized by recurrent panicattacks (i.e., periods of intense fear and discomfort) on anunpredictable basis.• medication as needed . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• routine or daily medication taken . . . . . . . . . .SELECT PREFERRED• with prior hospitalization(s) or disability . . . . . . . .UNINSURABLEPancreatitis – An inflammation of the pancreas.• single episode, no residual, completerecovery after 6 months . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• Chronic or with multiple episodes ordue to alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEParalysis (all forms) – A complete or partial loss of controlledmovement caused by an inability to contract one or more muscles.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEParkinson’s Disease – A chronic progressive nervous disease markedby tremor, muscular weakness, rigidity and peculiar gait.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPericarditis – A disorder caused by inflammation of the pericardium,which is the sac like covering of the heart.• acute, full recovery, no other cardiac orrelated health condition . . . . . . . . . . . . . . . . . .ULTRA PREFERREDPeripheral Neuropathy – A disease or degenerative state of theperipheral nerves marked by muscle weakness, atrophy, pain andnumbness.• if caused by nerve root compression . . . . . . . . . . . . . .PREFERRED• if caused by disease . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE38FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Peripheral Vascular Disease – A disease of the blood vesselscharacterized by narrowing and hardening of the arteries that supply thelegs and feet, causing a decrease in blood flow that can injure nervesand other tissues.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPhlebitis – Painful inflammation of a vein.• single attack, fully recoveredafter 3 months . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDPhysical Therapy• within the last 6 months . . . . . . . . . . . . . . . . . . . . . . . .POSTPONEPick’s Disease – A rare degenerative brain illness that causesdementia and is marked by progressive impairment of intellectand judgment.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPituitary Tumor, benign (see Brain tumor)Polio – A virus which invades the central nervous system marked bytremor, muscle pain, muscle weakness, stiffness, serious breathingproblems, or death.• history of, with full function,no past paralysis . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• history of paralysis, now with full function . .SELECT PREFERRED• with post polio syndrome or withcurrent residual paralysis . . . . . . . . . . . . . . . . . . . .UNINSURABLEPolycystic Kidney Disease – An inherited disease characterized bythe growth of numerous cysts filled with fluid in the kidneys.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPolycythemia – A blood disease with abnormal increase in red andwhite blood cells and platelets.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.39

Polymyalgia Rheumatica – An inflammatory syndrome, which ismarked by pain and stiffness in the muscles of the hips, thighs,shoulders and neck.• No symptoms and controlled with medication,in remission, No ongoing steroid use,No functional limits . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• controlled with low dose steroid medications . . . . . . .PREFERRED• with symptoms, frequent narcotic use,with functional limitations . . . . . . . . . . . . . . . . . . .UNINSURABLEPolyps – A tumor, which is commonly found in vascular organs such asthe nose, uterus, colon, and rectum.• surgically removed, benign . . . . . . . . . . . . . . . .ULTRA PREFERRED• malignant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .See CancerPost Traumatic Stress disorder – A psychiatric disorder that canoccur following a traumatic experience, a life threatening, or extremelydistressing situation that causes a person to feel intense fear, horror ora sense of helplessness.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEProstate Cancer (see Cancer)Prostate Enlargement• benign prostate hypertrophy (BPH), withor without surgery . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDPSA (Elevated) (Prostate-Specific Antigen) – An enzyme that isproduced by the prostate gland that can be measured in the blood.• Elevated, proven benign by biopsy, BPH treatedwith 1 medication or no medications . . . . . . . .ULTRA PREFERRED• if rising, not within normal limits for age ornot proven benign . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE• elevated, no biopsy done, monitoring . . . . . . . . . . . . . .POSTPONE40FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Psoriatic Arthritis – Pain and swelling of joints with patches of scalyskin related to psoriasis.• no functional limits, no joint deformities, treatedwith 1 medication (not steroids) . . . . . . . . . . .SELECT PREFERRED• moderate impairment, no functional limits, treated withsteroids, Methotrexate, Embrel, Plaquenil or similarmedications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• severe joint deformity, ongoing pain, treated withnarcotics, with functional limitations . . . . . . . . . . .UNINSURABLEPsychosis – A severe mental disorder in which the individual losescontact with reality.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPulmonary Embolism – A blockage in an artery in the lungs caused bya blood clot that travels through the blood vessels to the lungs.• one occurrence, no complications,off all blood thinners . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• recurrent, multiple . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEPulmonary Fibrosis – Scarring or thickening of tissues deep in the lungusually resulting from previous lung inflammation such as pneumonia, ortuberculosis.R• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLERaynaud’s Disease – A disorder of the small blood vessels of theextremities, is characterized by intermittent pallor, blanching andcoldness of the affected parts.• mild, non-progressive, with orwithout medications . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• progressive or with functional limitations . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.41

Raynaud’s Phenomenon – A circulatory disorder with similar signsand symptoms of Raynaud’s disease.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• due to serious underlying disease . . . . . . . . . . . . .UNINSURABLEReflex Sympathetic Dystrophy – A chronic pain condition that is theresult of dysfunction in the central or peripheral nervous system.• Current, mild degree of impairment,no functional limitations . . . . . . . . . . . . . . . . .SELECT PREFERREDRenal Failure – A gradual and progressive loss of the ability of thekidneys to excrete waste, concentrate urine, and conserve electrolytes.• current . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE• acute, after 1 year, fully recovered,no residuals . . . . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• chronic renal insufficiency . . . . . . . . . . . . . . . . . . . . . .PREFERREDRenal Insufficiency (not chronic) – Insufficient excretion of wastesby the kidneys.• after 12 months, stable . . . . . . . . . . . . . . . . . .SELECT PREFERREDRestless Leg Syndrome – A neurological disorder characterized byunpleasant sensations in the legs and an uncontrollable desire tomove them.• controlled on one medication . . . . . . . . . . . . .SELECT PREFERRED• multiple medications or use ofanti-Parkinson’s medications . . . . . . . . . . . . . . . . . . . .PREFERREDRetinal Artery Occlusion – A blockage of the main artery leading tothe retina or one of it’s branches.• after 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PREFERRED• within 2 years or multiple episodes . . . . . . . . . . . .UNINSURABLERetinitis Pigmentosa – A condition characterized by a degeneration ofthe rods and cones of the retina of the eye, which leads to blindness.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLE42FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Retinopathy (Diabetic) – A disease of the retina due to diabetes thatcan cause decreased vision and blindness.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLERheumatoid Arthritis (see Arthritis) – A chronic systemic diseasemarked by inflammatory changes in the joints.SSarcoidosis – A chronic multisystem disease of unknown causecharacterized by inflammatory cells, called granulomas that can producemany different symptoms.• no progression for at least 1 year, mild symptoms,no treatment, non-cigarette smoker . . . . . . . .SELECT PREFERRED• with current (or within past 12 months) cigarettesmoking or progressive . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESchizophrenia – A mental disorder that makes it difficult to tell thedifference between real and imagined experiences, to think logically, orto behave appropriately in social situations.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEScleroderma (Crest Syndrome) – An autoimmune disorder of theconnective tissue, which is characterized by formation of scar tissue inthe skin and organs of the body.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEScoliosis – A crookedness or lateral curvature of the spine.• mild, no functional limitations . . . . . . . . . . . . .ULTRA PREFERRED• severe but without physical limitations . . . . .SELECT PREFERREDSeizure Disorder (see Epilepsy)Self-Reported Memory Concerns• current or within 5 years . . . . . . . . . . . . . . . . . . . . .UNINSURABLEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.43

Shunts (Brain, Heart or Kidney) – A normal or abnormal passage bywhich bodily fluid is diverted from one channel, circulatory path, or partto another.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEShy-Drager Syndrome – A degenerative disease characterized byprogressive damage to the autonomic nervous system, muscle tremor,rigidity, and slow movement.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESickle Cell Anemia – A hereditary disorder in which the red bloodcells contain an abnormal hemoglobin (protein carried by red cells),which results in blood cells shaped like sickles.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESjogren’s Syndrome – A chronic disease in which white blood cellsattack the moisture producing glands, but it is a systemic disease,affecting many organs and may cause fatigue.• mild, no limitations . . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with disability or physical limitations . . . . . . . . . . .UNINSURABLESkin Cancer (not Melanoma) – Cancer that may arise on the surfaceof the body and form a small ulcer or pimple.• external, basal or squamous cell cancer . . . . .ULTRA PREFERREDSleep Apnea – A breathing disorder characterized by brief interruptionsof breathing during sleep.• Operated, Complete Recovery, No cardiac disease,Nonsmoker . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• mild or currently using CPAP . . . . . . . . . . . . . .SELECT PREFERRED• with cardiac disorder and/or overweight . . . . . . . . . . .PREFERREDSmoking Cigarettes• without medical problems . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• with chronic upper respiratory infections . . . . . . . . . . . . . .PREFERRED• with diabetes, heart or lung disease . . . . . . . . . . . . . . .UNINSURABLE44FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

7Spinal Stenosis – A narrowing of the space in the spinal canalthrough which nerves run.• mild, non-progressive . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• mild, multiple medications required,no functional limitations . . . . . . . . . . . . . . . . . . . . . . . .PREFERREDSplenectomy – Surgical removal of the spleen due to traumaor disease.• fully recovered . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDStent (cardiac) – A short or narrow metal plastic tube that isinserted into an artery or bile duct to keep a previously blockedpassageway open.• after 6 months, with good results . . . . . . . . .SELECT PREFERREDStroke – A loss of brain functions caused by a loss of blood circulationto areas of the brain.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESubarachnoid Hemorrhage – A disorder in which blood from aruptured blood vessel spreads over the surface of the brain.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESubclavian Steal Syndrome – A condition characterized by recurrentattacks of blurred or double vision, dizziness and loss of coordinationcaused by reduced blood flow to the base of the brain.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESubdural Hematoma – A collection of blood between the surface ofthe brain and its outer covering.• within 2 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONE• after 2 years, no residuals . . . . . . . . . . . . . . .SELECT PREFERREDSuicide Attempt – The unsuccessful act of ending one’s own life.• all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLESurgery Anticipated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.45

TTemporal Arteritis – A chronic inflammation of large arteries, typicallyof the temporal artery, an artery on the side of the scalp.• 1 year after recovery . . . . . . . . . . . . . . . . . . . .SELECT PREFERRED• in remission, currently taking Prednisoneor other steroid medication . . . . . . . . . . . . . . . . . . . . .PREFERREDTemporomandibular Joint Syndrome (TMJ) – A dysfunction oralteration of the temporomandibular joint, which is the joint that allowsjaw mobility.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ULTRA PREFERREDThrombocythemia (elevated blood platelets) . . . . . .UNINSURABLEThrombocytopenic Purpura (low blood platelets) . .UNINSURABLETIA (Transient Ischemic Attack) – A brief interruption of the bloodsupply to a part of the brain.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLETransverse Myelitis – A rare neurological disorder characterized byinflammation of the spinal cord.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLETremors – Involuntary movements in the muscles of the hands, arms,and head but can affect the legs.U - Z• Benign, Essential, Intention or Familial, Must bestable for 6 months with no progression and normalneurological Exam . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDUlcers (Duodenal or Peptic) – An erosion of the inner lining of thestomach usually caused by gastric acid and pepsin.• history of, occasional medication . . . . . . . . . . .ULTRA PREFERRED• chronic, frequent flare ups and/or bleeding . .SELECT PREFERRED• surgery scheduled . . . . . . . . . . . . . . . . . . . . . . . . . . . . .POSTPONE46FOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.

Varicose Veins – Enlarged, twisted, painful superficial veins resultingfrom poorly functioning valves.• uncomplicated, without medication . . . . . . . . .ULTRA PREFERRED• medication required or with skin ulcers . . . . .SELECT PREFERRED• with FUNCTIONAL LIMITATIONS or other complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEVertebral Basilar Insufficiency – A condition in which blood flow tothe vertebral arteries is restricted or insufficient.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEVertigo – A type of dizziness that is characterized by the sensationof spinning.• controlled with medication . . . . . . . . . . . . . . .SELECT PREFERRED• not controlled . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEVon Willebrand’s Disease – An inherited disorder of the blood, whichleads to abnormal bleeding.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEWaldenstrom’s Disease – Excessive production of red blood cells,white blood cells, and platelets in the bone marrow.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEWilson’s Disease – An inherited disorder in which excessive amountsof copper accumulate in the body.• . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UNINSURABLEWolf-Parkinson-White Syndrome – An abnormal heart rhythmcausing increased heart rate.• asymptomatic, no medication, and/or successfully treated byradiofrequency ablation . . . . . . . . . . . . . . . . . .ULTRA PREFERRED• episodes of tachycardia or treatedwith medication . . . . . . . . . . . . . . . . . . . . . . . .SELECT PREFERREDFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.47

500 Series Prescription Drug GuideDrug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedA.Z.T. Azidothymidine HIV Infection Antiretroviral Not InsurableAbilify Depression Anti Psychotic Not InsurableAcamrosate Alcoholism Not InsurableAccolate Zafirlukast Respiratory Antiasthmatic, Bronchodilator Other than UltraAccuNeb Albuterol Respiratory Bronchodilator Other than UltraAccupril Quinapril Cardiac Antihypertensive Usually UltraAccurbron Theophylline Respiratory Bronchodilator Other than UltraActiq Fentanyl Narcotic Pain Medication Opioid Analgesic Not InsurableActonel Risedronate Osteoporosis, Paget’s Bone Resorption Inhibitor Other than UltraActos Pioglitazone (NIDDM) Antidiabetic Other than UltraActron Ketoprofen Arthritis, Pain NSAID Other than UltraAcyclovir Acyclovir Herpes Infections Antiviral Usually UltraAdalat Nifedipine Cardiac-Calcium Channel Blocker Antianginal, Antihpertensives Other than UltraAdenocard Adenosine Cardiac Antiarrhythmic Other than UltraAdderall Attention Deficit Disorder Usually UltraAdriamycin Doxorubicin Hydrochloride Cancer Antineoplastic Not InsurableAdvair Fluticasone/Salmeterol Combo Respiratory Other than UltraAdvil Ibuprofen Arthritis, Pain NSAID Other than UltraAerobid-M Inhaler Flunisolide Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraAgenerase HIV Not InsurableAggrenox ASA/Dipyrimadole Ciculation Antiplatelet Agent Other than UltraAgrylin Thrombocytopenia Not InsurableAFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.48

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedA-hyrdroCort Hydrocortisone Steroid Antiasthmatic, Corticosteroid Other than UltraAiret Albuterol Respiratory Bronchodilator Other than UltraAkineton Biperiden Parkinson‚ Antiparkinson Not InsurableAlbuterol Albuterol Respiratory Bronchodilator Other than UltraAlcar Dementia Not InsurableAldactazide e Combo Cardiac, Edema Antihypertensive, Diuretic Usually UltraAldactone Spironolactone Edema Diuretic, Potassium-Sparing Usually UltraAldazine Anti Psychotic Not InsurableAldomet Methyldopa Cardiac Antihypertensive Usually UltraAldoril Combo Cardiac Antihypertensive Usually UltraAlendronate Alendronate Osteoporosis Bone Resorption Inhibitors Other than UltraAleve Naproxen Arthritis, Pain NSAID Other than UltraAlkeran Cancer Antineoplastic Not InsurableAllopurinol Allopurinol Gout Antigout Agent Usually UltraAlmotriptan Almotriptan Migraines Vascular Headache Suppressant Usually UltraAlprazolam Alprazolam Anxiety-Benzodiazepine Antianxiety Other than UltraAltace Ramipril Cardiac Antihypertensive Usually UltraAlupent Metaproterenol Respiratory Inhaler Bronchodilator Other than UltraAmantadine Amantadine Parkinson, Viral Infections Antiparkinson, Antiviral Not InsurableAmaryl Glimepiride (NIDDM) Antidiabetic Other than UltraAmbien Zolpidem Sleeping pill Sedative/Hypnotic Usually UltraAmcort Triamcinolone Steroid Antiasthmatic, Corticosteroid Other than UltraAmerge Naratriptan Migraines Vascular Headache Suppressant Usually UltraA-Methapred Methylprednisolone Steroid Antiasthmatic, Corticosteroid Other than UltraAmethopterin Methotrexate Rheumatoid Arthritis DMARD, Immunosuppressant Other than UltraAminophylline Aminophylline Respiratory Bronchodilator Other than UltraAmiodarone Amiodarone Cardiac Antiarrhythmics Other than UltraAmitriptyline Amitriptyline Depression, Chronic Pain Antidepressant Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.49

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedAmlodipine Amlodipine Cardiac-Calcium Channel Blocker Antihypertensive Usually UltraAnaflex Salsalate Arthritis, Pain NSAID Other than UltraAnafranil Clomipramine Depression Antiobsessive Agent Other than UltraAnakinra Anakinra Rheumatoid Arthritis DMARD Other than UltraAnaprox Naproxen Arthritis, Pain NSAID Other than UltraAnaspaz Hyoscyamine Urinary, Gastrointestinal Antispasmodic, Anticholinergic Usually UltraAnastrazole Anastrazole Breast Cancer Antineoplastic Other than UltraAnexsia Hydrocodone/Acetaminophen Narcotic Pain Medication Opioid Analgesic Not InsurableAnsaid Flurbiprofen Arthritis NSAID, Antirheumatic Other than UltraAntabuse Alcoholism Not InsurableAntivert Meclizine Motion Sickness, Vertigo Antiemetics, Antihistamines Other than UltraApo-Flurbiprofen Flurbiprofen Arthritis NSAID, Antirheumatic Other than UltraApokyn Parkinson’s Anti Parkinson’s Not InsurableApo-Selegiline Selegiline Parkinson Antiparkinson Not InsurableApo-Verap Verapamil Cardiac-Calcium Channel Blocker Antihypertensive, Vascular Headaches Other than UltraApresoline Hydralazine Cardiac Antihypertensive Other than UltraAptivus Antiretroviral Not InsurableAranesp Injectable Darbepoetin Anemia of Chronic Renal Failure Anti-Anemic Not InsurableArava Leflunomide Rheumatoid Arthritis DMARD Other than UltraAredia Pamidronate Hypercalcemia, Paget’s Bone Resorption Inhibitor Other than UltraAricept Donepezil Memory Loss Anti-Alzheirmer Not InsurableArimedex Anastrazole Breast Cancer Antineoplastic Other than UltraAristocort Triamcinolone Steroid Antiasthmatic, Corticosteroid Other than UltraArmour Thyroid Thyroid Thyroid Preparations Hormone Usually UltraAromasin Exemestane Cancer Antineoplastic CallArranon Cancer Leukemia Not InsurableArtane Trihexyphenidyl Parkinson Antiparkinson Not InsurableArthropan Choline Salicylate Arthritis NSAID Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.50

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedArthrotec Diclofenac/Misoprostol Combo Arthritis NSAID with Antiulcer Agent Other than UltraArticulose Prednisolone Steroid Antiasthmatic, Corticosteroid Other than UltraAsacol Mesalamine Gastrointestinal-Ulcerative Colitis GI Antiinflammatory Other than UltraAscendin Amoxapine Depression Antidepressant Other than UltraAsmalix Theophylline Respiratory Bronchodilator Other than UltraAsparaginase Cancer Leukemia Not InsurableAsthmaHaler Mist Epinephrine Respiratory Vasopressors Other than UltraAstramorph Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableAtacand Candesartan Hypertension Antihypertensive Usually UltraAtamep Parkinson’s Anti Parkinson Not InsurableAtarax Hydroxyzine Anxiety, Itching, Sedation Antihistamine Usually UltraAtenolol Atenolol Cardiac-Beta Blocker Antianginal, Antihypertensive Usually UltraAtepryl Parkinson’s Anti Parkinson Not InsurableAtivan Lorazepam Anxiety Antianxiety, Sedative/Hypnotic Other than UltraAtolone Triamcinolone Steroid Antiasthmatic, Corticosteroid Other than UltraAtorvastatin Atorvastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraAtretol Carbamazepine Neuralgia Anticonvulsant Other than UltraAtripla HIV Antiretroviral Not InsurableAtrovent Ipratropium Respiratory Inhaler Bronchodilator Other than UltraAuranofin Gold Therapy Arthritis Other than UltraAvandia Rosiglitazone (NIDDM) Antidiabetic Other than UltraAvapro Irbesartan Hypertension Antihypertensive Usually UltraAvastin Cancer Cancer Other than UltraAventyl Nortriptyline Depression Antidepressant Other than UltraAvonex Multiple Sclerosis Multiple Sclerosis Not InsurableAxert Almotriptan Migraines Vascular Headache Suppressant Usually UltraAzathioprine Multiple Sclerosis Multiple Sclerosis Not InsurableAzathoprine Azathoprine Arthritis, Crohn’s Immunosuppressant Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.51

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedAzidothymidine Azidothymidine HIV Infection Antiretroviral Not InsurableAzmacort Triamcinolone Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraAzulfidine Sulfasalazine Rheumatoid Arthritis, Crohn’s DMARD, GI Antiinflammatory Other than UltraAZT HIV Antiretroviral Not InsurableBBaclofen Baclofen Lesions Antispasticity Agent Not InsurableBanflex Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraBeclovent Beclomethasone Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraBenazepril Benazepril Cardiac Antihypertensive Usually UltraBendopa Parkinson’s Anti Parkinson Not InsurableBentyl Dicyclomine Gastrointestinal-Irritable Bowel Antispasmodic Usually UltraBenztropine Benztropine Parkinson Antiparkinson Not InsurableBepridil Bepridil Cardiac-Calcium Channel Blocker Anti-Anginal Other than UltraBetamethasone Betamethasone Steroid Antiasthmatic, Corticosteroid Other than UltraBetapace Sotalol Cardiac-Beta Blocker Antiarrhythmic Other than UltraBetaseron Multiple Sclerosis Multiple Sclerosis Not InsurableBethanecol Bethanecol Urinary-Bladder Urinary Tract Stimulant Usually UltraBextra Valdecoxib Arthritis, Pain NSAID Other than UltraBiperiden Biperiden Parkinson Antiparkinson Not InsurableBlenoxane Cancer Cancer Not InsurableBlocodren Timolol Cardiac, Glaucoma, Migraines Headaches, Antiglaucoma Usually UltraBonine Meclizine Motion Sickness, Vertigo Antiemetics, Antihistamines Other than UltraBoniva Osteoporosis Osteoporosis Other than UltraBotox Cosmetic surgery, Dyskinesia Usually UltraBrethaire Terbutaline Respiratory Inhaler Bronchodilator Other than UltraBrevibloc Esmolol Cardiac-Beta Blocker Antiarrhythmic Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.52

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedBriacanyl Respiratory Respiratory Other than UltraBromocriptine Parkinson’s Parkinson’s Disease Not InsurableBrovana Respiratory Respiratory Other than UltraBudesonide Inhaler Budesonide Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraBulsufan Cancer Cancer Not InsurableBumex Bumetanide Edema Other than UltraBupropion Bupropion Depression, Smoking Cessation Anitdepressant, Smoking Deterrant Other than UltraBuSpar Buspirone Anxiety Antianxiety Other than UltraByetta Diabetes Anti diabetic Other than UltraCCafergot Ergotamine/Caffeine Combo Migraines Vascular Headache Suppressant Usually UltraCalan SR Verapamil Cardiac-Calcium Channel Blocker Antihypertensive, Vascular Headaches Other than UltraCalcitonin Calcitonin Osteoporosis, Paget’s Hypocalcemic Other than UltraCampral Alcoholism Alcoholism Not InsurableCapoten Captopril Cardiac Antihypertensive Usually UltraCapsaicin Capsaicin Pain Management, Topical Nonopioid Analgesics (Topical) Other than UltraCaptopril Captopril Cardiac Antihypertensive Usually UltraCarafate Sucralfate Gastrointestinal Antiulcer Agent Usually UltraCarbacot Methocarbamol Muscle Spasms Skeletal Muscle Relaxant Other than UltraCarbamazepine Carbamazepine Neuralgia Anticonvulsant Other than UltraCarbatrol Carbamazepine Neuralgia Anticonvulsant Other than UltraCarbex Selegiline Parkinson Antiparkinson Not InsurableCarbidopa Parkinson’s Parkinson’s Disease Not InsurableCardene Nicardipine Cardiac-Calcium Channel Blocker Antianginal, Antihpertensives Other than UltraCardizem Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraCardura Doxazosin Cardiac Antihypertensive Usually UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.53

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedCarisoprodol Carisoprodol Muscle Spasms Skeletal Muscle Relaxant Other than UltraCartiaXT Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraCasodex Cancer Antineoplastic Not InsurableCataflam Declofenac Arthritis NSAID Other than UltraCatapres Clonidine Cardiac Antihypertensive Usually UltraCee Nu Cancer Cancer Not InsurableCelebrex Celecoxib Arthritis NSAID, Antirheumatic Other than UltraCelestone Betamethasone Steroid Antiasthmatic, Corticosteroid Other than UltraCelexa Citalopram Depression Antidepressant Other than UltraCelontin Cerebral Artery Disease Not InsurableCephulac Lactulose Gastrointestinal-Constipation Laxative Usually UltraCerubidine Cancer Not InsurableCevimeline Cevimeline Sjogren’s Syndrome Cholinergic Other than UltraChantix Smoking Cessation Other than UltraChloral Hydrate Chloral Hydrate Sedative Sedative/Hyponotic Other than UltraChlorambucil Chlorambucil Cancer Antineoplastic, Immunosuppressant Not InsurableChlordiazepoxide Chlordiazepoxide Anxiety-Benzodiazepine Antianxiety, Sedative/Hypnotic Other than UltraChlorothiazide Chlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraChlorpromazine Chlorpromazine Psychoses Antipsychotics, Antiemetic Not InsurableChlorpropamide Diabetes Antidiabetes Other than UltraChlorthalidone Chlorthalidone Cardiac, Edema Antihypertensive, Diuretic Usually UltraCholestyramine Cholestyramine Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraCholine Salicylate Choline Salicylate Arthritis NSAID Other than UltraChronulac Lactulose Gastrointestinal-Constipation Laxative Usually UltraCilostazol Cilostazol Circulation Antiplatelet Agent Not InsurableCimetidine Cimetidine Gastrointestinal Antiulcer Agent Usually UltraCin-Quin Quinidine Sulfate Cardiac Antiarrythmics Other than UltraCisplatin Cancer Not InsurableFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.54

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedCladribine Leukemia, Multiple Sclerosis Anti neoplastic Not InsurableClarinex Desloratadine Allergies, Hives Antihistamine Usually UltraClinoril Sulindac Arthritis, Pain NSAID, Antirheumatic Other than UltraClonazepam Clonazepam Seizure Disorder Anticonvulsant Other than UltraClonidine Clonidine Cardiac Antihypertensive Usually UltraClorazil Depression Anti psychotic Not InsurableClozapine Clozapine Schizophrenia Antipsychotic Not InsurableCodeine Codeine Narcotic Pain Medication Opioid Analgesic CallCogentin Benztropine Parkinson Antiparkinson Not InsurableCognex Tacrine Memory Loss Anti-Alzheirmer Not InsurableColazal Balsalazide Gastrointestinal: Ulcerative Colitis GI Antiinflammatory Usually UltraColchicine Colchicine Gout Antigout Agent Usually UltraColesevelam Colesevelam Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraColestid Colestipol Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraCombipres Chlorthalidone/Clonidine Combo Cardiac Antihypertensive Usually UltraCombivent Combo Respiratory Inhaler Bronchodilator Other than UltraCompazine Prochlorperazine Psychoses Antiemetic, Antipsychotic Not InsurableComtan Entacapone Parkinson Antiparkinson Not InsurableConcerta Attention Deficit Disorder CNS Stimulant Usually UltraCopaxone Multiple Sclerosis immunomodultor Not InsurableCordrol Prednisone Steroid Antiasthmatic, Corticosteroid Other than UltraCoreg Carvedilol Cardiac- Beta Blocker Antihypertensive Usually UltraCorgard Nadolol Cardiac Antianginal, Antihypertensive Other than UltraCortef Hydrocortisone Steroid Antiasthmatic, Corticosteroid Other than UltraCortisone Cortisone Steroid Antiasthmatic, Corticosteroid Other than UltraCortone Cortisone Steroid Antiasthmatic, Corticosteroid Other than UltraCorvert Ibutilide Cardiac Antiarrhythmics Other than UltraCorzide Combo Cardiac Antianginal, Antihypertensive Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.55

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedCotolone Prednisolone Steroid Antiasthmatic, Corticosteroid Other than UltraCoumadin Warfarin Blood Thinner Anticoagulant Other than UltraCovera-HS Verapamil Cardiac-Calcium Channel Blocker Antihypertensive, Vascular Headaches Usually UltraCozaar Losartan Hypertension Antihypertensive Usually UltraCrixivan HIV Antiretroviral Not InsurableCromolyn Cromolyn Respiratory Inhaler/Nebulizer Allergy, Antiasthmatic Usually UltraCuprimine Penicillamine Rheumatoid Arthritis DMARD, Immunosuppressant Other than UltraCyclobenzaprine Cyclobenzaprine Muscle Spasms Skeletal Muscle Relaxant Other than UltraCyclophosphamide Cancer Cancer Not InsurableCycloserine Alzheimer’s Alzheimer's Disease Not InsurableCyclosporine Cyclosporine Arthritis, Ulcerative Colitis Immunosuppressant Other than UltraCylert Pemoline Stimulant, ADHD Cental Nervous System Stimulant Usually UltraCymbalta Depression Anti Psychotic Not InsurableCystospaz Hyoscyamine Urinary, Gastrointestinal Antispasmodic, Anticholinergic Usually UltraCytomel Liothyronine Thyroid Preparations Hormone Usually UltraCytotec Misoprostol Gastrointestinal-Prevent GI ulcers Antiulcer Agent Usually UltraCytoxan Cyclophosphamide Cancer, Rheumatoid Arthritis Immunosuppressant Not InsurableDDalalone Dexamethasone Steroid Antiasthmatic, Corticosteroid Other than UltraDalmane Flurazepam Sleeping Pill Sedative/Hypnotic Usually UltraDantrium Multiple Sclerosis Multiple Sclerosis Not InsurableDantrolene Cerebral Palsy Anti spasmodic Not InsurableDarvocet-N Propoxyphene/Acetaminophen Narcotic Pain Medication Opioid Analgesic CallDarvon Propoxyphene Narcotic Pain Medication Opioid Analgesic CallDaypro Oxaprozin Arthritis, Pain NSAID, Antirheumatic Other than UltraDecadron Dexamethasone Steroid Antiasthmatic, Corticosteroid Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.56

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedDeclofenac Declofenac Arthritis NSAID Other than UltraDelavirdine Delavirdine HIV Infection Antiretroviral Not InsurableDemadex Torsemide Edema Diuretic Other than UltraDemerol Meperidine Narcotic Pain Medication Opioid Analgesic CallDepakene Valproic Acid Seizure Disorder Anticonvulsant, Vascular Headaches Other than UltraDepakote Divalproex Sodium Seizure Disorder Anticonvulsant, Vascular Headaches Other than UltraDepoMedrol Methylprednisolone Steroid Antiasthmatic, Corticosteroid Other than UltraDeponit Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraDepo Provera Cancer Cancer Not InsurableDeprynel Dementia, Parkinson’s Anti Parkinson’s Not InsurableDes Cancer Cancer Not InsurableDesipramine Desipramine Depression Antidepressant Other than UltraDesyrel Trazodone Depression Antidepressant Other than UltraDetrol Tolterodine Urinary-Bladder Anticholinergic Usually UltraDexedrine Dextroamphetamine Stimulant, ADHD, Narcolepsy Cental Nervous System Stimulant Other than UltraDiaBeta Glyburide (NIDDM) Antidiabetic Other than UltraDiabinese Diabetes NDDM Antidiabetes Other than UltraDiazepam Diazepam Relaxant Anticonvulsant Other than UltraDidronel Etidronate Osteoporosis, Paget’s Hypocalcemic Other than UltraDiflucan Fluconazole Fungal Infections Antifungal Usually UltraDigoxin Digoxin Cardiac Antharrhythmic Other than UltraDihydroergotamine Dihydroergotamine Migraines Vascular Headache Suppressant Usually UltraDilacor XR Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraDilantin Phenytoin Seizure Disorder Antiarrythmic, Anticonvulsant Other than UltraDilatrate-SR Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraDiltiazem Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraDiovan Valsartan Hypertension Antihpertensive Usually UltraDiphenylhydantoin Phenytoin Seizure Disorder Antiarrythmic, Anticonvulsant Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.57

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedDipyrimadole Dipyrimadole Circulatory Antiplatelet Agent Not InsurableDisalcid Salsalate Arthritis, Pain NSAID Other than UltraDisopyramide Disopyramide Cardiac Antiarrhythmic Other than UltraDitropan Oxybutynin Urinary-Bladder Anticholinergic Usually UltraDiuril Chlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraDivalproex Sodium Divalproex Sodium Seizure Disorder Anticonvulsant, Vascular Headaches Other than UltraDizac Diazepam Relaxant Anticonvulsant Other than UltraDocetaxel Cancer Cancer Not InsurableDolophine Methadone Narcotic Pain Medication Opioid Analgesic Not InsurableDolorac Capsaicin Pain Management, Topical Nonopioid Analgesics (Topical) Other than UltraDonepezil Donepezil Memory Loss Anti-Alzheirmer Not InsurableDonnamar Hyoscyamine Urinary, Gastrointestinal Antispasmodic, Anticholinergic Usually UltraDonnatal ne/Scopolamine Combo Gastrointestinal Gastrointestinal Usually UltraDopar Levodopa Parkinson’s Antiparkinson Not InsurableDoxazosin Doxazosin Cardiac Antihypertensive Usually UltraDoxepin Doxepin Depression Antianxiety, Antidepressant Other than UltraDPH Phenytoin Seizure Disorder Antiarrythmic, Anticonvulsant Other than UltraDroxia Hydroxyurea Cancer Antineoplastic Not InsurableDuphalac Lactulose Gastrointestinal-Constipation Laxative Usually UltraDuraclon Clonidine Cardiac Antihypertensive Usually UltraDuragesic Fentanyl Transdermal Opioid Analgesic Not InsurableDuralone Methylprednisolone Steroid Antiasthmatic, Corticosteroid Other than UltraDuramorph Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableDuvoid Bethanecol Urinary-Bladder Urinary Tract Stimulant Usually UltraDyazide Hydrochlorothiazide/Triamterene Cardiac Antihypertensive Usually UltraDynaCirc Isradipine Cardiac-Calcium Channel Blocker Antianginal, Antihypertensive Other than UltraDymelor Diabetes Anti diabetic Other than UltraDyrenium Triamterene Edema Diuretic, Potassium-Sparing Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.58

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedEdur-Acin Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraEffexor Venlafaxine Depression Antianxiety, Antidepressant Other than UltraElavil Amitriptyline Depression, Chronic Pain Antidepressant Other than UltraEldepryl Selegiline Parkinson‚Äôs Antiparkinson Not InsurableElixophyllin Theophylline Respiratory Bronchodilator Other than UltraEmcyt Cancer Antineoplastic Not InsurableEmtriva HIV Anteretroviral Not InsurableEnalapril/Enalaprilat Enalapril/Enalaprilat Cardiac Antihypertensive Usually UltraEnbrel Etanercept Rheumatoid Arthritis DMARD Other than UltraEndep Amitriptyline Depression, Chronic Pain Antidepressant Other than UltraEndocodone Oxycodone Narcotic Pain Medication Opioid Analgesic Not InsurableEntacapone Entacapone Parkinson’s Antiparkinson Not InsurableEntocort EC Budesonide Steroid Antiasthmatic, Corticosteroid Other than UltraEnulose Lactulose Gastrointestinal-Constipation Laxative Usually UltraEpitol Carbamazepine Neuralgia Anticonvulsant Other than UltraEpivir HIV Antiretroviral Not InsurableEpoetin Epoetin Anemia of Chronic Renal Failure Anti-Anemic Not InsurableEptifibatide Eptifibatide Cardiac Antiplatelet Agemt Not InsurableErgotamine Ergotamine Migraines Vascular Headache Suppressant Usually UltraErgotstat Ergotamine Migraines Vascular Headache Suppressant Usually UltraErythropoietin-Injectable Epoetin Anemia of Chronic Renal Failure Anti-Anemic Not InsurableEsidrex Hydrochlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraEskalith Lithium Manic-Depression Antimanic Not InsurableEsmolol Esmolol Cardiac-Beta Blocker Antiarrhythmic Other than UltraEsomeprazole Esomeprazole Gastrointestinal Aniulcer Agent Usually UltraEFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.59

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedEstradiol Estradiol Estrogen Replacement Therapy Hormone Usually UltraEtanercept Etanercept Rheumatoid Arthritis DMARD Other than UltraEthmozine Moricizine Cardiac Antiarrhythmic Other than UltraEtidronate Etidronate Osteoporosis, Paget’s Hypocalcemic Other than UltraEulexin Flutamide Cancer Antineoplastic Not InsurableEvalose Lactulose Gastrointestinal-Constipation Laxative Usually UltraEvista Raloxifene Osteoporosis Bone Resorption Inhibitors Other than UltraEvoxac Cevimeline Sjogren’s Syndrome Cholinergic Other than UltraExelon Rivastigmine Alzheimers/Memory Anti-Alzheirmer Not InsurableFFeldene Piroxicam Arthritis, Pain NSAID, Antirheumatic Other than UltraFenofibrate Fenofibrate Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraFentanyl Fentanyl Narcotic Pain Medication Opioid Analgesic Not InsurableFeosol Ferrous Sulfate Iron-Deficiency Anemia Anti-Anemic Other than UltraFergon Ferrous Gluconate Iron-Deficiency Anemia Anti-Anemic Other than UltraFerrous Gluconate Ferrous Gluconate Iron-Deficiency Anemia Anti-Anemic Other than UltraFerrous Sulfate Ferrous Sulfate Iron-Deficiency Anemia Anti-Anemic Other than UltraFioricet Combo Narcotic Pain Medication Barbituates CallFiorinal Butalbital/Aspirin/Caffeine Combo Narcotic Pain Medication CallFlagyl Metronidazole Infections Agent Usually UltraFlecainide Flecainide Cardiac Antiarrhythmic Other than UltraFlexeril Cyclobenzaprine Muscle Spasms Skeletal Muscle Relaxant Other than UltraFlexon Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraFlovent Fluticasone Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraFluconazole Fluconazole Fungal Infections Antifungal Usually UltraFlunisolide Flunisolide Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.60

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedFluoxetine Fluoxetine Depression Antidepressant Other than UltraFluphenazine Fluphenazine Psychoses Antipsychotic Not InsurableFlurazepam Flurazepam Sleeping Pill Sedative/Hypnotic Usually UltraFlurbiprofen Flurbiprofen Arthritis NSAID, Antirheumatic Other than UltraFlutamide Flutamide Cancer Antineoplastic Not InsurableFluticasone Inhaler Fluticasone Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraFluvastatin Fluvastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraFluvoxamine Fluvoxamine Depression Antidepressant Other than UltraFolate Folic Acid Anemia, Vitamin Anti-Anemic Usually UltraFolex Methotrexate Rheumatoid Arthritis DMARD, Immunosuppressant Other than UltraFolic Acid Folic Acid Anemia, Vitamin Anti-Anemic Usually UltraFolvite Folic Acid Anemia, Vitamin Anti-Anemic Usually UltraFondaparinux Fondaparinux DVT Prophylaxis Anticoagulant Other than UltraFormoterol Formoterol Respiratory Inhaler Bronchodilator Other than UltraForteo Osteoporosis Bone Resorption inhibitors Other than UltraFosamax Alendronate Osteoporosis Bone Resorption Inhibitors Other than UltraFrovatriptan Frovatriptan Migraines Vascular Headache Suppressant Usually UltraFurosemide Furosemide Edema Diuretic Usually UltraFuzeon HIV Anteretroviral Not InsurableFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.61

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedGalantamine Galantamine Alzheimers/Memory Anti Alzheimer's Not InsurableGemfibrozil Gemfibrozil Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraGen-Selegiline Selegiline Parkinson’s Antiparkinson Not InsurableGeodon Ziprasidone Schizophrenia Antipsychotic Not InsurableGlatiramir Acetate Multiple Sclerosis Immunomodulator-MS Not InsurableGleevic Leukemia Not InsurableGlimepiride Glimepiride (NIDDM) Antidiabetic Other than UltraGlipizide Glipizide (NIDDM) Antidiabetic Other than UltraGlucophage Metformin (NIDDM) Antidiabetic Other than UltraGlucotrol Glipizide (NIDDM) Antidiabetic Other than UltraGlucovance Glyburide/Metformin Combo (NIDDM) Antidiabetic Other than UltraGlyburide Glyburide (NIDDM) Antidiabetic Other than UltraGlycopyrrolate Glycopyrrolate Gastrointestinal-Peptic Ulcer Disease Antispasmodic, Anticholinergic Usually UltraGlynase Glyburide (NIDDM) Antidiabetic Other than UltraGlyset Miglitol (NIDDM) Antidiabetic Other than UltraHHaloperidol Haloperidol Psychoses Antipsychotic Not InsurableHCTZ Hydrochlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraHeparin Injectable Heparin Injectable Blood Thinner Anticoagulant Not InsurableHeptalac Lactulose Gastrointestinal-Constipation Laxative Usually UltraHexadrol Dexamethasone Steroid Antiasthmatic, Corticosteroid Other than UltraHexalen Cancer Antineoplastic Not InsurableHivid HIV Anteretroviral Not InsurableHydormorphone Hydormorphone Narcotic Pain Medication Opioid Analgesic Not InsurableGFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.62

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedHydralazine Hydralazine Cardiac Antihypertensive Usually UltraHydrea Hydroxyurea Cancer Antineoplastic Not InsurableHydrocet Combo Narcotic Pain Medication Opioid Analgesic Not InsurableHydrochlorothiazide Hydrochlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraHydrocodone Hydrocodone Narcotic pain medication Opioid Analgesic Not InsurableHydrocortisone Hydrocortisone Steroid Antiasthmatic, Corticosteroid Other than UltraHydroDiuril Hydrochlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraHydropres Combo Cardiac Antihypertensive Usually UltraHydroxyurea Hydroxyurea Cancer Antineoplastic Not InsurableHydroxyzine Hydroxyzine Anxiety, Itching, Sedation Antihistamine Usually UltraHygroton Chlorthalidone Cardiac, Edema Antihypertensive, Diuretic Usually UltraHylorel Guanadrel Cardiac Antihypertensive Usually UltraHyoscyamine Hyoscyamine Urinary, Gastrointestinal Antispasmodic, Anticholinergic Usually UltraHytrin Terazosin Cardiac, Prostate Enlargement Antihypertensive, BPH Usually UltraHyzine-50 Hydroxyzine Anxiety, Itching, Sedation Antihistamine Usually UltraIIbuprofen Ibuprofen Arthritis NSAID Other than UltraIbutilide Ibutilide Cardiac Antiarrhythmics Other than UltraImdur Isosorbide Mononitrate Cardiac-Nitrate Anti-Anginal Other than UltraImipramine Imipramine Depression Antidepressant Other than UltraImitrex Sumatriptan Migraines Vascular Headache Suppressant Usually UltraImodium Loperamide Diarrhea Antidiarrheal Usually UltraImpril Imipramine Depression Antidepressant Other than UltraImuran Azathoprine Arthritis, Crohn’s Immunosuppressant Not InsurableIndapamide Indapamide Cardiac, Edema Antihypertensive, Diuretic Other than UltraInderal Propanolol Cardiac-Beta Blocker, Migraines Antihypertensive, Vascular Headaches Usually UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.63

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedInderide Combo Cardiac Antihypertensive Usually UltraIndocin Indomethacin Arthritis, Pain NSAID, Antirheumatic Other than UltraInfumorph Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableInsulin, Humulin 50/50 NPH/Regular Insulin Mixtures Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Humulin 70/30 NPH/Regular Insulin Mixtures Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Humulin L Lente Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Humulin N NPH Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Humulin U Ultralente Insulin, Extended Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Humulin-R Regular Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Iletin II R Regular Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Lente Iletin II Lente Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Novolin 70/30 NPH/Regular Insulin Mixtures Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Novolin L Lente Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Novolin N NPH Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Novolin R Regular Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Novolin U Insulin, Extended Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, NPH Iletin II NPH Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Ultralente U Insulin, Extended Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin, Velosulin BR Regular Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin; Humalog Insulin Lispro Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin; Humalog 50/50 Insulin Lispro/Protamine Mixture Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin; Humalog 75/25 Insulin Lispro/Protamine Mixture Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin; Novolog Insulin Aspart Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableInsulin; Lantus Insulin Glargine Diabetes, Insulin-Dependent (IDDM) Antidiabetic Not InsurableIntal Cromolyn Respiratory Inhaler/Nebulizer Allergy, Antiasthmatic Usually UltraInterferon Cancer/ Multiple Sclerosis Antineoplastic Not InsurableInvirase HIV Anteretroviral Not InsurableIrbesartan Irbesartan Hypertension Antihypertensive Usually UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.64

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedIso-Bid Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraIsonate Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraIsorbid Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraIsordil Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraIsosorbide Dinitrate Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraIsotrate ER Isosorbide Mononitrate Cardiac-Nitrate Anti-Anginal Other than UltraJJanuvia Diabetes Anti diabetic Other than UltraIsradipine Isradipine Cardiac-Calcium Channel Blocker Antianginal, Antihypertensive Other than UltraKKabolin-Injectable Nandrolone Decanoate Anemia of Renal Failure Anti-anemic Not InsurableKadian Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableK-Dur Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraKaletra HIV Anteretroviral Not InsurableKemadrin Parkinson’s Disease Anti Parkinson Not InsurableKenacort Triamcinolone Steroid Antiasthmatic, Corticosteroid Other than UltraKerlone Betaxolol Cardiac- Beta Blocker Antihypertensive Usually UltraKetoprofen Ketoprofen Arthritis, Pain NSAID Other than UltraKlonopin Clonazepam Seizure Disorder Anticonvulsant Other than UltraK-Lor Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraKlor-Con Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraKlorvess Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.65

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedK-Norm Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraKritalose Lactulose Gastrointestinal-Constipation Laxative Usually UltraK-Tab Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraLLabetalol Labetalol Cardiac- Beta Blocker Antianginal, Antihypertensive Other than UltraLactulose Lactulose Gastrointestinal-Constipation Laxative Usually UltraLamictal Lamotrigine Seizure Disorder Anticonvulsant Other than UltraLanophyllin Theophylline Respiratory Bronchodilator Other than UltraLanoxicaps Digoxin Cardiac Antharrhythmic Other than UltraLanoxin Digoxin Cardiac Antharrhythmic Other than UltraLanzac Depression Anti Psychotic Not InsurableLargactil Chlorpromazine Psychoses Antipsychotics, Antiemetic Not InsurableLarodopa Levodopa Parkinson’s Antiparkinson Not InsurableLasix Furosemide Edema Diuretic Usually UltraL-Dopa Levodopa Parkinson’s Antiparkinson Not InsurableLescol Fluvastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraLeucovorin Cancer Antineoplastic Not InsurableLeukeran Chlorambucil Cancer Antneoplastic, Immunosuppressant Not InsurableLevalbuterol Levalbuterol Respiratory Inhaler Bronchodilator Other than UltraLevetiracetam Levetiracetam Seizure Disorder Anticonvulsant Other than UltraLevodopa Levodopa Parkinson’s Antiparkinson Not InsurableLevothroid Levothyroxine Thyroid Preparations Hormone Usually UltraLevothyroxine Levothyroxine Thyroid Preparations Hormone Usually UltraLevoxyl Levothyroxine Thyroid Preparations Hormone Usually UltraLevsin Hyoscyamine Urinary, Gastrointestinal Antispasmodic, Anticholinergic Usually UltraLexapro Depression Antidepressant Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.66

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedeLexiva HIV Not InsurableLibrium Chlordiazepoxide Anxiety-Benzodiazepine Antianxiety, Sedative/Hypnotic Usually UltraLimbitrol Combo Anxiety, Depression Skeletal Muscle Relaxant Other than UltraLioresal Baclofen Lesions Antispasticity Agent Not InsurableLiotrix Liotrix Thyroid Preparations Hormone Usually UltraLipitor Atorvastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraLisinopril Lisinopril Cardiac Antihypertensive Usually UltraLispro Diabetes Anti diabetic Other than UltraLithium Lithium Manic-Depression Antimanic Not InsurableLoCHOLEST Cholestyramine Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraLodine Etodolac Arthritis, Pain Antirheumatic, Nonopiod Analgesic Other than UltraLomotil Diphenoxylate/Atropine Diarrhea Antidiarrheal Usually UltraLoniten Minoxidil Cardiac Antihypertensive Usually UltraLonox Diphenoxylate/Atropine Diarrhea Antidiarrheal Usually UltraLoperamide Loperamide Diarrhea Antidiarrheal Usually UltraLopid Gemfibrozil Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraLopressor Metoprolol Cardiac Antianginal, Antihypertensive Usually UltraLopurin Allopurinol Gout Antigout Agent Usually UltraLorazepam Lorazepam Anxiety Antianxiety, Sedative/Hypnotic Other than UltraLorcet Hydrocodone/Acetaminophen Narcotic Pain Medication Opioid Analgesic Not InsurableLortab Narcotic Analgesic CallLosartan Losartan Hypertension Antihypertensive Usually UltraLotensin Benazepril Cardiac Antihypertensive Usually UltraLotrel Benazepril/Amlodipine Combo Cardiac Antihypertensive Usually UltraLovastatin Lovastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraLozol Indapamide Cardiac, Edema Antihypertensive, Diuretic Usually UltralFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.67

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedLupron Cancer Antineoplastic Not InsurableLuvox Fluvoxamine Depression Antidepressant Other than UltraLyrica Epilepsy Anti seizure/nerve pain Other than UltraMMarthritic Salsalate Arthritis, Pain NSAID Other than UltraMaxair Inhaler Pirbuterol Respiratory Inhaler Bronchodilator Other than UltraMaxalt Rizatriptan Migraines Vascular Headache Suppressant Usually UltraMeclizine Meclizine Motion Sickness, Vertigo Antiemetics, Antihistamines Other than UltraMedrol Methylprednisolone Steroid Antiasthmatic, Corticosteroid Other than UltraMedroxyprogesterone Medroxyprogesterone Hormone Replacement Hormone Usually UltraMegace Cancer Antineoplastic Not InsurableMegestrol Cancer Antineoplastic Not InsurableMellaril Thioridazine Schizophrenia Antipsychotic Not InsurableMelphalan Cancer Antineoplastic Not InsurableMeperidine Meperidine Narcotic Pain Medication Opioid Analgesic Not InsurableMestinon Myasthenia Gravis Not InsurableMetformin Metformin (NIDDM) Antidiabetic Other than UltraMethadone Methadone Narcotic Pain Medication Opioid Analgesic Not InsurableMethocarbamol Methocarbamol Muscle Spasms Skeletal Muscle Relaxant Other than UltraMethotrexate Methotrexate Rheumatoid Arthritis DMARD, Immunosuppressant Other than UltraMethyldopa Methyldopa Cardiac Antihypertensive Usually UltraMevacor Lovastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraMiacalcin Injection Calcitonin Osteoporosis, Paget’s Hypocalcemic Other than UltraMicardis Telmisartan Hypertension Antihypertensive Usually UltraMicro-K Potassium Supplement Potassium Supplement Potassium Replacement Usually UltraMicronase Glyburide (NIDDM) Antidiabetic Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.68

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedMiglitol Miglitol (NIDDM) Antidiabetic Other than UltraMigranal Dihydroergotamine Migraines Vascular Headache Suppressant Usually UltraMilontin Epilepsy Anticonvulsant Other than UltraMinipress Prazosin Cardiac, Prostate Enlargement Antihypertensive, BPH Usually UltraMinitran Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraMinoxidil Minoxidil Cardiac Antihypertensive Usually UltraMirapex Pramipexole Parkinsons Antiparkinson Not InsurableMobic Arthritis NSAID Other than UltraMolindone Depression Antipsychotic Not InsurableMonoket Isosorbide Mononitrate Cardiac-Nitrate Anti-Anginal Other than UltraMonopril Fosinopril Cardiac Antihypertensive Usually UltraMorphine Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableMotofen Defenoxin/Atropine Diarrhea Antidiarrheal Usually UltraMotrin Ibuprofen Arthritis, Pain NSAID Usually UltraMS Contin Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableMutamycin Cancer Not InsurableMyleran Cancer Not InsurableMyotrol Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraMysoline Primadone Seizure Disorder Other than UltraNNabumetone Nabumetone Arthritis, Pain NSAID, Antirheumatic Other than UltraNalfon Arthritis Anti arthritic Other than UltraNaltrexone Alcoholism Antirheumatic Not InsurableNamenda Alzheimer’s Anti dementia Not InsurableNandrolone Decanoate Nandrolone Decanoate Anemia of Renal Failure Anti-anemic Not InsurableNaproxen Naproxen Arthritis, Pain NSAID Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.69

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedNaratriptan Naratriptan Migraines Vascular Headache Suppressant Usually UltraNardil Phenelzine Depression Antidepressant-MAO Inibitors Other than UltraNateglinide Nateglinide (NIDDM) Antidiabetic Other than UltraNavane Depression Antipsychotic Not InsurableNavelbine Cancer Cancer Not InsurableNedocromil Nedocromil Respiratory Antiasthmatic, Allergies Usually UltraNefazodone Nefazodone Depression Antidepressant Other than UltraNeoral Cyclosporine Arthritis, Ulcerative Colitis Immunosuppressant Not InsurableNeosar Cyclophosphamide Cancer, Rheumatoid Arthritis Immunosuppressant Not InsurableNeupogen Cancer Not InsurableNeurontin Gabapentin Migraines Anticonvulsant, Analgesic Adjunct Other than UltraNexium Esomeprazole Gastrointestinal Aniulcer Agent Usually UltraNia-Bid Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNiac Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNiacin Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNiacor Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNiaspan Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNicobid Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNicolar Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNicotinex Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNicotinic Acid Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraNitoglycerin Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitrek Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitro-Bid Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitrocot Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitro-Dur Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitroglynE-R Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitrol Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.70

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedNitro-par Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitropress Nitroprusside Cardiac Antihypertensive Usually UltraNitroprusside Nitroprusside Cardiac Antihypertensive Usually UltraNitrostat Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNitro-Time Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraNizatidine Nizatidine Gastrointestinal Antiulcer Agent Usually UltraNizoral Antifungal Usually UltraNolvadex Breast Cancer Other than UltraNorflex Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraNorfranil Imipramine Depression Antidepressant Other than UltraNorpace Disopyramide Cardiac Antiarrhythmic Other than UltraNorpramin Desipramine Depression Antidepressant Other than UltraNortriptyline Depression Other than UltraNorvasc Amlodipine Cardiac-Calcium Channel Blocker Antihypertensive Usually UltraNovo-Flurprofen Flurbiprofen Arthritis NSAID, Antirheumatic Other than UltraNovoHydrazide Hydrochlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraNPH Insulin NPH Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Other than UltraNubain Nalbuphine Narcotic Pain Medication Opioid Analgesic Not InsurableNu-Diltiaz Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraNuLev Hyoscyamine Urinary, Gastrointestinal Antispasmodic, Anticholinergic Usually UltraNuprin Ibuprofen Arthritis, Pain NSAID Other than UltraNu-Selegiline Selegiline Parkinson’s Antiparkinson Not InsurableFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.71

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedOctamide Metoclopramide Gastrointestinal Antiemetic Usually UltraOlanzapine Olanzapine Schizophrenia, Anroexia Nervosa Antipsychotic Not InsurableOmeprazole Omeprazole Gastrointestinal Aniulcer Agent Usually UltraOrap Depression Antipsychotic Not InsurableOretic Hydrochlorothiazide Cardiac, Edema Antihypertensive, Diuretic Usually UltraOrfro Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraOrinase Diabetes Anti diabetic Other than UltraOrphenadrine Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraOrphenate Orphenadrine Muscle Spasms Skeletal Muscle Relaxant Other than UltraOrudis Ketoprofen Arthritis, Pain NSAID Other than UltraOxaprozin Oxaprozin Arthritis, Pain NSAID, Antirheumatic Other than UltraOxazepam Oxazepam Anxiety Antianxiety, Sedative/Hypnotic Other than UltraOxcarbazepine Oxcarbazepine Seizure Disorder Anticonvulsant Other than UltraOxybutynin Continence Other than UltraOxycodone Oxycodone Narcotic Pain Medication Opioid Analgesic Not InsurableOxycontin Oxycodone Narcotic Pain Medication Opioid Analgesic Not InsurablePPacerone Amiodarone Cardiac Antiarrhythmics Other than UltraPamelor Nortriptyline Depression Antidepressant Other than UltraPamidronate Pamidronate Hypercalcemia, Paget’s Bone Resorption Inhibitor Other than UltraParafon Forte Chlorzoxazone Muscle Spasms Skeletal Muscle Relaxant Other than UltraParlodel Bromocriptine Fertility Antiparkinson Not InsurableParnate Tranylcypromine Depression Antidepressant-MAO Inibitors Other than UltraParoxetine Paroxetine Anxiety, Deprssion Antianxiety, Antidepressant Other than UltraOFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.72

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedPaxil Paroxetine Anxiety, Deprssion Antianxiety, Antidepressant Other than UltraPeganone Seizure Disorder Anti seizure Other than UltraPemoline Pemoline Stimulant, ADHD Cental Nervous System Stimulant Usually UltraPentamidine AIDS Antiretroviral Not InsurablePentasa Mesalamine Gastrointestinal-Ulcerative Colitis GI Antiinflammatory Other than UltraPentazine Promethazine Allergies, Sedation, Nausea/Vomiting Sedative/Hypnotic Usually UltraPepcid Tamotidine Gastrointestinal Aniulcer Agent Usually UltraPercocet Oxycodone/Acetaminophen Narcotic Pain Medication Opioid Analgesic CallPercodan Oxycodone/Aspirin Narcotic Pain Medication Opioid Analgesic CallPergolide Pergolide Parkinson’s Antiparkinson Not InsurablePerindopril Perindopril Cardiac Antihypertensive Usually UltraPeritrate Cardiac Anti anginal Other than UltraPermax Pergolide Parkinson’s Antiparkinson Not InsurablePermitil Depression Antipsychotic Not InsurablePexeva Depression Antipsychotic Not InsurablePhenelzine Phenelzine Depression Antidepressant-MAO Inibitors Other than UltraPhenergan Promethazine Allergies, Sedation, Nausea/Vomiting Sedative/Hypnotic Usually UltraPhenytoin Phenytoin Seizure Disorder Antiarrythmic, Anticonvulsant Other than UltraPhyllocontin Aminophylline Respiratory Bronchodilator Other than UltraPilocarpine Glaucoma Usually UltraPimecrolimus Pimecrolimus Dermatitis Topical Immunosuppressant Usually UltraPindolol Visken Cardiac- Beta Blocker Antihypertensive Usually UltraPioglitazone Pioglitazone (NIDDM) Antidiabetic Other than UltraPirbuterol Pirbuterol Respiratory Inhaler Bronchodilator Other than UltraPlaquenil Hydroxychloroquine Rhematoid Arthritis, SLE DMARD Other than UltraPlatinol Cancer Not InsurablePlavix Anticoagulant Other than UltraPlendil Felodipine Cardiac-Calcium Channel Blocker Antianginal, Antihypertensive Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.73

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedPortlac Lactulose Gastrointestinal-Constipation Laxative Usually UltraPramipexole Pramipexole Parkinsons Antiparkinson Not InsurablePrandin Repaglinide (NIDDM) Antidiabetic Other than UltraPravastatin Pravastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraPrazosin Prazosin Cardiac, Prostate Enlargement Antihypertensive, BPH Usually UltraPrecose Acarbose (NIDDM) Antidiabetic Other than UltraPrednisone Prednisone Steroid Antiasthmatic, Corticosteroid Other than UltraPrevacid Lansoprazole Gastrointestinal- Ulcer Disease Aniulcer Agent Usually UltraPrevalite Cholestyramine Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraPrezista HIV Antiretroviral Not InsurablePrilosec Omeprazole Gastrointestinal Aniulcer Agent Usually UltraPrinivil Lisinopril Cardiac Antihypertensive Usually UltraProbenecid Gout Usually UltraProcanbid Procainamide Cardiac Antiarrhythmics Other than UltraProcardia Nifedipine Cardiac-Calcium Channel Blocker Antianginal, Antihpertensives Usually UltraProcrit Epoetin Anemia of Chronic Renal Failure Anti-anemic Not InsurablePrograf Tacrolimus Diseases Immunosuppressant Not InsurableProlixin Fluphenazine Psychoses Antipsychotic Not InsurablePronestyl Procainamide Cardiac Antiarrhythmics Other than UltraProstigmin Myasthenia Gravis Not InsurableProtonix Pantoprazole Gastrointestinal Aniulcer Agent Usually UltraProvachol Pravastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraProventil Albuterol Respiratory Bronchodilator Other than UltraProvigil Narcolepsy Other than UltraProzac Fluoxetine Depression Antidepressant Other than UltraPulmicort Budesonide Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraPurinethol /MP6 Cancer Not InsurablePyridium Urinary-Bladder Anti bladder spasm Usually UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.74

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedQuestran Cholestyramine Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraQuetiapine Quetiapine Schizophrenia Antipsychotic Not InsurableQuibron-T Theophylline Respiratory Bronchodilator Other than UltraQuinalan Quinidine Gluconate Cardiac Antiarrythmics Other than UltraQuinidine Quinidine Sulfate Cardiac Antiarrythmics Other than UltraQuinidine Gluconate Quinidine Gluconate Cardiac Antiarrythmics Other than UltraQuinidine Sulfate Quinidine Sulfate Cardiac Antiarrythmics Other than UltraRRaloxifene Raloxifene Osteoporosis Bone Resorption Inhibitors Other than UltraRamipril Ramipril Cardiac Antihypertensive Usually UltraRanexa Cardiac Antianginal Other than UltraRanitidine Ranitidine Gastrointestinal Antiulcer Agent Usually UltraRebetron Hepatitis C Heptitis agent Not InsurableReglan Metoclopramide Gastrointestinal Antiemetic Usually UltraRegular Insulin Regular Insulin Diabetes, Insulin-Dependent (IDDM) Antidiabetic Other than UltraRelafen Nabumetone Arthritis, Pain NSAID, Antirheumatic Other than UltraRelaxazone Chlorzoxazone Muscle Spasms Skeletal Muscle Relaxant Other than UltraRemeron Mirtazapine Depression Antidepressant Other than UltraRemicade Infliximab Rheumatoid Arthritis, Crohn’s DMARD, GI Antiinflammatory Other than UltraReminyl Galantamine Alzheimers/Memory Anti-Alzheirmer Not InsurableRemular Chlorzoxazone Muscle Spasms Skeletal Muscle Relaxant Other than UltraRepaglinide Repaglinide (NIDDM) Antidiabetic Other than UltraRequip Ropinirole Parkinsons Antiparkinson Not InsurableRescriptor Delavirdine HIV Infection Antiretroviral Not InsurableQFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.75

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedReserpine Cardiac Other than UltraRespbid Theophylline Respiratory Bronchodilator Other than UltraResperidone Resperidone Psychotic Disorders Antipsychotic Not InsurableRestoril Sleeping Pill Usually UltraRetrovir Azidothymidine HIV Infection Antiretroviral Not InsurableRezulin Diabetes Other than UltraRheumatrex Methotrexate Rheumatoid Arthritis DMARD, Immunosuppressant Other than UltraRidaura (Gold) Arthritis Not InsurableRisperdal Risperidone Psychotic Disorders Antipsychotic Not InsurableRisperidone Risperidone Psychotic Disorders Antipsychotic Not InsurableRitalin Stimulant Usually UltraRituxin Cancer Not InsurableRivastigmine Rivastigmine Alzheimers/Memory Anti-Alzheirmer Not InsurableRizatriptan Rizatriptan Migraines Vascular Headache Suppressant Usually UltraRobaxin Methocarbamol Muscle Spasms Skeletal Muscle Relaxant Other than UltraRofecoxib Rofecoxib Arthritis NSAID Other than UltraRoferon Cancer Not InsurableRopinirole Ropinirole Parkinsons Antiparkinson Not InsurableRosiglitazone Rosiglitazone (NIDDM) Antidiabetic Other than UltraRowasa Mesalamine Gastrointestinal-Ulcerative Colitis GI Antiinflammatory Usually UltraRoxanol Morphine Narcotic Pain Medication Opioid Analgesic Not InsurableRoxicet Oxycodone/Acetaminophen Narcotic Pain Medication Opioid Analgesic Not InsurableRoxicodone Oxycodone Narcotic Pain Medication Opioid Analgesic Not InsurableRoxiprin Oxycodone/Aspirin Narcotic Pain Medication Opioid Analgesic Not InsurableRubex Doxorubicin Hydrochloride Cancer Antineoplastic Not InsurableRythmodan Disopyramide Cardiac Antiarrhythmic Other than UltraRythmol Propafenone Cardiac Antiarrhythmic Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.76

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedSalbutamol Albuterol Respiratory Bronchodilator Other than UltraSalflex Salsalate Arthritis, Pain NSAID Other than UltraSalgesic Salsalate Arthritis, Pain NSAID Other than UltraSalmeterol Salmeterol Respiratory Inhaler Bronchodilator Other than UltraSandimmune Cyclosporine Arthritis, Ulcerative Colitis Immunosuppressant Not InsurableSaquinavir HIV Antiretroviral Not InsurableSarafem Fluoxetine Depression Antidepressant Other than UltraScopalamine Scopalamine Motion Sickness (Transdermal) Anitemetic Usually UltraSD-Deprenyl Selegiline Parkinson’s Antiparkinson Not InsurableSectral Acebutolol Cardiac-Beta Blocker Antiarrhythmic, Antihypertensive Other than UltraSelegiline Selegiline Parkinson’s Antiparkinson Not InsurableSerax Oxazepam Anxiety Antianxiety, Sedative/Hypnotic Other than UltraSerevent Salmeterol Respiratory Inhaler Bronchodilator Other than UltraSerlect Depression Antipsychotic Not InsurableSeroquel Quetiapine Schizophrenia Antipsychotic Not InsurableSertraline Sertraline Depression Antidepressant Other than UltraSerzone Nefazodone Depression Antidepressant Other than UltraSimvastatin Simvastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraSinemet Carbidopa/Levodopa Parkinson’s, Used for Restless Leg Antiparkinson Not InsurableSinequan Doxepin Depression Antianxiety, Antidepressant Other than UltraSingulair Montelukast Respiratory Bronchodilator Other than UltraSkelaxin Metaxalone Muscle Spasms Skeletal Muscle Relaxant Other than UltraSlo-Niacin Niacin Hypercholesterolemia, Supplement Lipid-(fat)-Lowering drug, Vitamin Usually UltraSolaraze Declofenac Arthritis NSAID Other than UltraSolazine Trifluoperazine Antipsychotics Antipsychotics Not InsurableSFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.77

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedSoma Carisoprodol Muscle Spasms Skeletal Muscle Relaxant Other than UltraSorbitrate Isosorbide Dinitrate Cardiac-Nitrate Anti-Anginal Other than UltraSotalol Sotalol Cardiac-Beta Blocker Antiarrhythmic Other than UltraSparine Depression Antipsychotic Not InsurableStarlix Nateglinide (NIDDM) Antidiabetic Other than UltraStelazine Trifluoperazine Antipsychotics Antipsychotics Not InsurableStrattera Attention Deficit Disorder Usually UltraSulindac Sulindac Arthritis, Pain NSAID, Antirheumatic Other than UltraSumatriptan Sumatriptan Migraines Vascular Headache Suppressant Usually UltraSustaire Theophylline Respiratory Bronchodilator Other than UltraSymmetrel Amantadine Parkinson’s, Viral Infections Antiparkinson, Antiviral Not InsurableSynthroid Levothyroxine Thyroid Preparations Hormone Usually UltraTTace Cancer Not InsurableTacrine Tacrine Memory Loss Anti-Alzheirmer Not InsurableTacrolimus Tacrolimus Diseases Immunosuppressant Not InsurableTagamet Cimetidine Gastrointestinal Antiulcer Agent Usually UltraTalwin Pentazocine Narcotic Pain Medication Opioid Analgesic Not InsurableTambocor Flecainide Cardiac Antiarrhythmic Other than UltraTamotidine Tamotidine Gastrointestinal Aniulcer Agent Usually UltraTamoxifen Breast Cancer Other than UltraTaractan Antipsychotics Not InsurableTaxol Cancer Cancer Not InsurableTegretol Carbamazepine Neuralgia Anticonvulsant Other than UltraTelmisartan Telmisartan Hypertension Antihypertensive Usually UltraTenex Guanfacine Cardiac Antihypertensive Usually UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.78

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedTenoretic Cardiac Antihypertensive Usually UltraTenormin Cardiac Antihypertensive Usually UltraTerazosin Terazosin Cardiac, Prostate Enlargement Antihypertensive, BPH Usually UltraTerbutaline Terbutaline Respiratory Inhaler Bronchodilator Other than UltraTerfluzine Trifluoperazine Antipsychotics Antipsychotics Not InsurableTeveten Eprosartan Cardiac Antihypertensive Usually UltraTheo-24 Theophylline Respiratory Bronchodilator Other than UltraTheobid Theophylline Respiratory Bronchodilator Other than UltraTheoclear Theophylline Respiratory Bronchodilator Other than UltraTheo-Dur Theophylline Respiratory Bronchodilator Other than UltraTheolair Theophylline Respiratory Bronchodilator Other than UltraTheophylline Theophylline Respiratory Bronchodilator Other than UltraTheospan Theophylline Respiratory Bronchodilator Other than UltraTheovent Theophylline Respiratory Bronchodilator Other than UltraThioridazine Thioridazine Schizophrenia Antipsychotic Not InsurableThorazine Chlorpromazine Psychoses Antipsychotics, Antiemetic Not InsurableThyrar Thyroid Thyroid Preparations Hormone Usually UltraThyroid Thyroid Thyroid Preparations Hormone Usually UltraThyrolar Liotrix Thyroid Preparations Hormone Usually UltraTiamate Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraTiazac Diltiazem Cardiac-Calcium Channel Blocker Antihpertensives Usually UltraTigan Trimethobenzamide Nausea and Vomiting Antiemetics Usually UltraTimolide Combo Cardiac Antihypertensive Usually UltraTipramine Imipramine Depression Antidepressant Other than UltraTirofiban Tirofiban Cardiac Antiplatelet Agent Other than UltraTocainide Tocainide Cardiac Antiarrhythmics Other than UltraTofranil Imipramine Depression Antidepressant Other than UltraTolbutamide Diabetes Antidiabetic Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.79

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedTolcapone Parkinson’s Disease Not InsurableTolmetin Tolmetin Arthritis, Pain NSAID, Antirheumatic Other than UltraTolterodine Tolterodine Urinary-Bladder Anticholinergic Usually UltraTonocard Tocainide Cardiac Antiarrhythmics Other than UltraTopamax Topiramate Seizure Disorder Anticonvulsant Other than UltraTopiramate Topiramate Seizure Disorder Anticonvulsant Other than UltraToprol Metoprolol Cardiac Antianginal, Antihypertensive Usually UltraToradol Arthritis Other than UltraTorsemide Torsemide Edema Diuretic Usually UltraTracleer Bosentan Cardiac Pulmonary hypertension Not InsurableTrandolapril Trandolapril Cardiac Antihypertensive Usually UltraTransderm-Nitro Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraTransderm-Scp Scopalamine Motion Sickness (Transdermal) Anitemetic Usually UltraTranxene Anxiety Other than UltraTranylcypromine Tranylcypromine Depression Antidepressant-MAO Inibitors Other than UltraTrazadone Trazodone Depression Antidepressant Other than UltraTrexall Methotrexate Rheumatoid Arthritis DMARD, Immunosuppressant Other than UltraTrialodine Trazodone Depression Antidepressant Other than UltraTriamcinolone Inhaler Triamcinolone Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraTriamolone Triamcinolone Steroid Antiasthmatic, Corticosteroid Other than UltraTriamterene Triamterene Edema Diuretic, Potassium-Sparing Usually UltraTriavil Perphenazine/Amitriptyline Depression Other than UltraTricor Fenofibrate Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraTricosal Choline/Magnesium Salicylate Arthritis, Pain NSAID Other than UltraTridil Nitoglycerin Cardiac-Nitrate Anti-Anginal Other than UltraTridione Seizure Disorder Other than UltraTrifluoperazine Trifluoperazine Antipsychotics Antipsychotics Not InsurableTrihexane Trihexyphenidyl Parkinson’s Antiparkinson Not InsurableFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.80

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedTrihexyphenidyl Trihexyphenidyl Parkinson’s Antiparkinson Not InsurableTrilafon Antipsychotics Not InsurableTriiodothyronine Liothyronine Thyroid Preparations Hormone Usually UltraTrileptal Oxcarbazepine Seizure Disorder Anticonvulsant Other than UltraTrilisate Choline/Magnesium Salicylate Arthritis, Pain NSAID Other than UltraTriostat Liothyronine Thyroid Preparations Hormone Usually UltraTritec Ranitidine Bismuth Citrate Gastrointestinal Antiulcer Agent Usually UltraTruphylline Aminophylline Respiratory Bronchodilator Other than UltraTylox Oxycodone/Acetaminophen Narcotic Pain Medication Opioid Analgesic Not InsurableTysabri Multiple Sclerosis Multiple Sclerosis Not InsurableUUltram Narcotic pain medication Not InsurableUltrazine Prochlorperazine Psychoses Antiemetic, Antipsychotic Not InsurableUniphyl Theophylline Respiratory Bronchodilator Other than UltraUnivasc Moexipril Cardiac Antihypertensive Usually UltraUrabeth Bethanecol Urinary-Bladder Urinary Tract Stimulant Usually UltraUrecholine Bethanecol Urinary-Bladder Urinary Tract Stimulant Usually UltraUrised Urinary-Bladder Usually UltraUrispas Urinary-Bladder Usually UltraUrso Cirrhosis Not InsurableVValdecoxib Valdecoxib Arthritis, Pain NSAID Other than UltraValium Diazepam Relaxant Other than UltraValproate Sodium Valproate Sodium Seizure Disorder Anticonvulsant, Vascular Headaches Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.81

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedValproic Acid Valproic Acid Seizure Disorder Anticonvulsant, Vascular Headaches Other than UltraValsartan Valsartan Hypertension Antihpertensive Usually UltraVanadom Carisoprodol Muscle Spasms Skeletal Muscle Relaxant Other than UltraVanceril Inhaler Beclomethasone Inhaler Respiratory Inhaler Corticorsteroid Inhaler, Antiasthmatic Other than UltraVascor Bepridil Cardiac-Calcium Channel Blocker Anti-Anginal Other than UltraVaseretic Combo Cardiac Antihypertensive Usually UltraVasotec Enalapril/Enalaprilat Cardiac Antihypertensive Usually UltraVenlafaxine Venlafaxine Depression Antianxiety, Antidepressant Other than UltraVentolin Albuterol Respiratory Bronchodilator Other than UltraVicodin Acetaminophen/Hydrocodone Narcotic Pain Medication Analgesic CallVitamin B Folic Acid Anemia, Vitamin Anti-Anemic Usually UltraVivactil Depression Antipsychotic Not InsurableVolmax Albuterol Respiratory Bronchodilator Other than UltraVoltaren Declofenac Arthritis NSAID Other than UltraWWarfarin Warfarin Blood Thinner Anticoagulant Other than UltraWelchol Colesevelam Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraWellbutrin Bupropion Depression, Smoking Cessation Anitdepressant, Smoking Deterrant Other than UltraWesthroid Thyroid Thyroid Preparations Hormone Usually UltraWigraine Suppositories Ergotamine/Caffeine Combo Migraines Vasoconstrictor Usually UltraWygesic Propoxyphene/Acetaminophen Narcotic Pain Medication Opioid Analgesic CallWytensin Guanabenz Cardiac Antihypertensive Usually UltraXXanax Alprazolam Anxiety-Benzodiazepine Antianxiety Other than UltraFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.82

Drug-Generic Generic Name Description/ Therapeutic Class Probable Action& Trade Names Conditions TreatedXopenex Levalbuterol Respiratory Inhaler Bronchodilator Other than UltraZZantac Ranitidine Gastrointestinal Antiulcer Agent Usually UltraZaroxolyn Metolazone Cardiac, Edema Antihypertensive, Diuretic Usually UltraZebeta Bisoprolol Cardiac- Beta Blocker Antihypertensive Usually UltraZestoretic Combo Cardiac Antihypertensive Usually UltraZestril Lisinopril Cardiac Antihypertensive Usually UltraZiac Cardiac Antihypertensive Usually UltraZileuton Zileuton Respiratory Bronchodilator Other than UltraZiprasidone Ziprasidone Schizophrenia Antipsychotic Not InsurableZocor Simvastatin Hypercholesterolemia Lipid-(fat)-Lowering drug Usually UltraZoladex Goserelin Cancer, Prostate and Breast Antineoplastic Not InsurableZoledronic Acid Zoledronic Acid Multiple Myeloma Hypocalcemic Not InsurableZolmitriptan Zolmitriptan Migraines Vascular Headache Suppressant Usually UltraZoloft Sertraline Depression Antidepressant Other than UltraZolpidem Zolpidem Sleeping pill Sedative/Hypnotic Usually UltraZometa Zoledronic Acid Multiple Myeloma Hypocalcemic Not InsurableZomig Zolmitriptan Migraines Vascular Headache Suppressant Usually UltraZonalon Doxepin Depression Antidepressant Other than UltraZonegran Zonisamide Seizure Disorder Anticonvulsant Other than UltraZostrix Capsaicin Pain Management, Topical Nonopioid Analgesics (Topical) CallZovirax Acyclovir Herpes Infections Antiviral Usually UltraZyban Bupropion Depression, Smoking Cessation Anitdepressant, Smoking Deterrant Other than UltraZydone Hydrocodone/Acetaminophen Narcotic Pain Medication Opioid Analgesic Not InsurableZyflo Zileuton Respiratory Bronchodilator Other than UltraZyloprim Allopurinol Gout Antigout Agent Usually UltraZyprexa Olanzapine Schizophrenia, Anroexia Nervosa Antipsychotic Not InsurableFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.83

NotesFOR PRODUCER USE ONLY. NOT FOR USE WITH THE PUBLIC.84