master prescription drug list

MASTER PRESCRIPTION DRUG LIST North American – Liberty Bankers – Americo Eagle Premier

(USE CTR F TO SEARCH ALL THREE CARRIERS)

Eagle Premier ® Series

Prescription Drug Guide

2016 Edition For agent use only.

Not for public use.

13-178-12 (07/16)


This Prescription Drug Guide is used in conjunction with Americo’s underwriting guidelines and does not reflect the full

underwriting standards of Americo or all prescription drugs considered by Americo. This Guide provides a list of com-mon

drugs, their uses, and eligible Eagle Premier Series products available to an applicant taking one of the listed drugs.

Americo products listed below under the Benefit Eligibility column are not a guarantee of policy issuance, and prescription

drug combinations may result in ineligibility. Further, any prescription drug used in combination with a re-lated or unrelated

medical condition could result in ineligibility. Each application is reviewed based on the circumstances and conditions

represented therein and may involve additional requirements. Both this Guide and the full underwriting guidelines used by

Americo are subject to change. Note: The brand name drug is in ALL CAPS and its generic equivalent is next to it in

lowercase letters. This guide allows you to search either by generic or brand name.

Drug Name Drug Indication Rx Fill

Benefit Eligibility or Drug Category Within

A/B OTIC Ear pain any Eagle Level

abacavir (ZIAGEN) HIV/AIDS any Eagle Guaranteed

abacavir/lamivudine (EPZICOM) HIV/AIDS any Eagle Guaranteed

ABILIFY (aripiprazole) Psychotic disorders 24 months Eagle Level; decline 40-49

ABSORBINE ARTHRITIS Topical arthritis pain treatment any Eagle Level

ABSTRAL (fentanyl) sublingual tablets Cancer pain 24 months Eagle Guaranteed

acamprosate (CAMPRAL) Alcohol dependency treatment 24 months Eagle Guaranteed

acarbose (PRECOSE) Diabetes any Eagle Level (with no diabetic complications)

ACCOLATE (zafirlukast) Asthma any Eagle Level

ACCUNEB (albuterol) Asthma any Eagle Level

ACCUPRIL (quinapril) Hypertension any Eagle Level

ACCUZYME (papain and urea) Dermatological treatment any Eagle Level

acebutolol HCl (SECTRAL) Hypertension any Eagle Level

acebutolol HCl (SECTRAL) Arrhythmia any Eagle Level

ACEON (perindopril) Hypertension any Eagle Level

ACEON (perindopril) Coronary artery disease 12 months Eagle Guaranteed

acetaminophen with codeine #3 (TYLENOL WITH Pain relief - narcotic any Eagle Level

CODEINE #3)

ACETASOL HC (acetic acid w/hydrocortisone) External ear infection any Eagle Level

acetazolamide (DIAMOX) Congestive heart failure any Eagle Guaranteed

acetazolamide (DIAMOX) Seizures any Eagle Level

acetazolamide (DIAMOX) Mountain sickness any Eagle Level

acetazolamide (DIAMOX) Glaucoma any Eagle Level

ACETIC ACID External ear infection any Eagle Level

acetic acid/aluminum acetate (DOMEBORO) External ear infection any Eagle Level

acetic acid/hydrocortisone (ACETASOL HC) External ear infection any Eagle Level

acetylcysteine (MUCOMYST) Emphysema any Eagle Guaranteed

acetylcysteine (MUCOMYST) Tuberculosis any Eagle Guaranteed

acetylcysteine (MUCOMYST) Pneumonia/bronchitis any Eagle Level

acetylcysteine (MUCOMYST) Cystic fibrosis any Eagle Guaranteed

ACLOVATE (alclometasone dipropionate) Dermatological treatment any Eagle Level

ACTIGALL (ursodiol) Gallstones any Eagle Level

ACTIGALL (ursodiol) Liver cirrhosis any Eagle Level

ACTIQ (fentanyl citrate) lozenge Cancer pain 24 months Eagle Guaranteed

ACTIVELLA (estradiol/norethindrone) Menopausal symptoms any Eagle Level

p. 2



ACTONEL (risedronate) Osteoporosis any Eagle Level

ACTOPLUS MET (metformin and pioglitazone) Diabetes any Eagle Level (with no diabetic complications)

ACTOS (pioglitazone) Diabetes any Eagle Level (with no diabetic complications)

ACULAR LS Eye drops any Eagle Level

acyclovir (ZOVIRAX) Shingles/chickenpox/genital herpes any Eagle Level

ADALAT (nifedipine) Hypertension any Eagle Level

adalimumab (HUMIRA) Rheumatoid arthritis/juvenile

any Eagle Level psoriatic arthritis

adalimumab (HUMIRA) Crohn’s disease any Eagle Level

adalimumab (HUMIRA) Ankylosing spondylitis any Eagle Level

adalimumab (HUMIRA) Plaque psoriasis any Eagle Level

ADDERALL (dextroamphetamine/amphetamine) ADHD/narcolepsy any Eagle Level

adefovir (HEPSERA) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle

Guaranteed)

ADVAIR DISKUS (fluticasone propionate/salmeterol) Asthma any Eagle Level

ADVAIR DISKUS (fluticasone propionate/salmeterol) Chronic obstructive pulmonary

any Eagle Guaranteed disease (COPD)

ADVICOR (niacin/lovastatin) Elevated cholesterol any Eagle Level

AEROBID (flunisolide) Asthma any Eagle Level

AFEDITAB (nifedipine) Hypertension any Eagle Level

AGGRENOX (aspirin/dipyridamole) Stroke/TIA 12 months Eagle Guaranteed

AGRYLIN (anagrelide HCl) Cancer 24 months Eagle Guaranteed

albuterol (ACCUNEB, PROAIR HFA, PROVENTIL, Asthma any Eagle Level

VENTOLIN)

albuterol/ipratropium (COMBIVENT, DUONEB) Chronic obstructive pulmonary


alclometasone dipropionate (ACLOVATE) Dermatological treatment any Eagle Level

ALDACTAZIDE (hydrochlorothiazide/spironolactone) Hypertension any Eagle Level

ALDACTAZIDE (hydrochlorothiazide/spironolactone) Liver cirrhosis any Eagle Guaranteed

ALDACTAZIDE (hydrochlorothiazide/spironolactone) Congestive heart failure any Eagle Guaranteed

ALDACTAZIDE (hydrochlorothiazide/spironolactone) Kidney disease any Eagle Guaranteed

ALDACTONE (spironolactone) Hyperaldosteronism/low potassium any Eagle Level

ALDACTONE (spironolactone) Hypertension any Eagle Level

ALDACTONE (spironolactone) Liver cirrhosis any Eagle Guaranteed

ALDACTONE (spironolactone) Congestive heart failure any Eagle Guaranteed

ALDACTONE (spironolactone) Kidney disease any Eagle Guaranteed

ALDARA (imiquimod) Dermatological treatment any Eagle Level

ALDOMET (methyldopa) Hypertension any Eagle Level

ALINIA Gastrointestinal infection any Eagle Level

aliskiren (TEKTURNA) Hypertension any Eagle Level

aliskiren/hydrochlorothiazide (TEKTURNA HCT) Hypertension any Eagle Level

ALLOPURINOL Gout any Eagle Level

ALLOPURINOL Cancer treatment-related uric acid

24 months Eagle Guaranteed elevation

ALPHAGAN (brimonidine tartrate) Glaucoma any Eagle Level

p. 3




ALPRAZOLAM Anxiety/panic disorder any Eagle Level

ALTABAX Dermatological treatment any Eagle Level

ALTACE (ramipril) Hypertension any Eagle Level

ALTACE (ramipril) Congestive heart failure any Eagle Guaranteed

ALTOCOR (lovastatin) Elevated cholesterol any Eagle Level

ALTOPREV (lovastatin) Elevated cholesterol any Eagle Level

ALUPENT (metaproterenol sulfate) Asthma any Eagle Level

ALUPENT (metaproterenol sulfate) Emphysema any Eagle Guaranteed

amantadine HCl (SYMMETREL) Parkinson’s disease any Eagle Level

amantadine HCl (SYMMETREL) Drug-induced movement disorders any Eagle Level

AMARYL (glimepiride) Diabetes any Eagle Level (with no diabetic complications)

AMBIEN (zolpidem tartrate) Insomnia any Eagle Level

AMCINONIDE Dermatological treatment any Eagle Level

AMDRY-D Cough/cold/allergies any Eagle Level

amiloride (MIDAMOR) Congestive heart failure any Eagle Guaranteed

amiloride (MIDAMOR) Hypertension any Eagle Level

AMINOPHYLLINE Asthma any Eagle Level

AMINOPHYLLINE Emphysema/chronic obstructive

any Eagle Guaranteed pulmonary disease (COPD)

amiodarone (CORDARONE, PACERONE) Heart arrhythmia any Eagle Level

AMITIZA (lubiprostone) Constipation any Eagle Level

AMITRIPTYLINE HCL Depression 24 months Eagle Level

amlodipine (NORVASC) Hypertension any Eagle Level

amlodipine (NORVASC) Coronary artery disease 12 months Eagle Guaranteed

amlodipine/atorvastatin (CADUET ) Hypertension any Eagle Level

amlodipine/atorvastatin (CADUET ) Coronary artery disease 12 months Eagle Guaranteed

amlodipine/benazepril (LOTREL) Hypertension any Eagle Level

amlodipine/olmesartan (AZOR) Hypertension any Eagle Level

amlodipine/valsartan (EXFORGE) Hypertension any Eagle Level

ammonium lactate (LAC-HYDRIN) Dermatological treatment any Eagle Level

AMOXICILLIN Antibiotic any Eagle Level

amoxicillin/potassium clavulanate (AUGMENTIN) Antibiotic any Eagle Level

AMPHOTERICIN B Antifungal treatment any Eagle Level

AMPICILLIN Antibiotic any Eagle Level

ANAFRANIL (clomipramine HCl) Obsessive compulsive disorder any Eagle Level

anagrelide HCl (AGRYLIN) Cancer 24 months Eagle Guaranteed

ANAPLEX DMX Cough/cold/allergies any Eagle Level

anastrozole (ARIMIDEX) Cancer 24 months Eagle Guaranteed

ANDROGEL Testosterone replacement any Eagle Level

ANEMAGEN Iron supplementation any Eagle Level

ANIMI-3 Vitamin supplement any Eagle Level

ANTABUSE Alcohol dependency treatment 24 months Eagle Guaranteed

ANTARA (fenofibrate) Elevated cholesterol/triglycerides any Eagle Level

p. 4



ANUCORT-HC Hemorrhoidal treatment any Eagle Level

APEXICON E Dermatological treatment any Eagle Level

APIDRA (insulin glulisine) Diabetes any Eagle Level (with no diabetic complications)

APLENZIN (bupropion) Depression any Eagle Level

aprepitant (EMEND) Nausea/vomiting prevention

any Eagle Level pre-SURGERY

aprepitant (EMEND) Nausea/vomiting prevention

24 months Eagle Guaranteed pre-CHEMOTHERAPY

APRESOLINE (hydralazine HCl) Hypertension any Eagle Level

ARAVA (leflunomide) Rheumatoid arthritis any Eagle Level

AREDIA (pamidronate) Cancer 24 months Eagle Guaranteed

AREDIA (pamidronate) Paget’s bone disease any Eagle Level

arformoterol inhalation (BROVANA) Chronic obstructive pulmonary


ARICEPT (donepezil) Alzheimer’s disease any Eagle Guaranteed

ARIMIDEX (anastrozole) Cancer 24 months Eagle Guaranteed

aripiprazole (ABILIFY) Psychotic disorders 24 months Eagle Level; decline 40-49

ARIXTRA (fondaparinux sodium) Presurgical PREVENTION of blood

any Eagle Level clot

ARIXTRA (fondaparinux sodium) Treatment of blood clot any Eagle Level

ARIXTRA (fondaparinux sodium) Treatment of pulmonary embolism

any Eagle Level (clot)

ARMOUR THYROID Thyroid replacement any Eagle Level

AROMASIN (exemestane) Cancer 24 months Eagle Guaranteed

ARTANE (trihexyphenidyl) Parkinson’s disease any Eagle Level

ARTHROTEC 75 Pain relief - anti-inflammatory any Eagle Level

ASACOL (mesalamine) Ulcerative colitis any Eagle Level

ASCOMP/CODEINE Tension headache any Eagle Level

ASMANEX Asthma any Eagle Level

ASPIRIN/CODEINE Pain relief any Eagle Level

aspirin/dipyridamole (AGGRENOX) Stroke/TIA 12 months Eagle Guaranteed

ASTELIN (azelastine) Nasal spray any Eagle Level

ATACAND (candesartan) Hypertension any Eagle Level

ATACAND (candesartan) Congestive heart failure any Eagle Guaranteed

ATACAND HCT (candesartan/hydrochlorothiazide) Hypertension any Eagle Level

atazanavir (REYATAZ) HIV-related anemia any Eagle Guaranteed

atenolol (TENORMIN) Hypertension any Eagle Level

atenolol (TENORMIN) Angina 12 months Eagle Guaranteed

atenolol (TENORMIN) Heart attack 12 months Eagle Guaranteed

atenolol/chlorthalidone (TENORETIC) Hypertension any Eagle Level

ATIVAN (lorazepam) Anxiety any Eagle Level

atorvastatin (LIPITOR) Elevated cholesterol any Eagle Level

ATRIPLA (efavirenz/emtricitabine/tenofovir disoproxil HIV/AIDS any Eagle Guaranteed

fumarate)

ATROPINE SULFATE Eye drops any Eagle Level

p. 5




ATROVENT HFA (ipratropium bromide HFA) Chronic obstructive pulmonary

any Eagle Guaranteed disease (COPD)/emphysema

ATROVENT NASAL SPRAY (ipratropium bromide nasal Allergic and non-allergic nasal any Eagle Level

spray) symptoms

ATUSS DS Cough/cold/allergies any Eagle Level

AUGMENTED BETAMETHASONE DIPROPIONATE Dermatological treatment any Eagle Level

AUGMENTIN (amoxicillin/potassium clavulanate) Antibiotic any Eagle Level

AVALIDE (irbesartan/hydrochlorothiazide) Hypertension any Eagle Level

AVANDAMET (metformin/rosiglitazone) Diabetes any Eagle Level (with no diabetic complications)

AVANDARYL (glimepiride/rosiglitazone) Diabetes any Eagle Level (with no diabetic complications)

AVANDIA (rosiglitazone) Diabetes any Eagle Level (with no diabetic complications)

AVAPRO (irbesartan) Hypertension any Eagle Level

AVAPRO (irbesartan) Diabetic kidney disease any Eagle Guaranteed

AVELOX (moxifloxacin) Antibiotic any Eagle Level

AVINZA (morphine sulfate) Moderate to severe pain any Eagle Level

AVODART (dutasteride) Benign prostatic hypertrophy any Eagle Level

AVONEX (interferon beta-1a) Multiple sclerosis any Eagle Level

AXID (nizatidine) Ulcers/esophagitis any Eagle Level

AZASAN (azathioprine) Kidney transplant rejection

any Eagle Guaranteed prevention

AZASAN (azathioprine) Rheumatoid arthritis any Eagle Level

AZASITE Ophthalmic agent any Eagle Level

azathioprine (IMURAN, AZASAN) Kidney transplant rejection


azathioprine (IMURAN, AZASAN) Rheumatoid arthritis any Eagle Level

azelastine (ASTELIN) Nasal spray any Eagle Level

AZELEX Dermatological treatment any Eagle Level

AZILECT (rasagiline) Parkinson’s disease any Eagle Level

AZITHROMYCIN Antibiotic any Eagle Level

AZMACORT (triamcinolone oral inhalation) Asthma any Eagle Level

AZOPT Ophthalmic agent any Eagle Level

AZOR (amlodipine/olmesartan) Hypertension any Eagle Level

BACITRACIN Dermatological treatment any Eagle Level

BACITRACIN/POLYMYXIN B Ophthalmic agent any Eagle Level

BACLOFEN Muscular sclerosis any Eagle Level

BACLOFEN Spasticity from spinal cord injury any Eagle Level

BACTROBAN Dermatological antibiotic any Eagle Level

BACTROBAN NASAL Nasal infection any Eagle Level

BARACLUDE (entecavir) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle

Guaranteed)

beclomethasone (QVAR) Asthma any Eagle Level

BECONASE AQ Nasal agent any Eagle Level

BELLADONNA ALKALOIDS/PHENOBARBITAL Ulcers any Eagle Level

benazepril HCl (LOTENSIN) Hypertension any Eagle Level

p. 6



BENICAR HCT (olmesartan) Hypertension any Eagle Level

BENTYL (dicyclomine) Irritable bowel syndrome any Eagle Level

BENZACLIN Dermatological treatment any Eagle Level

BENZONATATE Cough/cold/allergies any Eagle Level

benztropine mesylate (COGENTIN) Parkinson’s disease any Eagle Level

BEPREVE Ophthalmic agent any Eagle Level

BETAMETHASONE DIPROPIONATE Dermatological treatment any Eagle Level

BETAPACE (sotalol) Heart arrhythmia any Eagle Level

BETHANECHOL CHLORIDE Urinary spasm/retention any Eagle Level

BETIMOL Ophthalmic agent any Eagle Level

BETOPTIC-S Eye drops any Eagle Level

BIAXIN XL Antibiotic any Eagle Level

bicalutamide (CASODEX) Cancer 24 months Eagle Guaranteed

BICILLIN L-A Antibiotic any Eagle Level

BIDIL (isosorbide dinitrate and hydralazine Congestive heart failure any Eagle Guaranteed

hydrochloride)

BILTRICIDE Worm infection any Eagle Level

BIONECT Dermatological treatment any Eagle Level

BISACODYL EC Constipation any Eagle Level

BISMATROL Diarrhea any Eagle Level

BISOPROLOL FUMARATE Hypertension any Eagle Level

BISOPROLOL FUMARATE/HCTZ Hypertension any Eagle Level

BLEPHAMIDE Eye drops any Eagle Level

BONIVA (ibandronate) Osteoporosis any Eagle Level

BOTOX (onabotulinumtoxinA) Spasticity/multiple indications any Eagle Level

BRETHINE (terbutaline) Asthma/bronchitis any Eagle Level

BRETHINE (terbutaline) Emphysema any Eagle Guaranteed

BRICANYL (terbutaline) Asthma/bronchitis any Eagle Level

BRICANYL (terbutaline) Emphysema any Eagle Guaranteed

brimonidine tartrate (ALPHAGAN) Glaucoma any Eagle Level

BROMETANE DX Cough/cold/allergies any Eagle Level

BROVANA (arformoterol inhalation) Chronic obstructive pulmonary


BUDEPRION (bupropion) Depression 24 months Eagle Level

budesonide/formoterol (SYMBICORT) Asthma any Eagle Level

budesonide/formoterol (SYMBICORT) Chronic obstructive pulmonary


bumetanide (BUMEX) Congestive heart failure any Eagle Guaranteed

bumetanide (BUMEX) Liver disease any Eagle Guaranteed

bumetanide (BUMEX) Kidney disease any Eagle Guaranteed

BUMEX (bumetanide) Congestive heart failure any Eagle Guaranteed

BUMEX (bumetanide) Liver disease any Eagle Guaranteed

BUMEX (bumetanide) Kidney disease any Eagle Guaranteed

BUPROBAN (bupropion) Smoking cessation 12 months Smoking rates (Eagle Level)

p. 7




bupropion (APLENZIN, BUDEPRION, FORFIVO, Depression 24 months Eagle Level

WELLBUTRIN)

bupropion (BUPROBAN, ZYBAN) Smoking cessation 12 months Smoking rates (Eagle Level)

BUSPAR (buspirone HCl) Anxiety any Eagle Level

buspirone HCl (BUSPAR) Anxiety any Eagle Level

BUTALBITAL/ACETAMINOPHEN/CAFFEINE/ Tension headache any Eagle Level

CODEINE

BUTORPHANOL TARTRATE Pain relief any Eagle Level

BYETTA (exenatide) Diabetes any Eagle Level (with no diabetic complications)

BYSTOLIC (nebivolol) Hypertension any Eagle Level

CABERGOLINE Hyperprolactinemic disorders any Eagle Level

CADUET (amlodipine besylate, atorvastatin calcium) Hypertension any Eagle Level

CADUET (amlodipine besylate, atorvastatin calcium) Coronary artery disease 12 months Eagle Guaranteed

CALAMINE Dermatological treatment any Eagle Level

CALAN (verapamil) Hypertension any Eagle Level

CALAN (verapamil) Angina 12 months Eagle Guaranteed

CALAN (verapamil) Arrhythmia any Eagle Level

CALCIFOLIC-D Mineral/electrolyte replacement any Eagle Level

calcitonin (MIACALCIN) Osteoporosis any Eagle Level

calcitonin (MIACALCIN) Paget’s bone disease any Eagle Level

calcitriol (ROCALTROL) Calcium replacement in PRIMARY

any Eagle Level parathyroid disease

calcitriol (ROCALTROL) Kidney failure any Eagle Guaranteed

CALCIUM ACETATE Hyperphosphatemia in kidney failure any Eagle Guaranteed

CALCIUM CARBONATE Antacid any Eagle Level

CALCIUM/VITAMIN D Vitamin/mineral supplement any Eagle Level

CAL-NATE Vitamin supplement any Eagle Level

CAMPRAL (acamprosate) Alcohol dependency treatment 24 months Eagle Guaranteed

candesartan (ATACAND) Hypertension any Eagle Level

candesartan (ATACAND) Congestive heart failure any Eagle Guaranteed

candesartan hydrochlorothiazide (ATACAND HCT) Hypertension any Eagle Level

capecitabine (XELODA) Cancer 24 months Eagle Guaranteed

CAPOTEN (captopril) Hypertension any Eagle Level

CAPOTEN (captopril) Congestive heart failure any Eagle Guaranteed

CAPOTEN (captopril) Diabetic kidney disease any Eagle Guaranteed

CAPOZIDE (captopril/hydrochlorothiazide) Hypertension any Eagle Level

captopril (CAPOTEN) Hypertension any Eagle Level

captopril (CAPOTEN) Congestive heart failure any Eagle Guaranteed

captopril (CAPOTEN) Diabetic kidney disease any Eagle Guaranteed

captopril/hydrochlorothiazide (CAPOZIDE) Hypertension any Eagle Level

CARAC Dermatological treatment any Eagle Level

carbamazepine (CARBATROL, TEGRETOL) Epilepsy any Eagle Level

carbamazepine (CARBATROL, TEGRETOL) Facial nerve disorder any Eagle Level

CARBATROL (carbamazepine) Epilepsy any Eagle Level

p. 8



CARBATROL (carbamazepine) Facial nerve disorder any Eagle Level

CARBATUSS-CL Cough/cold/allergies any Eagle Level

carbidopa/levodopa (SINEMET) Parkinson’s disease any Eagle Level

CARDIZEM (diltiazem) Hypertension any Eagle Level

CARDIZEM (diltiazem) Angina 12 months Eagle Guaranteed

CARDOXIN (digoxin) Heart failure any Eagle Guaranteed

CARDURA (doxazosin mesylate) Benign prostatic hypertrophy any Eagle Level

CARDURA (doxazosin mesylate) Hypertension any Eagle Level

CARISOPRODOL Muscular pain any Eagle Level

CARISOPRODOL/ASPIRIN Muscular pain any Eagle Level

CARTIA XT (diltiazem) Hypertension any Eagle Level

CARTIA XT (diltiazem) Angina 12 months Eagle Guaranteed

carvedilol (COREG) Hypertension any Eagle Level

carvedilol (COREG) Congestive heart failure any Eagle Guaranteed

CASODEX (bicalutamide) Cancer 24 months Eagle Guaranteed

CATAFLAM (diclofenac) Pain relief - anti-inflammatory any Eagle Level

CATAPRES (clonidine HCl) Hypertension any Eagle Level

CAVERJECT (alprostadil) Erectile dysfunction any Eagle Level

CEDAX Antibiotic any Eagle Level

CEFACLOR Antibiotic any Eagle Level

CEFADROXIL Antibiotic any Eagle Level

CEFPODOXIME PROXETIL Antibiotic any Eagle Level

CEFTRIAXONE SODIUM Antibiotic any Eagle Level

CEFUROXIME AXETIL Antibiotic any Eagle Level

CEFZIL Antibiotic any Eagle Level

CELEBREX (celecoxib) Pain relief - anti-inflammatory any Eagle Level

celecoxib (CELEBREX) Pain relief - anti-inflammatory any Eagle Level

CELESTONE Multiple indications - corticosteroid any Eagle Level

CELEXA (citalopram hydrobromide) Depression any Eagle Level

CELLCEPT (mycophenolate) Organ transplant rejection


CELLUVISC Eye drops any Eagle Level

CELONTIN (methsuximide) Seizures any Eagle Level

CENESTIN Menopausal symptoms any Eagle Level

CEPHADYN Pain relief - nonnarcotic any Eagle Level

CEPHALEXIN Antibiotic any Eagle Level

CEREFOLIN Vitamin any Eagle Level

CERON-DM Cough/cold/allergies any Eagle Level

CETAPHIL Dermatological treatment any Eagle Level

CHANTIX (varenicline) Smoking cessation 12 months smoking rates (Eagle Level)

CHERATUSSIN AC Cough/cold/allergies any Eagle Level

CHLORAL HYDRATE Insomnia any Eagle Level

chlordiazepoxide (LIBRIUM) Alcohol withdrawal 24 months Eagle Guaranteed

p. 9




chlordiazepoxide/amitriptyline (LIMBITROL) Depression/anxiety 24 months Eagle Level; 40-49 decline

chlordiazepoxide/clidinium (LIBRAX) Irritable bowel syndrome any Eagle Level

chlorhexidine gluconate (PERIDEX) Antiseptic rinse any Eagle Level

chloroquine phosphate Malaria any Eagle Level

chlorpheniramine/pseudoephedrine CR Cold/cough/allergies any Eagle Level

(DYNAHIST ER)

chlorpromazine HCl (THORAZINE) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49

chlorthalidone (HYDONE, HYGROTON, THALITONE) Hypertension any Eagle Level

chlorthalidone (HYDONE, HYGROTON, THALITONE) Congestive heart failure any Eagle Guaranteed

chlorthalidone (HYDONE, HYGROTON, THALITONE) Liver cirrhosis any Eagle Guaranteed

chlorthalidone (HYDONE, HYGROTON, THALITONE) Edema related to estrogen therapy any Eagle Level

chlorzoxazone (PARAFON FORTE DSC) Musculoskeletal pain any Eagle Level

cholestyramine (QUESTRAN) Elevated cholesterol any Eagle Level

CHOLINE MAGNESIUM TRISALICYLATE Pain relief - nonnarcotic any Eagle Level

CHORIONIC GONADOTROPIN Hormonal treatment any Eagle Level

CHROMAGEN Dietary supplement any Eagle Level

CIALIS (tadalafil) Erectile dysfunction any Eagle Level

CICLOPIROX OLAMINE Dermatological treatment any Eagle Level

cilostazol (PLETAL) Circulatory disease any Eagle Level

cimetidine (TAGAMET) Heartburn any Eagle Level

cinacalcet (SENSIPAR) Primary parathyroid disease any Eagle Level

cinacalcet (SENSIPAR) Parathyroid cancer 24 months Eagle Guaranteed

cinacalcet (SENSIPAR) Kidney disease any Eagle Guaranteed

CIPRO (ciprofloxacin) Antibiotic any Eagle Level

CIPRODEX External ear infection any Eagle Level

ciprofloxacin HCL (CIPRO) Antibiotic any Eagle Level

citalopram hydrobromide (CELEXA) Depression 24 months Eagle Level; decline 40-49

CITRACAL MAXIMUM Dietary supplement any Eagle Level

CLARINEX Cough/cold/allergies any Eagle Level

CLEMASTINE FUMARATE Antihistamine any Eagle Level

CLENIA FOAMING WASH Dermatological treatment any Eagle Level

CLEOCIN (clindamycin HCl) Antibiotic any Eagle Level

clindamycin HCl (CLEOCIN) Antibiotic any Eagle Level

CLINDAMYCIN PHOSPHATE Dermatological treatment any Eagle Level

CLINDESSE Bacterial vaginosis any Eagle Level

CLOBETASOL PROPIONATE Dermatological treatment any Eagle Level

CLODERM Dermatological treatment any Eagle Level

CLOMID (clomiphene citrate) Hormonal treatment any Eagle Level

clomiphene citrate (CLOMID) Hormonal treatment any Eagle Level

clomipramine HCl (ANAFRANIL) Obsessive compulsive disorder any Eagle Level

clonazepam (KLONOPIN) Seizures any Eagle Level

clonazepam (KLONOPIN) Panic disorder 24 months Eagle Level; decline 40-49

clonidine/chlorthalidone (CLORPRESS) Hypertension any Eagle Level

p. 10



clonidine HCl (CATAPRES) Hypertension any Eagle Level

clopidogrel (PLAVIX) Heart attack 12 months Eagle Guaranteed

clopidogrel (PLAVIX) Stroke 12 months Eagle Guaranteed

clorazepate dipotassium (TRANXENE) Anxiety disorder any Eagle Level

clorazepate dipotassium (TRANXENE) Seizures any Eagle Level

clorazepate dipotassium (TRANXENE) Alcohol withdrawal 24 months Eagle Guaranteed

CLORPRESS (clonidine/chlorthalidone) Hypertension any Eagle Level

clotrimazole (MYCELEX) Fungal infection any Eagle Level

CODAL-DH Cough/cold/allergies any Eagle Level

COGENTIN (benztropine mesylate) Parkinson’s disease any Eagle Level

colchicine (COLCRYS) Gout any Eagle Level

COLCRYS (colchicine) Gout any Eagle Level

colesevelam (WELCHOL) Elevated cholesterol any Eagle Level

colesevelam (WELCHOL) Diabetes any Eagle Level (with no diabetic complications)

COLESTID (colestipol) Elevated cholesterol any Eagle Level

colestipol (COLESTID) Elevated cholesterol any Eagle Level

COMBIGAN Glaucoma any Eagle Level

COMBIVENT (albuterol/ipratropium) Chronic obstructive pulmonary


COMBIVIR (lamivudine/zidovudine) HIV/AIDS any Eagle Guaranteed

COMPRO (prochlorperazine) Nausea/vomiting any Eagle Level

COMTAN (entacapone) Parkinson’s disease any Eagle Level

CONCERTA (methylphenidate hydrochloride) ADHD any Eagle Level

CONDYLOX Dermatological treatment any Eagle Level

COPAXONE (glatiramer) Multiple sclerosis any Eagle Level

COPEGUS (ribavirin) Hepatitis C 24 months Eagle Guaranteed

CORDARONE (amiodarone) Heart arrhythmia any Eagle Level

COREG (carvedilol) Hypertension any Eagle Level

COREG (carvedilol) Congestive heart failure any Eagle Guaranteed

CORGARD (nadolol) Hypertension any Eagle Level

CORGARD (nadolol) Angina 12 months Eagle Guaranteed

CORICIDIN HBP FLU Cough/cold/allergies any Eagle Level

CORZIDE (nadolol/bendroflumethiazide) Hypertension any Eagle Level

COSOPT Glaucoma any Eagle Level

COUMADIN (warfarin) Clot prevention after heart valve

12 months Eagle Guaranteed placement

COUMADIN (warfarin) Atrial fibrillation any Eagle Level

COVERA-HS (verapamil) Hypertension any Eagle Level

COVERA-HS (verapamil) Angina 12 months Eagle Level

COVERA-HS (verapamil) Arrhythmia any Eagle Level

COZAAR (losartan) Hypertension any Eagle Level

COZAAR (losartan) Diabetic Kidney Disease 24 months Eagle Guaranteed

p. 11




CREON (pancrelipase) Pancreatic enzyme - cystic fibrosis any Eagle Guaranteed

CREON (pancrelipase) Pancreatic enzyme - chronic

12 months Eagle Level; decline 40-49 pancreatitis

CREON (pancrelipase) Pancreatic enzyme - pancreatectomy 12 months Eagle Level; decline 40-49

CRESTOR (rosuvastatin) Elevated cholesterol any Eagle Level

CRESYLATE External ear infection any Eagle Level

CROMOLYN SODIUM Allergies any Eagle Level

CUBICIN Skin infections any Eagle Level

CYANOCOBALAMIN Vitamin supplement any Eagle Level

cyclobenzaprine (FLEXERIL) Muscle relaxant any Eagle Level

CYCLOPENTOLATE HCL Eye drops any Eagle Level

cyclophosphamide (CYTOXAN) Cancer 24 months Eagle Guaranteed

cyclophosphamide (CYTOXAN) Nephrotic syndrome (kidney

any Eagle Guaranteed disease)

cyclophosphamide (CYTOXAN) Juvenile rheumatoid arthritis vasculitis any Eagle Level

cyclosporine (GENGRAF) Organ transplant rejection


CYMBALTA (duloxetine) Depression/anxiety 24 months Eagle Level; decline 40-49

CYMBALTA (duloxetine) Fibromyalgia/musculoskeletal pain any Eagle Level

CYMBALTA (duloxetine) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed

CYPROHEPTADINE HCL Antihistamine any Eagle Level

CYTOMEL (liothyronine) Thyroid replacement any Eagle Level

CYTOTEC (misoprostol) Ulcer any Eagle Level

CYTOXAN (cyclophosphamide) Cancer 24 months Eagle Guaranteed

CYTOXAN (cyclophosphamide) Nephrotic syndrome (kidney

any Eagle Guaranteed disease)

CYTOXAN (cyclophosphamide) Juvenile rheumatoid arthritis vasculitis any Eagle Level

CYTRA K CRYSTALS Urinary treatment/prevention of

any Eagle Level gout/kidney stones

DALMANE (flurazepam) Insomnia any Eagle Level

DAPSONE Leprosy/skin infections any Eagle Level

DARVON (propoxyphene) Pain relief - narcotic any Eagle Level

DEMADEX (torsemide) Hypertension any Eagle Level

DEMADEX (torsemide) Liver disease any Eagle Guaranteed

DEMADEX (torsemide) Congestive heart failure any Eagle Guaranteed

DEMADEX (torsemide) Kidney disease any Eagle Guaranteed

DEMSER (metyrosine) Pheochromocytomas any Eagle Level

DEPAKOTE (divalproex sodium) Bipolar 24 months Eagle Level; decline 40-49

DEPAKOTE (divalproex sodium) Epilepsy any Eagle Level

DEPAKOTE (divalproex sodium) Migraine any Eagle Level

DEPLIN Depression any Eagle Level

DEPO-MEDROL Multiple indications - corticosteroid any Eagle Level

DERMATOP Dermatological treatment any Eagle Level

DERMOTIC Ear drops any Eagle Level

p. 12



desipramine HCl (NORPRAMIN) Depression any Eagle Level

DESMOPRESSIN ACETATE Hormonal treatment any Eagle Level

DESONIDE Dermatological treatment any Eagle Level

DESOXIMETASONE Dermatological treatment any Eagle Level

DESYREL (trazodone) Depression any Eagle Level

DETROL LA Urinary antispasmodic any Eagle Level

DEXAMETHASONE Multiple indications - corticosteroid any Eagle Level

DEXAPHEN SA Cough/cold/allergies any Eagle Level

DEXEDRINE (dextroamphetamine) Narcolepsy any Eagle Level

DEXEDRINE (dextroamphetamine) ADHD any Eagle Level

dexmethylphenidate HCL (FOCALIN) ADHD/narcolepsy/obesity any Eagle Level

dextroamphetamine (DEXEDRINE) Narcolepsy any Eagle Level

dextroamphetamine (DEXEDRINE) ADHD any Eagle Level

dextroamphetamine/amphetamine (ADDERALL) ADHD/narcolepsy any Eagle Level

DIABETA (glyburide) Diabetes any Eagle Level (with no diabetic complications)

DIAMOX (acetazolamide) Congestive heart failure any Eagle Guaranteed

DIAMOX (acetazolamide) Seizures any Eagle Level

DIAMOX (acetazolamide) Mountain sickness any Eagle Level

DIAMOX (acetazolamide) Glaucoma any Eagle Level

diazepam (VALIUM) Anxiety disorder any Eagle Level

diazepam (VALIUM) Convulsive disorder/muscle spasms any Eagle Level

diazepam (VALIUM) Alcohol withdrawal 24 months Eagle Guaranteed

DIBENZYLINE Pheochromocytoma any Eagle Level

diclofenac (CATAFLAM) Pain relief - anti-inflammatory any Eagle Level

DICLOXACILLIN SODIUM Antibiotic any Eagle Level

dicyclomine (BENTYL) Irritable bowel syndrome any Eagle Level

diethylpropion (TENUATE) Obesity any Eagle Level

DIFFERIN Dermatological treatment any Eagle Level

DIFLORASONE DIACETATE Dermatological treatment any Eagle Level

diflunisal (DOLOBID) Pain relief - nonnarcotic any Eagle Level

DIGITEK (digoxin) Heart failure any Eagle Guaranteed

digoxin (DIGITEK, LANOXICAPS, LANOXIN, CAR- Heart failure any Eagle Guaranteed

DOXIN)

DILACOR (diltiazem) Hypertension any Eagle Level

DILACOR (diltiazem) Angina 12 months Eagle Guaranteed

DILANTIN (phenytoin) Seizures any Eagle Level

diltiazem (CARTIA XT, CARDIZEM, DILACOR, TIAZAC) Hypertension any Eagle Level

diltiazem (CARTIA XT, CARDIZEM, DILACOR, TIAZAC) Angina 12 months Eagle Guaranteed

DIOVAN (valsartan) Hypertension any Eagle Level

DIOVAN (valsartan) Congestive heart failure any Eagle Guaranteed

DIOVAN (valsartan) Treatment after heart attack 12 months Eagle Guaranteed

DIOVAN HCT (hydrochlorothiazide/valsartan) Hypertension any Eagle Level

DIPHENHYDRAMINE HCL Antihistamine any Eagle Level

p. 13




DIPHENOXYLATE/ATROPINE Diarrhea any Eagle Level

dipyridamole (PERSANTINE) Clot prevention after valve

12 months Eagle Guaranteed replacement

DITROPAN XL Urinary spasm any Eagle Level

divalproex sodium (DEPAKOTE) Bipolar 24 months Eagle Level; decline 40-49

divalproex sodium (DEPAKOTE) Epilepsy any Eagle Level

divalproex sodium (DEPAKOTE) Migraine any Eagle Level

docetaxel (TAXOTERE) Cancer 24 months Eagle Guaranteed

DOC-Q-LACE Constipation any Eagle Level

DOCUSATE CALCIUM Constipation any Eagle Level

dofetilide (TIKOSYN) Heart arrhythmia any Eagle Level

DOLOBID (diflunisal) Pain relief - nonnarcotic any Eagle Level

DOMEBORO (acetic acid/aluminum acetate) External ear infection any Eagle Level

DOMPERIDONE BP Parkinson’s disease any Eagle Level

DOMPERIDONE BP Nausea/vomiting any Eagle Level

DONATUSSIN Cough/cold/allergies any Eagle Level

donepezil (ARICEPT) Alzheimer’s disease any Eagle Guaranteed

DOVONEX Dermatological treatment any Eagle Level

doxazosin mesylate (CARDURA) Benign prostatic hypertrophy any Eagle Level

doxazosin mesylate (CARDURA) Hypertension any Eagle Level

doxepin HCl (SINEQUAN) Depression/anxiety any Eagle Level

doxercalciferol (HECTOROL) Parathyroidism due to chronic kidney

any Eagle Guaranteed disease

DOXYCYCLINE Antibiotic any Eagle Level

dronabinol (MARINOL) Appetitive stimulant in patients with

any Eagle Guaranteed AIDS

dronabinol (MARINOL) Nausea and vomiting related to

24 months Eagle Guaranteed chemotherapy

DUAC Dermatological treatment any Eagle Level

DUET DHA Vitamin supplement any Eagle Level

DUETACT (glimepiride/pioglitazone) Diabetes any Eagle Level (with no diabetic complications)

duloxetine (CYMBALTA) Depression/anxiety 24 months Eagle Level; decline 40-49

duloxetine (CYMBALTA) Fibromyalgia/musculoskeletal pain any Eagle Level

duloxetine (CYMBALTA) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed

DUONEB (albuterol/ipratropium) Chronic obstructive pulmonary


DURAFLU Cough/cold/allergies any Eagle Level

DURAGESIC (fentanyl) patch Continuous, persistent moderate to

any Eagle Level severe chronic pain

DURAGESIC (fentanyl) patch Cancer pain 24 months Eagle Guaranteed

DURAHIST D Cough/cold/allergies any Eagle Level

DURAPHEN FORTE Cough/cold/allergies any Eagle Level

DUREZOL Eye drops any Eagle Level

dutasteride (AVODART) Benign prostatic hypertrophy any Eagle Level

DYAZIDE (triamterene/hydrochlorothiazide) Hypertension any Eagle Level

p. 14



DYAZIDE (triamterene/hydrochlorothiazide) Edema any Eagle Level

DYNA HIST ER (chlorpheniramine/ Cold/cough/allergies any Eagle Level

pseudoephedrine CR)

DYNACIRC-CR (isradipine) Hypertension any Eagle Level

dyphylline/guaifenesin (DYPHYLLINE-GG) Asthma any Eagle Level

dyphylline/guaifenesin (DYPHYLLINE-GG) Emphysema/chronic bronchitis any Eagle Guaranteed

DYPHYLLINE-GG (dyphylline/guaifenesin) Asthma any Eagle Level

DYPHYLLINE-GG (dyphylline/guaifenesin) Emphysema/chronic bronchitis any Eagle Guaranteed

ECONAZOLE NITRATE Dermatological treatment any Eagle Level

ED A-HIST Cough/cold/allergies any Eagle Level

efavirenz (SUSTIVA) HIV/AIDS any Eagle Guaranteed

EFFEXOR (venlafaxine) Depression/anxiety any Eagle Level

ELDEPRYL (selegiline) Parkinson’s disease any Eagle Level

ELESTAT Eye drops any Eagle Level

ELIDEL Dermatological treatment any Eagle Level

ELMIRON Bladder pain any Eagle Level

EMEND (aprepitant) Nausea/vomiting prevention

any Eagle Level pre-surgery

EMEND (aprepitant) Nausea/vomiting prevention

24 months Eagle Guaranteed pre-chemotherapy

emtricitabine/tenofovir (TRUVADA) HIV/AIDS any Eagle Guaranteed

ENABLEX Urinary spasm any Eagle Level

enalapril (VASOTEC) Hypertension any Eagle Level

enalapril (VASOTEC) Congestive heart failure any Eagle Guaranteed

enalapril/hydrochlorothiazide (VASERETIC) Hypertension any Eagle Level

ENBREL (etanercept) Rheumatoid arthritis/psoriatic

any Eagle Level arthritis/ankylosing spondylitis

ENCORA Vitamin supplement any Eagle Level

ENDOMETRIN Hormonal treatment any Eagle Level

ENDURON (methyclothiazide) Hypertension any Eagle Level

ENDURON (methyclothiazide) Edema due to hormone or steroid

any Eagle Level therapy

ENDURON (methyclothiazide) Liver cirrhosis any Eagle Guaranteed

ENDURON (methyclothiazide) Congestive heart failure any Eagle Guaranteed

enoxaparin (LOVENOX) Deep vein thrombosis (clot) any Eagle Level

enoxaparin (LOVENOX) Unstable angina 12 months Eagle Guaranteed

enoxaparin (LOVENOX) Heart attack 12 months Eagle Guaranteed

entacapone (COMTAN) Parkinson’s disease any Eagle Level

entecavir (BARACLUDE) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle

Guaranteed)

ENTOCORT EC Crohn’s disease any Eagle Level

ENULOSE Constipation any Eagle Level

EPICREAM Dermatological treatment any Eagle Level

EPINEPHRINE HCL Asthma any Eagle Level

EPIPEN Allergic reaction any Eagle Level

p. 15




EPIVIR (lamivudine) HIV/AIDS any Eagle Guaranteed

eplerenone (INSPRA) Hypertension any Eagle Level

eplerenone (INSPRA) Congestive heart failure any Eagle Guaranteed

epoetin alfa (PROCRIT) Cancer-related anemia 24 months Eagle Guaranteed

epoetin alfa (PROCRIT) HIV-related anemia any Eagle Guaranteed

epoetin alfa (PROCRIT) Kidney disease-related anemia any Eagle Guaranteed

EPZICOM (abacavir/lamivudine) HIV/AIDS any Eagle Guaranteed

ERTACZO Dermatological treatment any Eagle Level

ERY-TAB Antibiotic any Eagle Level

ERYTHROCIN STEARATE Antibiotic any Eagle Level

escitalopram (LEXAPRO) Depression/anxiety 24 months Eagle Level; decline 40-49

esomeprazole (NEXIUM) GERD/ulcers any Eagle Level

ESTAZOLAM Insomnia any Eagle Level

ESTRADIOL Hormonal treatment any Eagle Level

estradiol/norethindrone (ACTIVELLA) Menopausal symptoms any Eagle Level

ESTRATEST H.S. Hormonal treatment any Eagle Level

ESTRIOL Hormonal treatment any Eagle Level

ESTROPIPATE Hormonal treatment any Eagle Level

eszopiclone (LUNESTA) Insomnia any Eagle Level

etanercept (ENBREL) Rheumatoid arthritis/psoriatic

any Eagle Level arthritis/ankylosing spondylitis

ETODOLAC Pain relief - anti-inflammatory any Eagle Level

etravirine (INTELENCE) HIV/AIDS any Eagle Guaranteed

EVISTA (raloxifene) Osteoporosis any Eagle Level

EVOXAC Dry mouth due to Sjögren’s

any Eagle Level syndrome

EXELDERM Dermatological treatment any Eagle Level

EXELON (rivastigmine transdermal) Alzheimer’s disease/dementia any Eagle Guaranteed

exemestane (AROMASIN) Cancer 24 months Eagle Guaranteed

exenatide (BYETTA) Diabetes any Eagle Level (with no diabetic complications)

EXFORGE (amlodipine/valsartan) Hypertension any Eagle Level

ezetimibe (ZETIA) Elevated cholesterol any Eagle Level

FACTIVE Antibiotic any Eagle Level

famciclovir (FAMVIR) Cold sores/shingles/herpes any Eagle Level

famciclovir (FAMVIR) Herpes in HIV-infected patients any Eagle Guaranteed

FAMOTIDINE Heartburn any Eagle Level

FAMVIR (famciclovir) Cold sores/shingles/herpes any Eagle Level

FAMVIR (famciclovir) Herpes in HIV-infected patients any Eagle Guaranteed

felbamate (FELBATOL) Epilepsy any Eagle Level

FELBATOL (felbamate) Epilepsy any Eagle Level

felodipine (PLENDIL) Hypertension any Eagle Level

FEMARA (letrozole) Breast cancer/cancer remission

24 months Eagle Guaranteed maintenance

FEMHRT 1/5 Hormonal treatment any Eagle Level

p. 16



fenofibrate (ANTARA) Elevated cholesterol/triglycerides any Eagle Level

fenofibrate (TRICOR) Elevated cholesterol/triglycerides any Eagle Level

FENOPROFEN CALCIUM Pain relief - anti-inflammatory any Eagle Level

fentanyl citrate (ACTIQ lozenge, ABSTRAL sublingual tablets, DURAGESIC patch, FENTORA tablet, IONSYS

Continuous, persistent moderate to any Eagle Level (inpatient hospital use only), LAZANDA nasal spray,

severe chronic pain ONSOLIS buccal soluble film, SUBSYS sublingual

spray)

fentanyl citrate (ACTIQ lozenge, ABSTRAL sublingual tablets, DURAGESIC patch, FENTORA tablet, IONSYS

(inpatient hospital use only), LAZANDA nasal spray, Cancer pain 24 months Eagle Guaranteed ONSOLIS buccal soluble film, SUBSYS sublingual

spray)

FENTORA (fentanyl) tablet Cancer pain 24 months Eagle Guaranteed

FERRALET 90 Iron supplementation any Eagle Level

FERREX 150 FORTE Iron supplementation any Eagle Level

FERROGELS FORTE Iron supplementation any Eagle Level

FERROUS FUMARATE 324 Iron supplementation any Eagle Level

FERROUS GLUCONATE Iron supplementation any Eagle Level

FERROUS SULFATE Iron supplementation any Eagle Level

FEXOFENADINE HCL Antihistamine any Eagle Level

filgrastim (NEUPOGEN) Cancer 24 months Eagle Guaranteed

FINACEA Dermatological treatment any Eagle Level

finasteride (PROPECIA, PROSCAR) Benign prostatic hypertrophy/male

any Eagle Level pattern baldness

FLAREX Eye drops any Eagle Level

FLAVOXATE HCL Urinary spasm any Eagle Level

flecainide (TAMBOCOR) Heart arrhythmia any Eagle Level

FLECTOR Dermatological treatment any Eagle Level

FLEXERIL (cyclobenzaprine) Muscle relaxant any Eagle Level

FLEXTRA-650 Pain relief - nonnarcotic any Eagle Level

FLOMAX (tamsulosin) Benign prostatic hypertrophy any Eagle Level

FLORICAL Calcium supplement any Eagle Level

FLOVENT (fluticasone) Asthma any Eagle Level

FLOXIN OTIC Ear infection any Eagle Level

FLUCONAZOLE Fungal infection any Eagle Level

FLUDROCORTISONE ACETATE Addison’s disease any Eagle Level

flumazenil (ROMAZICON) Drug overdose management 24 months Eagle Guaranteed

flunisolide (AEROBID) Asthma any Eagle Level

FLUOCINONIDE Dermatological treatment any Eagle Level

FLUOCINONIDE-E Dermatological treatment any Eagle Level

FLUOROMETHOLONE Eye drops any Eagle Level

fluoxetine (PROZAC) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49

fluoxetine/olanzapine (SYMBYAX) Depression/bipolar disorder 24 months Eagle Level; decline 40-49

fluphenazine (PROLIXIN) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49

flurazepam (DALMANE) Insomnia any Eagle Level

p. 17




FLURBIPROFEN SODIUM drops Eye drops any Eagle Level

FLURBIPROFEN tablet Rheumatoid arthritis/osteoarthritis any Eagle Level

fluticasone (FLOVENT) Asthma any Eagle Level

fluticasone propionate Allergies any Eagle Level

fluticasone propionate/salmeterol (ADVAIR DISKUS) Chronic obstructive pulmonary


fluticasone propionate/salmeterol (ADVAIR DISKUS) Asthma any Eagle Level

fluvastatin (LESCOL) Elevated cholesterol any Eagle Level

fluvoxamine (LUVOX) Obsessive compulsive disorder any Eagle Level

FOCALIN (dexmethylphenidate HCl) ADHD/narcolepsy/obesity any Eagle Level

FOLBEE Iron supplementation any Eagle Level

FOLBIC Vitamin supplement any Eagle Level

FOLGARD OS Vitamin supplement any Eagle Level

FOLITAB Vitamin supplement any Eagle Level

FOLTRIN Vitamin supplement any Eagle Level

fondaparinux sodium (ARIXTRA) Presurgical prevention of blood clot any Eagle Level

fondaparinux sodium (ARIXTRA) Treatment of blood clot any Eagle Level

fondaparinux sodium (ARIXTRA) reatment of pulmonary embolism

any Eagle Guaranteed (clot)

FORADIL AEROLIZER (formoterol) Asthma any Eagle Level

Chronic obstructive pulmonary FORADIL AEROLIZER (formoterol) disease (COPD)/emphysema/ any Eagle Guaranteed

chronic bronchitis

FORFIVO (bupropion) Depression any Eagle Level

formoterol (FORADIL AEROLIZER) Asthma any Eagle Level

Chronic obstructive pulmonary formoterol (FORADIL AEROLIZER) disease (COPD)/emphysema/ any Eagle Guaranteed

chronic bronchitis

FORTAMET (metformin) Diabetes any Eagle Level (with no diabetic complications)

FORTEO Osteoporosis any Eagle Level

FOSAMAX Osteoporosis any Eagle Level

fosinopril (MONOPRIL) Hypertension any Eagle Level

fosinopril (MONOPRIL) Congestive heart failure any Eagle Guaranteed

fosinopril/hydrochlorothiazide (MONOPRIL HCT) Hypertension any Eagle Level

FOSRENOL (lanthanum carbonate) Kidney disease any Eagle Guaranteed

FRESHKOTE Eye drops any Eagle Level

FROVA Migraine any Eagle Level

furosemide (LASIX) Hypertension any Eagle Level

furosemide (LASIX) Congestive heart failure any Eagle Guaranteed

furosemide (LASIX) Kidney disease any Eagle Guaranteed

furosemide (LASIX) Liver disease any Eagle Guaranteed

gabapentin (NEURONTIN) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed

gabapentin (NEURONTIN) Epilepsy any Eagle Level

GABITRIL (tiagabine) Seizures any Eagle Level

galantamine (RAZADYNE) Alzheimer’s disease any Eagle Guaranteed

p. 18



GAMMAGARD LIQUID Primary immunodeficiency any Eagle Guaranteed

GEMFIBROZIL Elevated triglycerides any Eagle Level

GENGRAF (cyclosporine) Transplant rejection any Eagle Guaranteed

GENTAMICIN SULFATE Antibiotic any Eagle Level

GEODON (ziprasidone) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

glatiramer (COPAXONE) Multiple sclerosis any Eagle Level

glimepiride (AMARYL) Diabetes any Eagle Level (with no diabetic complications)

glimepiride/pioglitazone (DUETACT) Diabetes any Eagle Level (with no diabetic complications)

glimepiride/rosiglitazone (AVANDARYL) Diabetes any Eagle Level (with no diabetic complications)

glipizide (GLUCOTROL) Diabetes any Eagle Level (with no diabetic complications)

glipizide/metformin (METAGLIP) Diabetes any Eagle Level (with no diabetic complications)

GLUCAGEN Diabetes - Hypoglycemia treatment any Eagle Level (with no diabetic complications)

GLUCOPHAGE (metformin) Diabetes any Eagle Level (with no diabetic complications)

GLUCOTROL (glipizide) Diabetes any Eagle Level (with no diabetic complications)

GLUCOVANCE (glyburide/metformin) Diabetes any Eagle Level (with no diabetic complications)

GLUMETZA (metformin) Diabetes any Eagle Level (with no diabetic complications)

glyburide (DIABETA, MICRONASE) Diabetes any Eagle Level (with no diabetic complications)

glyburide/metformin (GLUCOVANCE) Diabetes any Eagle Level (with no diabetic complications)

GLYCOLAX Constipation any Eagle Level

glycopyrrolate (ROBINUL) Ulcers any Eagle Level

GLYSET (miglitol) Diabetes any Eagle Level (with no diabetic complications)

golimumab (SIMPONI) Rheumatoid arthritis/psoriatic

any Eagle Level arthritis

golimumab (SIMPONI) Ankylosing spondylitis any Eagle Level

granisetron (KYTRIL) Nausea and vomiting, postoperative any Eagle Level

granisetron (KYTRIL) Nausea and vomiting,


GRIFULVIN V Antifungal any Eagle Level

GRIS-PEG Antifungal any Eagle Level

GUAIFENEX DM Cough/cold/allergies any Eagle Level

guanfacine (INTUNIV, TENEX) Hypertension any Eagle Level

GUIADEX DM Cough/cold/allergies any Eagle Level

HALCION (triazolam) Insomnia any Eagle Level

HALDOL (haloperidol) Schizophrenia/psychosis 24 months Eagle Level; decline 40-49

HALDOL (haloperidol) Tourette’s disorder any Eagle Level

HALOBETASOL PROPIONATE Dermatological treatment any Eagle Level

haloperidol (HALDOL) Schizophrenia/psychosis 24 months Eagle Level; decline 40-49

haloperidol (HALDOL) Tourette’s disorder any Eagle Level

HECTOROL (doxercalciferol) Parathyroidism due to chronic kidney

any Eagle Guaranteed disease

HELIDAC Ulcers any Eagle Level

HEMATINIC Vitamin supplement any Eagle Level

HEMAX Vitamin supplement any Eagle Level

p. 19




HEPSERA (adefovir) Hepatitis B 24 months Eagle Level (if diagnosed as chronic Eagle

Guaranteed)

HISTA-VENT DA Cough/cold/allergies any Eagle Level

HISTINEX HC Cough/cold/allergies any Eagle Level

HUMALOG (insulin) Diabetes any Eagle Level (with no diabetic complications)

HUMIRA (adalimumab) Rheumatoid arthritis/juvenile

any Eagle Level psoriatic arthritis

HUMIRA (adalimumab) Crohn’s disease any Eagle Level

HUMIRA (adalimumab) Ankylosing spondylitis any Eagle Level

HUMIRA (adalimumab) Plaque psoriasis any Eagle Level

HUMULIN (insulin) Diabetes any Eagle Level (with no diabetic complications)

HYALGAN Osteoarthritis any Eagle Level

HYDONE (chlorthalidone) Hypertension any Eagle Level

HYDONE (chlorthalidone) Congestive heart failure any Eagle Guaranteed

HYDONE (chlorthalidone) Liver cirrhosis any Eagle Guaranteed

HYDONE (chlorthalidone) Edema related to estrogen therapy any Eagle Level

hydralazine (APRESOLINE) Hypertension any Eagle Level

HYDREA (hydroxyurea) Cancer 24 months Eagle Guaranteed

HYDREA (hydroxyurea) Essential thrombocytopenia any Eagle Level

hydrochlorothiazide Hypertension any Eagle Level

hydrochlorothiazide/losartan (HYZAAR) Hypertension any Eagle Level

hydrochlorothiazide/losartan (HYZAAR) Left ventricular hypertrophy 12 months Eagle Guaranteed

hydrochlorothiazide/moexipril (UNIRETIC) Hypertension any Eagle Level

hydrochlorothiazide/spironolactone (ALDACTAZIDE) Hypertension any Eagle Level

hydrochlorothiazide/spironolactone (ALDACTAZIDE) Liver cirrhosis any Eagle Guaranteed

hydrochlorothiazide/spironolactone (ALDACTAZIDE) Congestive heart failure any Eagle Guaranteed

hydrochlorothiazide/spironolactone (ALDACTAZIDE) Kidney disease any Eagle Guaranteed

hydrochlorothiazide/telmisartan (MICARDIS) Hypertension any Eagle Level

hydrochlorothiazide/valsartan (DIOVAN HCT) Hypertension any Eagle Level

HYDROCODONE BITARTRATE Cough/cold/allergies any Eagle Level

HYDROCODONE/ACETAMINOPHEN Pain relief - narcotic any Eagle Level

HYDROCODONE/GUAIFENESIN Cough syrup any Eagle Level

HYDROCODONE/HOMATROPINE Cough syrup any Eagle Level

HYDROCODONE/IBUPROFEN Pain relief - narcotic any Eagle Level

HYDROCORTISONE Dermatological treatment any Eagle Level

HYDRO-DP Cough/cold/allergies any Eagle Level

HYDROMORPHONE HCL Pain relief - narcotic any Eagle Level

HYDRON PSC Cough/cold/allergies any Eagle Level

HYDROQUINONE Dermatological treatment any Eagle Level

HYDRO-TUSSIN Cough syrup any Eagle Level

HYDROXYCHLOROQUINE SULFATE Malaria any Eagle Level

hydroxyurea (HYDREA) Cancer 24 months Eagle Guaranteed

hydroxyurea (HYDREA) Essential thrombocytopenia any Eagle Level

p. 20



HYDROXYZINE HCL Anxiety any Eagle Level

HYDROXYZINE HCL Itching due to allergies any Eagle Level

HYGROTON (chlorthalidone) Hypertension any Eagle Level

HYGROTON (chlorthalidone) Congestive heart failure any Eagle Guaranteed

HYGROTON (chlorthalidone) Liver cirrhosis any Eagle Guaranteed

HYGROTON (chlorthalidone) Edema related to estrogen therapy any Eagle Level

HYOSCYAMINE SULFATE ER Ulcers any Eagle Level

HYTRIN (terazosin) Benign prostatic hypertrophy any Eagle Level

HYZAAR (hydrochlorothiazide/losartan) Hypertension any Eagle Level

HYZAAR (hydrochlorothiazide/losartan) Left ventricular hypertrophy 12 months Eagle Guaranteed

ibandronate (BONIVA) Osteoporosis any Eagle Level

imipramine (TOFRANIL) Depression 24 months Eagle Level; decline 40-49

imiquimod (ALDARA) Dermatological treatment any Eagle Level

IMITREX (sumatriptan) Migraine any Eagle Level

IMURAN (azathioprine) Kidney transplant rejection


IMURAN (azathioprine) Rheumatoid arthritis any Eagle Level

indapamide (LOZOL) Hypertension any Eagle Level

indapamide (LOZOL) Congestive heart failure any Eagle Guaranteed

INDERAL (propranolol) Hypertension any Eagle Level

INDERAL (propranolol) Migraine any Eagle Level

INDERAL (propranolol) Angina 12 months Eagle Guaranteed

INDERAL (propranolol) Hypertrophic subaortic stenosis

any Eagle Guaranteed (cardiomyopathy)

INDOCIN (indomethacin) Rheumatoid arthritis any Eagle Level

indomethacin (INDOCIN) Rheumatoid arthritis any Eagle Level

INSPRA (eplerenone) Hypertension any Eagle Level

INSPRA (eplerenone) Congestive heart failure any Eagle Guaranteed

insulin glulisine (APIDRA) Diabetes any Eagle Level (with no diabetic complications)

INTELENCE (etravirine) HIV/AIDS any Eagle Guaranteed

interferon alfa-2b (INTRON) Cancer 24 months Eagle Guaranteed

interferon alfa-2b (INTRON) Hepatitis C 24 months Eagle Guaranteed

interferon alfa-2b (INTRON) AIDS-related Kaposi’s sarcoma any Eagle Guaranteed

interferon alfa-2b (INTRON) Genital warts any Eagle Level

Interferon beta-1a (AVONEX, REBIF) Multiple sclerosis any Eagle Level

INTRON-A (interferon alfa-2b) Cancer 24 months Eagle Guaranteed

INTRON-A (interferon alfa-2b) Hepatitis C 24 months Eagle Guaranteed

INTRON-A (interferon alfa-2b) AIDS-related Kaposi’s sarcoma any Eagle Guaranteed

INTRON-A (interferon alfa-2b) Genital warts any Eagle Level

INTUNIV (guanfacine) Hypertension any Eagle Level

INVEGA (paliperidone) Schizophrenia 24 months Eagle Level; decline 40-49

IONSYS (fentanyl) HOSPITAL USE ONLY Continuous, persistent moderate to

any Eagle Level severe chronic pain

p. 21




ipratropium bromide HFA (ATROVENT HFA) Chronic obstructive pulmonary

any Eagle Guaranteed disease (COPD)/emphysema

ipratropium bromide nasal spray (ATROVENT NASAL Allergic and non-allergic nasal any Eagle Level

SPRAY) symptoms

IQUIX Eye drops any Eagle Level

irbesartan (AVAPRO) Hypertension any Eagle Level

irbesartan (AVAPRO) Diabetic kidney disease any Eagle Guaranteed

irbesartan and hydrochlorothiazide (AVALIDE) Hypertension any Eagle Level

ISOMETHEPTENE/DICHLORALPHENAZONE/ ACET- Migraine any Eagle Level

AMINOPHEN

isoniazid (NYDRAZID) Tuberculosis any Eagle Guaranteed

ISOPTIN (verapamil) Hypertension any Eagle Level

ISOPTIN (verapamil) Angina 12 months Eagle Guaranteed

ISOPTIN (verapamil) Arrhythmia any Eagle Level

ISOPTO HOMATROPINE Eye drops any Eagle Level

ISORDIL (isosorbide) Angina 12 months Eagle Guaranteed

isosorbide (ISORDIL) Angina 12 months Eagle Guaranteed

isosorbide dinitrate and hydralazine hydrochloride Congestive heart failure any Eagle Guaranteed

(BIDIL)

isradipine (DYNACIRC-CR) Hypertension any Eagle Level

JALYN Benign prostatic hypertrophy any Eagle Level

JANUMET (metformin/sitagliptin) Diabetes any Eagle Level (with no diabetic complications)

JANUVIA (sitagliptin) Diabetes any Eagle Level (with no diabetic complications)

KALETRA (lopinavir/ritonavir) HIV/AIDS any Eagle Guaranteed

KAPIDEX Esophagitis/heartburn/GERD any Eagle Level

KENALOG-40 Multiple indications - corticosteroid any Eagle Level

KEPPRA (levetiracetam) Epilepsy any Eagle Level

KEROL Dermatological treatment any Eagle Level

KETOCONAZOLE Fungal infection any Eagle Level

KETOPROFEN Pain relief - anti-inflammatory any Eagle Level

KETOROLAC TROMETHAMINE Seasonal allergic symptoms any Eagle Level

KLARON Dermatological treatment any Eagle Level

KLONOPIN (clonazepam) Seizures any Eagle Level

KLONOPIN (clonazepam) Panic disorder 24 months Eagle Level; decline 40-49

KLOR-CON 10 Potassium supplementation any Eagle Level

KYTRIL (granisetron) Nausea and vomiting, postoperative any Eagle Level

KYTRIL (granisetron) Nausea and vomiting,


labetalol (NORMODYNE, TRANDATE) Hypertension any Eagle Level

LAC-HYDRIN (ammonium lactate) Dermatological treatment any Eagle Level

LACTULOSE Constipation any Eagle Level

LAMICTAL (lamotrigine) Epilepsy any Eagle Level

LAMICTAL (lamotrigine) Bipolar disorder 24 months Eagle Level; decline 40-49

LAMISIL Fungal infection any Eagle Level



lamivudine (EPIVIR) HIV/AIDS any Eagle Guaranteed

lamivudine/zidovudine (COMBIVIR) HIV/AIDS any Eagle Guaranteed

lamotrigine (LAMICTAL) Epilepsy any Eagle Level

lamotrigine (LAMICTAL) Bipolar disorder 24 months Eagle Level; decline 40-49

LANOXICAPS (digoxin) Heart failure any Eagle Guaranteed

LANOXIN (digoxin) Heart failure any Eagle Guaranteed

lansoprazole (PREVACID) Ulcers any Eagle Level

lanthanum carbonate (FOSRENOL) Kidney disease any Eagle Guaranteed

LANTUS (insulin) Diabetes any Eagle Level (with no diabetic complications)

LASIX (furosemide) Hypertension any Eagle Level

LASIX (furosemide) Congestive heart failure any Eagle Guaranteed

LASIX (furosemide) Kidney disease any Eagle Guaranteed

LASIX (furosemide) Liver disease any Eagle Guaranteed

LAZANDA (fentanyl) nasal spray Cancer pain 24 months Eagle Guaranteed

leflunomide (ARAVA) Rheumatoid arthritis any Eagle Level

lenalidomide (REVLIMID) Cancer 24 months Eagle Guaranteed

LESCOL (fluvastatin) Elevated cholesterol any Eagle Level

letrozole (FEMARA) Breast cancer/cancer remission


LEUCOVORIN CALCIUM Cancer 24 months Eagle Guaranteed

LEVAQUIN Antibiotic any Eagle Level

LEVEMIR FLEXPEN (insulin) Diabetes any Eagle Level (with no diabetic complications)

levetiracetam (KEPPRA) Epilepsy any Eagle Level

LEVITRA Erectile dysfunction any Eagle Level

LEVOBUNOLOL HCL Eye drops any Eagle Level

LEXAPRO (escitalopram) Depression/anxiety 24 months Eagle Level; decline 40-49

LIBRAX (chlordiazepoxide/clidinium) Irritable bowel syndrome any Eagle Level

LIBRIUM (chlordiazepoxide HCl) Alcohol withdrawal 24 months Eagle Guaranteed

LIDODERM Dermatological treatment any Eagle Level

LIMBITROL (chlordiazepoxide/amitriptyline) Depression/anxiety 24 months Eagle Level; decline 40-49

LIMBREL Osteoarthritis any Eagle Level

LINCOCIN Antibiotic any Eagle Level

liothyronine (CYTOMEL) Thyroid replacement any Eagle Level

LIPITOR (atorvastatin) Elevated cholesterol any Eagle Level

LIQUITEARS Eye drops any Eagle Level

liraglutide (VICTOZA) Diabetes any Eagle Level (with no diabetic complications)

lisinopril (PRINIVIL, ZESTRIL) Hypertension any Eagle Level

lisinopril (PRINIVIL, ZESTRIL) Congestive heart failure any Eagle Guaranteed

lisinopril (PRINIVIL, ZESTRIL) Heart attack 12 months Eagle Guaranteed

lisinopril/hydrochlorothiazide (PRINZIDE, Hypertension any Eagle Level

ZESTORETIC)

LITHIUM CARBONATE Bipolar disorder any Eagle Level; decline 40-49

LOCOID LIPOCREAM Dermatological treatment any Eagle Level

p. 23




LODRANE 24D Cough/cold/allergies any Eagle Level

LOPERAMIDE HCL Diarrhea any Eagle Level

lopinavir/ritonavir (KALETRA) HIV/AIDS any Eagle Guaranteed

LOPRESSOR (metoprolol) Hypertension any Eagle Level

LOPRESSOR (metoprolol) Angina 12 months Eagle Guaranteed

LOPRESSOR (metoprolol) Congestive heart failure any Eagle Guaranteed

LORATADINE Antihistamine any Eagle Level

lorazepam (ATIVAN) Anxiety any Eagle Level

losartan (COZAAR) Hypertension any Eagle Level

losartan (COZAAR) Diabetic Kidney Disease 24 months Eagle Guaranteed

LOTEMAX Eye drops any Eagle Level

LOTENSIN (benazepril HCl) Hypertension any Eagle Level

LOTREL (amlodipine/benazepril) Hypertension any Eagle Level

LOTRONEX Irritable bowel syndrome any Eagle Level

lovastatin (ALTOPREV, MEVACOR, ALTOCOR) Elevated cholesterol any Eagle Level

LOVAZA (omega-3-acid ethyl esters) Elevated triglycerides any Eagle Level

LOVENOX (enoxaparin) Deep vein thrombosis (clot) any Eagle Level

LOVENOX (enoxaparin) Unstable angina 12 months Eagle Guaranteed

LOVENOX (enoxaparin) Heart attack 12 months Eagle Guaranteed

LOXAPINE SUCCINATE Schizophrenia 24 months Eagle Level; decline 40-49

LOZOL (indapamide) Hypertension any Eagle Level

LOZOL (indapamide) Congestive heart failure any Eagle Guaranteed

lubiprostone (AMITIZA) Constipation any Eagle Level

LUMIGAN Eye drops any Eagle Level

LUNESTA (eszopiclone) Insomnia any Eagle Level

LUPRON DEPOT Cancer 24 months Eagle Guaranteed

LUVOX (fluvoxamine) Obsessive compulsive disorder any Eagle Level

LUXIQ Dermatological treatment any Eagle Level

LYRICA (pregabalin) Neuropathic pain - diabetic/

24 months Eagle Guaranteed postherpetic

LYRICA (pregabalin) Seizures any Eagle Level

LYRICA (pregabalin) Fibromyalgia any Eagle Level

MAGNESIUM SULFATE Convulsion any Eagle Level

MAGNESIUM SULFATE Magnesium deficiency any Eagle Level

MALARONE Malaria any Eagle Level

MAPAP Pain relief - nonnarcotic any Eagle Level

MAPAP PM Insomnia any Eagle Level

MAPAP SINUS MAXIMUM STRENGTH Cough/cold/allergies any Eagle Level

MARINOL (dronabinol) Appetite stimulant in patients with


MARINOL (dronabinol) Nausea and vomiting related to


MARPLAN Depression any Eagle Level

MAVIK (trandolapril) Hypertension any Eagle Level

p. 24



MAVIK (trandolapril) Congestive heart failure any Eagle Guaranteed

MAXAIR AUTOHALER (pirbuterol inhaler) Asthma any Eagle Level

MAXALT Migraine any Eagle Level

MAXARON FORTE Iron supplementation any Eagle Level

MAXIDEX Eye drops any Eagle Level

MAXZIDE (triamterene/hydrochlorothiazide) Hypertension any Eagle Level

MAXZIDE (triamterene/hydrochlorothiazide) Edema any Eagle Level

MEBENDAZOLE Worm infection any Eagle Level

MECLIZINE HCL Nausea any Eagle Level

MEFLOQUINE HCL Malaria any Eagle Level

MEGACE ES (megestrol) liquid Appetite stimulant in patients with


MEGACE ES (megestrol) liquid Cancer-related weight loss 24 months Eagle Guaranteed

MEGACE ES (megestrol) tablets Breast or uterine cancer palliative

24 months Eagle Guaranteed therapy

megestrol (MEGACE) liquid Appetite stimulant in patients with


megestrol (MEGACE) liquid Cancer-related weight loss 24 months Eagle Guaranteed

megestrol (MEGACE) tablets Breast or uterine cancer palliative

24 months Eagle Guaranteed therapy

memantine (NAMENDA) Alzheimer’s disease any Eagle Guaranteed

MENEST (esterified estrogen) Menopausal symptoms any Eagle Level

MENEST (esterified estrogen) Breast and prostatic cancer 24 months Eagle Guaranteed

MENTAX Dermatological treatment any Eagle Level

MEPERIDINE HCL Moderate to severe pain - narcotic any Eagle Level

MEPHYTON Coagulation disorder any Eagle Level

MEPROZINE Moderate to severe pain - narcotic any Eagle Level

mercaptopurine (PURINETHOL) Cancer 24 months Eagle Guaranteed

mesalamine (ASACOL) Ulcerative colitis any Eagle Level

mesalamine (ROWASA) Ulcerative colitis/proctitis any Eagle Level

METAGLIP (glipizide/metformin) Diabetes any Eagle Level

METANX Diabetic neuropathy 24 months Eagle Guaranteed

metaproterenol sulfate (ALUPENT) Asthma any Eagle Level

metaproterenol sulfate (ALUPENT) Emphysema any Eagle Guaranteed

metformin (FORTAMET, GLUCOPHAGE, Diabetes any Eagle Level (with no diabetic complications)

GLUMETZA, RIOMET)

metformin/pioglitazone (ACTOPLUS MET) Diabetes any Eagle Level (with no diabetic complications)

metformin/repaglinide (PRANDIMET) Diabetes any Eagle Level (with no diabetic complications)

metformin/rosiglitazone (AVANDAMET) Diabetes any Eagle Level (with no diabetic complications)

metformin/sitagliptin (JANUMET) Diabetes any Eagle Level (with no diabetic complications)

methadone HCl (DISKETS, DOLOPHINE, Moderate to severe pain - narcotic any Eagle Level

METHADOSE)

methadone HCl (DISKETS, DOLOPHINE, Opiate addiction 24 months Eagle Guaranteed

METHADOSE)

METHAZOLAMIDE Glaucoma any Eagle Level




METHENAMINE HIPPURATE Urinary tract infection any Eagle Level

METHERGINE Obstetric care any Eagle Level

METHIMAZOLE Thyroid any Eagle Level

methocarbamol (ROBAXIN) Muscle relaxer any Eagle Level

methotrexate (RHEUMATREX DOSE PACK, TREXALL) Rheumatoid arthritis any Eagle Level

methotrexate (RHEUMATREX DOSE PACK, TREXALL) Psoriasis, severe any Eagle Level

methotrexate (RHEUMATREX DOSE PACK, TREXALL) Cancer 24 months Eagle Guaranteed

methsuximide (CELONTIN) Seizures any Eagle Level

methyclothiazide (ENDURON) Hypertension any Eagle Level

methyclothiazide (ENDURON) Edema due to hormone or steroid

any Eagle Level therapy

methyclothiazide (ENDURON) Liver cirrhosis any Eagle Guaranteed

methyclothiazide (ENDURON) Congestive heart failure any Eagle Guaranteed

methyldopa (ALDOMET) Hypertension any Eagle Level

methylphenidate hydrochloride (CONCERTA) ADHD any Eagle Level

methylprednisolone Multiple indications - corticosteroid any Eagle Level

methyltestosterone (TESTRED) Males: hormonal treatment any Eagle Level

methyltestosterone (TESTRED) Females: Inoperable breast cancer 24 months Eagle Guaranteed

METIPRANOLOL Eye drops any Eagle Level

metoclopramide HCl (REGLAN) GERD any Eagle Level

metoclopramide HCl (REGLAN) Diabetic gastroparesis (delayed

any Eagle Level digestion)

metoclopramide HCl (REGLAN) Nausea and vomiting related to


metolazone (ZAROXOLYN) Hypertension any Eagle Level

metolazone (ZAROXOLYN) Congestive heart failure any Eagle Guaranteed

metolazone (ZAROXOLYN) Kidney disease any Eagle Guaranteed

metoprolol (LOPRESSOR, TOPROL-XL) Hypertension any Eagle Level

metoprolol (LOPRESSOR, TOPROL-XL) Angina 12 months Eagle Guaranteed

metoprolol (LOPRESSOR, TOPROL-XL) Congestive heart failure any Eagle Guaranteed

METROGEL Dermatological treatment any Eagle Level

METRONIDAZOLE Antibiotic any Eagle Level

metyrosine (DEMSER) Pheochromocytomas any Eagle Level

MEVACOR (lovastatin) Elevated cholesterol any Eagle Level

mexiletine (MEXITIL) Heart arrhythmia any Eagle Level

MEXITIL (mexiletine) Heart arrhythmia any Eagle Level

MIACALCIN (calcitonin) Osteoporosis any Eagle Level

MIACALCIN (calcitonin) Paget’s bone disease any Eagle Level

MI-ACID Antacid any Eagle Level

MICARDIS (hydrochlorothiazide/telmisartan) Hypertension any Eagle Level

MICRONASE (glyburide) Diabetes any Eagle Level (with no diabetic complications)

MIDAMOR (amiloride HCl) Hypertension any Eagle Level

MIDAMOR (amiloride HCl) Congestive heart failure any Eagle Guaranteed

MIDODRINE HCL Low blood pressure any Eagle Level

p. 26



miglitol (GLYSET) Diabetes any Eagle Level (with no diabetic complications)

MIGRANAL Migraine any Eagle Level

MIGRATEN Migraine any Eagle Level

milnacipran (SAVELLA) Fibromyalgia any Eagle Level

MIMYX Dermatological treatment any Eagle Level

MINIPRESS (prazosin) Hypertension any Eagle Level

MINOCYCLINE HCL Antibiotic any Eagle Level

MINOXIDIL Hypertension any Eagle Level

MINOXIDIL Hair regrowth treatment any Eagle Level

MINTOX PLUS Antacid any Eagle Level

MIRAPEX (pramipexole) Restless legs syndrome any Eagle Level

MIRAPEX (pramipexole) Parkinson’s disease any Eagle Level

mirtazapine (REMERON) Depression any Eagle Level

misoprostol (CYTOTEC) Ulcers any Eagle Level

MOBIC Pain relief - anti-inflammatory any Eagle Level

MOBISYL Dermatological treatment any Eagle Level

modafinil (PROVIGIL) Narcolepsy (improves excessive

any Eagle Level sleepiness)

moexipril (UNIVASC) Hypertension any Eagle Level

MOMETASONE FUROATE Dermatological treatment any Eagle Level

MONOPRIL (fosinopril) Hypertension any Eagle Level

MONOPRIL (fosinopril) Congestive heart failure any Eagle Guaranteed

MONOPRIL HCT (fosinopril/hydrochlorothiazide) Hypertension any Eagle Level

montelukast (SINGULAIR) Allergies/asthma any Eagle Level

morphine sulfate (AVINZA) Moderate to severe pain - narcotic any Eagle Level

MOVIPREP Constipation any Eagle Level

moxifloxacin (AVELOX) Antibiotic any Eagle Level

MST 600 Pain relief - nonnarcotic any Eagle Level

MUCOMYST (acetylcysteine) Emphysema any Eagle Guaranteed

MUCOMYST (acetylcysteine) Tuberculosis any Eagle Guaranteed

MUCOMYST (acetylcysteine) Pneumonia/bronchitis any Eagle Level

MUCOMYST (acetylcysteine) Cystic fibrosis any Eagle Guaranteed

MULTAQ Heart arrhythmia any Eagle Level

MULTIRET FOLIC-500 Vitamin supplement any Eagle Level

MUPIROCIN Dermatological treatment any Eagle Level

MYCELEX (clotrimazole) Fungal infection any Eagle Level

mycophenolate (CELLCEPT) Transplant rejection any Eagle Guaranteed

mycophenolic acid (MYFORTIC) Organ transplant rejection any Eagle Guaranteed

MYFORTIC (mycophenolic acid) Organ transplant rejection any Eagle Guaranteed

nabumetone (RELAFEN) Rheumatoid arthritis/osteoarthritis any Eagle Level

nadolol (CORGARD) Hypertension any Eagle Level

nadolol (CORGARD) Angina 12 months Eagle Guaranteed

nadolol/bendroflumethiazide (CORZIDE) Hypertension any Eagle Level

p. 27




NAFCILLIN SODIUM Antibiotic any Eagle Level

NAFTIN Dermatological treatment any Eagle Level

NALDEX Cough/cold/allergies any Eagle Level

naloxone (NARCAN) Opiate overdose 24 months Eagle Guaranteed

naltrexone (REVIA) Alcohol dependence 24 months Eagle Guaranteed

naltrexone (VIVITROL) Alcohol dependence/opiate

24 months Eagle Guaranteed dependence

NAMENDA (memantine) Alzheimer’s disease any Eagle Guaranteed

NAPROXEN Pain relief - anti-inflammatory any Eagle Level

NARCAN (naloxone) Opiate overdose 24 months Eagle Guaranteed

NASACORT AQ Allergy symptoms any Eagle Level

NASAREL Allergy symptoms any Eagle Level

NASONEX Allergy symptoms any Eagle Level

NATAFORT Vitamin supplement any Eagle Level

NATALCARE GLOSSTABS Vitamin supplement any Eagle Level

NATATAB RX Vitamin supplement any Eagle Level

nateglinide (STARLIX) Diabetes any Eagle Level (with no diabetic complications)

nebivolol (BYSTOLIC) Hypertension any Eagle Level

NEEVO DHA Vitamin supplement any Eagle Level

NEFAZODONE HCL Depression any Eagle Level

NEO AC Cough/cold/allergies any Eagle Level

NEOMYCIN/POLYMYXIN/BACITRACIN Eye drops any Eagle Level

NEOMYCIN/POLYMYXIN/DEXAMETHASONE Eye drops any Eagle Level

NEOMYCIN/POLYMYXIN/GRAMICIDIN Eye drops any Eagle Level

NEOMYCIN/POLYMYXIN/HYDROCORTISONE Eye drops any Eagle Level

NEOMYCIN SULFATE Topical antibiotic any Eagle Level

NERVO B-12 SL Vitamin supplement any Eagle Level

NEUPOGEN (filgrastim) Cancer 24 months Eagle Guaranteed

NEURONTIN (gabapentin) Diabetic peripheral neuropathy pain 24 months Eagle Guaranteed

NEURONTIN (gabapentin) Epilepsy any Eagle Level

NEUTRA-PHOS Mineral/electrolyte supplement any Eagle Level

NEVANAC Eye drops any Eagle Level

NEXAVAR (sorafenib) Cancer 24 months Eagle Guaranteed

NEXIUM (esomeprazole) GERD/ulcers any Eagle Level

niacin (NIASPAN) Elevated cholesterol any Eagle Level

niacin/lovastatin (ADVICOR) Elevated cholesterol any Eagle Level

NIACOR Vitamin supplement/elevated

any Eagle Level cholesterol

NIASPAN (niacin) Elevated cholesterol any Eagle Level

NICORETTE STARTER KIT Smoking cessation 12 months Smoker rates (Eagle Level)

NICOTINE Smoking cessation 12 months Smoker rates (Eagle Level)

NIFEDICAL (nifedipine) Hypertension any Eagle Level

nifedipine (ADALAT, PROCARDIA, NIFEDICAL, Hypertension any Eagle Level

AFEDITAB)

p. 28



NIFEREX Iron supplementation any Eagle Level

nisoldipine (Sular) Hypertension any Eagle Level

NITROFURANTOIN Urinary tract antibiotic any Eagle Level

nitroglycerine (NITRO-TIME, NITROLINGUAL, Angina 12 months Eagle Guaranteed

NITROMIST, NITROSTAT, NITROQUICK

NITROLINGUAL (nitroglycerin) Angina 12 months Eagle Guaranteed

NITROMIST (nitroglycerin) Angina 12 months Eagle Guaranteed

NITROQUICK (nitroglycerin) Angina 12 months Eagle Guaranteed

NITROSTAT (nitroglycerin) Angina 12 months Eagle Guaranteed

NITRO-TIME (nitroglycerin) Angina 12 months Eagle Guaranteed

nizatidine (AXID) Ulcers/esophagitis any Eagle Level

NOHIST-EXT Antihistamine any Eagle Level

NOREL SR Cough/cold/allergies any Eagle Level

NORETHINDRONE ACETATE Hormonal treatment any Eagle Level

NORFLEX (orphenadrine) Muscle relaxer any Eagle Level

NORMODYNE (labetalol) Hypertension any Eagle Level

NOROXIN Antibiotic any Eagle Level

NORPRAMIN (desipramine HCl) Depression any Eagle Level

NORTRIPTYLINE HCL Depression any Eagle Level

NORVASC (amlodipine) Hypertension any Eagle Level

NORVASC (amlodipine) Coronary artery disease 12 months Eagle Guaranteed

NORVIR (ritonavir) HIV/AIDS any Eagle Guaranteed

NOVACORT Dermatological treatment any Eagle Level

NOVOLOG (insulin) Diabetes any Eagle Level (with no diabetic complications)

NUCYNTA Moderate to severe pain - narcotic any Eagle Level

NUTROPIN AQ PEN Hormonal treatment any Eagle Level

NUVIGIL Narcolepsy (improves excessive


NYDRAZID (isoniazid) Tuberculosis any Eagle Guaranteed

NYSTATIN Fungal infection any Eagle Level

NYSTATIN/TRIAMCINOLONE Dermatological treatment any Eagle Level

NYSTOP Dermatological treatment any Eagle Level

OFLOXACIN Eye drops any Eagle Level

olanzapine (ZYPREXA) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

olmesartan (BENICAR HCT) Hypertension any Eagle Level

OLUX-E Dermatological treatment any Eagle Level

omega-3-acid ethyl esters (LOVAZA) Elevated triglycerides any Eagle Level

omeprazole (PRILOSEC) Ulcers/GERD/esophagitis any Eagle Level

omeprazole/sodium bicarbonate (ZEGERID) Ulcers/GERD/esophagitis any Eagle Level

OMNARIS Allergies any Eagle Level

OMNICEF Antibiotic any Eagle Level

onabotulinumtoxinA (BOTOX) Spasticity/multiple indications any Eagle Level

ondansetron (ZOFRAN) Nausea/vomiting related to


p. 29




ONGLYZA (saxagliptin) Diabetes any Eagle Level (with no diabetic complications)

ONSOLIS (fentanyl) buccal soluble film Cancer pain 24 months Eagle Guaranteed

OPANA ER Moderate to severe pain - narcotic any Eagle Level

OPTI-CLEAR Eye drops any Eagle Level

OPTIVAR Eye drops any Eagle Level

ORACEA Dermatological treatment any Eagle Level

ORAP Tourette’s disorder any Eagle Level

orphenadrine (NORFLEX) Muscle relaxer any Eagle Level

OVIDE Dermatological treatment any Eagle Level

OXAPROZIN Pain relief - anti-inflammatory any Eagle Level

oxazepam (SERAX) Anxiety any Eagle Level

oxcarbazepine (TRILEPTAL) Seizures any Eagle Level

OXISTAT Dermatological treatment any Eagle Level

OXSORALEN ULTRA Psoriasis, severe any Eagle Level

OXYCODONE Moderate to severe pain - narcotic any Eagle Level

OXYTROL Urinary spasm any Eagle Level

OYSCO 500 Mineral/electrolyte supplement any Eagle Level

OYST-CAL Mineral/electrolyte supplement any Eagle Level

PACERONE (amiodarone) Heart arrhythmia any Eagle Level

paliperidone (INVEGA) Schizophrenia 24 months Eagle Level; decline 40-49

pamidronate (AREDIA) Cancer 24 months Eagle Guaranteed

pamidronate (AREDIA) Paget’s bone disease any Eagle Level

PAMINE FORTE Ulcer any Eagle Level

pancrelipase (CREON) Pancreatic enzyme - cystic fibrosis any Eagle Guaranteed

pancrelipase (CREON) Pancreatic enzyme - chronic

12 months Eagle Level; decline 40-49 pancreatitis

pancrelipase (CREON) Pancreatic enzyme - pancreatectomy 12 months Eagle Level; decline 40-49

PANLOR SS Moderate to severe pain - narcotic any Eagle Level

pantoprazole (PROTONIX) GERD/ulcers any Eagle Level

papain and urea (ACCUZYME) Dermatological treatment any Eagle Level

PARAFON FORTE DSC (chlorzoxazone) Musculoskeletal pain any Eagle Level

PAREGORIC Diarrhea any Eagle Level

paricalcitol (ZEMPLAR) Kidney disease any Eagle Guaranteed

paroxetine (PAXIL, PEXEVA) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49

PATANASE Allergies any Eagle Level

PATANOL Eye drops any Eagle Level

PAXIL (paroxetine) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49

PEDIOX-S Antihistamine any Eagle Level

PEGASYS (peginterferon alfa-2a) Hepatitis B and C 24 months Eagle Guaranteed

PEG-INTRON Hepatitis C 24 months Eagle Guaranteed

PENICILLIN V POTASSIUM Antibiotic any Eagle Level

PENLAC NAIL LACQUER Dermatological treatment any Eagle Level

PENTAZOCINE/ACETAMINOPHEN Pain relief - narcotic any Eagle Level

p. 30



PENTAZOCINE/NALOXONE HCL Moderate to severe pain - narcotic any Eagle Level

pentoxifylline (PENTOXIL, TRENTAL) Circulation disorder any Eagle Level

PENTOXIL (pentoxifylline) Circulation disorder any Eagle Level

PERIDEX (chlorhexidine gluconate) Antiseptic rinse any Eagle Level

perindopril (ACEON) Hypertension any Eagle Level

perindopril (ACEON) Coronary artery disease 12 months Eagle Guaranteed

PERMETHRIN Dermatological treatment any Eagle Level

PERPHENAZINE Schizophrenia 24 months Eagle Level; decline 40-49

PERPHENAZINE Severe nausea/vomiting any Eagle Level

PERPHENAZINE/AMITRIPTYLINE Depression/anxiety any Eagle Level

PERSANTINE (dipyridamole) Clot prevention after valve

12 months Eagle Guaranteed replacement

PEXEVA (paroxetine) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49

PHENAVENT LA Cough/cold/allergies any Eagle Level

PHENAZOPYRIDINE HCL Urinary spasm any Eagle Level

PHENDIMETRAZINE TARTRATE Obesity any Eagle Level

PHENOBARBITAL Sedative/seizures any Eagle Level

PHENTERMINE HCL ADHD/narcolepsy/obesity any Eagle Level

phenytoin (DILANTIN) Seizures any Eagle Level

PHENYTOIN SODIUM EXTENDED Seizures any Eagle Level

P-HIST Cough/cold/allergies any Eagle Level

PHOSPHA 250 NEUTRAL Mineral/electrolyte supplement any Eagle Level

PILOCARPINE HCL (Ophthalmic) Eye drops any Eagle Level

PILOCARPINE HCL (Oral) Dry mouth any Eagle Level

PILOCARPINE HCL (Oral) Dry mouth due to cancer radiation

24 months Eagle Guaranteed treatment

PINDOLOL Hypertension any Eagle Level

pioglitazone (ACTOS) Diabetes any Eagle Level (with no diabetic complications)

pirbuterol inhaler (MAXAIR AUTOHALER) Asthma any Eagle Level

PIROXICAM Pain relief - anti-inflammatory any Eagle Level

PLAVIX (clopidogrel) Heart attack 12 months Eagle Guaranteed

PLAVIX (clopidogrel) Stroke 12 months Eagle Guaranteed

PLENDIL (felodipine) Hypertension any Eagle Level

PLETAL (cilostazol) Circulatory disease any Eagle Level

POLY HIST FORTE Cough/cold/allergies any Eagle Level

POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE Eye drops any Eagle Level

pramipexole (MIRAPEX) Restless legs syndrome any Eagle Level

pramipexole (MIRAPEX) Parkinson’s disease any Eagle Level

pramlintide (SYMLIN) Diabetes any Eagle Level (with no diabetic complications)

PRAMOSONE Dermatological treatment any Eagle Level

PRANDIMET (metformin/repaglinide) Diabetes any Eagle Level (with no diabetic complications)

PRANDIN (repaglinide) Diabetes any Eagle Level (with no diabetic complications)

PRAVACHOL (pravastatin) Elevated cholesterol any Eagle Level

p. 31




pravastatin (PRAVACHOL) Elevated cholesterol any Eagle Level

prazosin (MINIPRESS) Hypertension any Eagle Level

PRECOSE (acarbose) Diabetes any Eagle Level (with no diabetic complications)

PREDNISOLONE Multiple indications - corticosteroid any Eagle Level

PREDNISOLONE ACETATE Eye drops any Eagle Level

PREDNISONE Multiple indications - corticosteroid any Eagle Level

pregabalin (LYRICA) Neuropathic pain - diabetic/

24 months Eagle Guaranteed postherpetic

pregabalin (LYRICA) Seizures any Eagle Level

pregabalin (LYRICA) Fibromyalgia any Eagle Level

PREMARIN Hormonal treatment any Eagle Level

PREMPRO Hormonal treatment any Eagle Level

PRENATAL 19 Vitamin supplement any Eagle Level

PRENATAL PLUS Vitamin supplement any Eagle Level

PREVACID (lansoprazole) Ulcers any Eagle Level

PREVPAC Ulcers any Eagle Level

PRILOSEC (omeprazole) Ulcers/GERD/esophagitis any Eagle Level

PRIMACARE ONE Vitamin supplement any Eagle Level

PRIMIDONE Epilepsy any Eagle Level

PRINIVIL (lisinopril) Hypertension any Eagle Level

PRINIVIL (lisinopril) Congestive heart failure any Eagle Guaranteed

PRINIVIL (lisinopril) Heart attack 12 months Eagle Guaranteed

PRINZIDE (lisinopril/hydrochlorothiazide) Hypertension any Eagle Level

PRISTIQ Depression any Eagle Level

PROAIR HFA (albuterol) Asthma any Eagle Level

PROBENECID Gout any Eagle Level

PROCARDIA (nifedipine) Hypertension any Eagle Level

prochlorperazine (COMPRO) Nausea/vomiting any Eagle Level

PROCHLORPERAZINE MALEATE Nausea/vomiting, severe any Eagle Level (unless coupled w/cancer)

PROCHLORPERAZINE MALEATE Schizophrenia/anxiety 24 months Eagle Level; decline 40-49

PROCRIT (epoetin alfa) Cancer-related anemia 24 months Eagle Guaranteed

PROCRIT (epoetin alfa) HIV-related anemia any Eagle Guaranteed

PROCRIT (epoetin alfa) Kidney disease-related anemia any Eagle Guaranteed

PROCTOFOAM HC Hemorrhoids any Eagle Level

PROCTOSOL HC Hemorrhoids any Eagle Level

PROGRAF (tacrolimus) Organ transplant rejection any Eagle Guaranteed

PROLIXIN (fluphenazine) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49

PROMETHAZINE Cough/cold/allergies any Eagle Level

PROMETHAZINE HCL Antihistamine any Eagle Level

PROMETRIUM Hormonal treatment any Eagle Level

PROPAFENONE HCL Heart arrhythmia any Eagle Level

PROPANTHELINE BROMIDE Ulcers any Eagle Level

PROPECIA (finasteride) Male pattern baldness any Eagle Level

p. 32



propoxyphene (DARVON) Pain relief - narcotic any Eagle Level

propoxyphene-N/acetaminophen Pain relief - narcotic any Eagle Level

propranolol (INDERAL) Hypertension any Eagle Level

propranolol (INDERAL) Migraine any Eagle Level

propranolol (INDERAL) Angina 12 months Eagle Guaranteed

propranolol (INDERAL) Hypertrophic subaortic stenosis

any Eagle Guaranteed (cardiomyopathy)

PROPYLTHIOURACIL Thyroid any Eagle Level

PROSCAR (finasteride) Benign prostatic hypertrophy any Eagle Level

PROSED/DS Urinary antibiotic any Eagle Level

PROTONIX (pantoprazole) GERD/ulcers any Eagle Level

PROTOPIC Dermatological treatment any Eagle Level

PROVENTIL (albuterol) Asthma any Eagle Level

PROVIGIL (modafinil) Narcolepsy (improves excessive


PROZAC (fluoxetine) Depression/OCD/panic disorder 24 months Eagle Level; decline 40-49

PRUDOXIN Dermatological treatment any Eagle Level

PSEUDOEPHEDRINE/GUAIFENESIN/ DEXTRO- Cough/cold/allergies any Eagle Level

METHORPHAN

PSEUDOVENT 400 Cough/cold/allergies any Eagle Level

PURINETHOL (mercaptopurine) Cancer 24 months Eagle Guaranteed

PYLERA Ulcers any Eagle Level

PYRIDOSTIGMINE BROMIDE Myasthenia gravis any Eagle Level

QDALL AR Antihistamine any Eagle Level

QUALAQUIN Malaria any Eagle Level

QUESTRAN (cholestyramine) Elevated cholesterol any Eagle Level

quetiapine (SEROQUEL) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

quinapril (ACCUPRIL) Hypertension any Eagle Level

quinapril/hydrochlorothiazide (QUINARETIC) Hypertension any Eagle Level

QUINARETIC (quinapril/hydrochlorothiazide) Hypertension any Eagle Level

QUINIDINE SULFATE Heart arrhythmia any Eagle Level

QUINIDINE SULFATE Malaria any Eagle Level

QVAR (beclomethasone) Asthma any Eagle Level

raloxifene (EVISTA) Osteoporosis any Eagle Level

ramelteon (ROZEREM) Insomnia any Eagle Level

ramipril (ALTACE) Hypertension any Eagle Level

ramipril (ALTACE) Congestive heart failure any Eagle Guaranteed

RANEXA (ranolazine) Angina 12 months Eagle Guaranteed

RANITIDINE HCL Heartburn/indigestion any Eagle Level

ranolazine (RANEXA) Angina 12 months Eagle Guaranteed

RAPAFLO Benign prostatic hypertrophy any Eagle Level

RAPAMUNE (sirolimus) Organ transplant rejection


rasagiline (AZILECT) Parkinson’s disease any Eagle Level

p. 33




RAZADYNE (galantamine) Alzheimer’s disease any Eagle Guaranteed

RE 10 WASH Dermatological treatment any Eagle Level

REBIF (interferon beta-1a) Multiple sclerosis any Eagle Level

RECLAST (zoledronic acid) Osteoporosis any Eagle Level

REGLAN (metoclopramide) GERD any Eagle Level

REGLAN (metoclopramide) Diabetic gastroparesis (delayed

24 months Eagle Guaranteed digestion)

REGLAN (metoclopramide) Nausea and vomiting related to


REGRANEX Dermatological treatment any Eagle Level

RELAFEN (nabumetone) Rheumatoid arthritis/osteoarthritis any Eagle Level

RELISTOR Constipation any Eagle Level

RELPAX Migraine any Eagle Level

REMERON (mirtazapine) Depression 24 months Eagle Level; decline 40-49

RENACIDIN Kidney stones any Eagle Level

RENAGEL (sevelamer) Kidney disease any Eagle Guaranteed

RENAL Vitamin supplement any Eagle Level

RENVELA (sevelamer) Kidney disease any Eagle Guaranteed

repaglinide (PRANDIN) Diabetes any Eagle Level (with no diabetic complications)

REPLIVA 21/7 Iron supplementation any Eagle Level

REQUIP (ropinirole) Restless legs syndrome any Eagle Level

REQUIP (ropinirole) Parkinson’s disease any Eagle Level

RESTASIS Eye drops any Eagle Level

RESTORIL (temazepam) Insomnia any Eagle Level

RETIN-A MICRO Dermatological treatment any Eagle Level

RETROVIR (zidovudine) HIV/AIDS any Eagle Guaranteed

REVIA (naltrexone) Alcohol dependence 24 months Eagle Guaranteed

REVLIMID (lenalidomide) Cancer 24 months Eagle Guaranteed

REYATAZ (atazanavir) HIV-related anemia any Eagle Guaranteed

RHINOCORT AQUA Nasal spray any Eagle Level

ribavirin (COPEGUS) Hepatitis C 24 months Eagle Guaranteed

RIFAMPIN Tuberculosis any Eagle Guaranteed

RIMANTADINE HCL Influenza any Eagle Level

RINNOVI NAIL SYSTEM Dermatological treatment any Eagle Level

RIOMET (metformin) Diabetes any Eagle Level (with no diabetic complications)

risedronate (ACTONEL) Osteoporosis any Eagle Level

RISPERDAL (risperidone) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

risperidone (RISPERDAL) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

ritonavir (NORVIR) HIV/AIDS any Eagle Guaranteed

rivastigmine transdermal (EXELON) Alzheimer’s disease/dementia any Eagle Guaranteed

ROBAXIN (methocarbamol) Muscle relaxer any Eagle Level

ROBINUL (glycopyrrolate) Ulcers any Eagle Level

ROCALTROL (calcitriol) Calcium replacement in PRIMARY

any Eagle Level parathyroid disease

p. 34



ROCALTROL (calcitriol) Kidney failure; SECONDARY para-

any Eagle Guaranteed thyroid disease

ROMAZICON (flumazenil) Drug overdose management 24 months Eagle Guaranteed

ropinirole (REQUIP) Restless legs syndrome any Eagle Level

ropinirole (REQUIP) Parkinson’s disease any Eagle Level

ROSAC Dermatological treatment any Eagle Level

rosiglitazone (AVANDIA) Diabetes any Eagle Level (with no diabetic complications)

rosuvastatin (CRESTOR) Elevated cholesterol any Eagle Level

ROWASA (mesalamine) Ulcerative colitis/proctitis any Eagle Level

ROZEREM (ramelteon) Insomnia any Eagle Level

R-TANNA Cough/cold/allergies any Eagle Level

SALKERA Dermatological treatment any Eagle Level

salmeterol (SEREVENT) Asthma any Eagle Level

salmeterol (SEREVENT) Chronic obstructive pulmonary


SALSALATE Pain relief - nonnarcotic any Eagle Level

SANCTURA XR Overactive bladder any Eagle Level

SANTYL Dermatological treatment any Eagle Level

SAVELLA (milnacipran) Fibromyalgia any Eagle Level

saxagliptin (ONGLYZA) Diabetes any Eagle Level (with no diabetic complications)

SECTRAL (acebutolol HCl) Hypertension any Eagle Level

SECTRAL (acebutolol HCl) Arrhythmia any Eagle Level

selegiline (ELDEPRYL, ZELAPAR) Parkinson’s disease any Eagle Level

SELENIUM SULFIDE Dermatological treatment any Eagle Level

SENNA Constipation any Eagle Level

SENNA S Constipation any Eagle Level

SENSIPAR (cinacalcet) Primary parathyroid disease any Eagle Level

SENSIPAR (cinacalcet) Parathyroid cancer 24 months Eagle Guaranteed

SENSIPAR (cinacalcet) Kidney disease any Eagle Guaranteed

SERAX (oxazepam) Anxiety any Eagle Level

SEREVENT DISKUS (salmeterol) Asthma any Eagle Level

SEREVENT DISKUS (salmeterol) Chronic obstructive pulmonary


SEROQUEL (quetiapine) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

sertraline (ZOLOFT) Depression any Eagle Level

sevelamer (RENAGEL, RENVELA) Kidney disease any Eagle Guaranteed

SILVER SULFADIAZINE Dermatological treatment any Eagle Level

SIMCOR (simvastatin/niacin) Elevated cholesterol any Eagle Level

SIMPONI (golimumab) Rheumatoid arthritis/psoriatic

any Eagle Level arthritis

SIMPONI (golimumab) Ankylosing spondylitis any Eagle Level

simvastatin (ZOCOR) Elevated cholesterol any Eagle Level

simvastatin/niacin (SIMCOR) Elevated cholesterol any Eagle Level

SINEMET (carbidopa/levodopa) Parkinson’s disease any Eagle Level

p. 35




SINEQUAN (doxepin HCl) Depression/anxiety any Eagle Level

SINGULAIR (montelukast) Allergies/asthma any Eagle Level

sirolimus (RAPAMUNE) Organ transplant rejection


sitagliptin (JANUVIA) Diabetes any Eagle Level (with no diabetic complications)

SKELAXIN Muscle relaxer any Eagle Level

SODIUM SULFACETAMIDE Eye drops any Eagle Level

SOLARAZE Dermatological treatment any Eagle Level

SOLTAMOX (tamoxifen) Breast cancer/cancer remission


SONATA (zaleplon) Insomnia any Eagle Level

sorafenib (NEXAVAR) Cancer 24 months Eagle Guaranteed

SORBITOL Constipation any Eagle Level

SORBUTUSS Cough/cold/allergies any Eagle Level

SORIATANE Dermatological treatment any Eagle Level

SORIATANE CK Dermatological treatment any Eagle Level

SORINE (sotalol) Heart arrhythmia any Eagle Level

sotalol (BETAPACE, SORINE) Heart arrhythmia any Eagle Level

SPECTRACEF Antibiotic any Eagle Level

SPIRIVA (tiotropium) Chronic obstructive pulmonary


spironolactone (ALDACTONE) Hyperaldosteronism/low potassium any Eagle Level

spironolactone (ALDACTONE) Hypertension any Eagle Level

spironolactone (ALDACTONE) Liver cirrhosis any Eagle Guaranteed

spironolactone (ALDACTONE) Congestive heart failure any Eagle Guaranteed

spironolactone (ALDACTONE) Kidney disease any Eagle Guaranteed

STALEVO 100 Parkinson’s disease any Eagle Level

STARLIX (nateglinide) Diabetes any Eagle Level (with no diabetic complications)

STRATTERA ADHD any Eagle Level

STROMECTOL Worm infection any Eagle Level

STROVITE ADVANCE Vitamin supplement any Eagle Level

SUBOXONE Opiate dependency 24 months Eagle Guaranteed

SUBSYS (fentanyl) sublingual spray Cancer pain 24 months Eagle Guaranteed

SUBUTEX Opiate dependency 24 months Eagle Guaranteed

SUCRALFATE Ulcers any Eagle Level

SULAR (nisoldipine) Hypertension any Eagle Level

SULFAMETHOXAZOLE/TRIMETHOPRIM DS Antibiotic any Eagle Level

SULFASALAZINE Ulcerative colitis any Eagle Level

SULINDAC Pain relief - anti-inflammatory any Eagle Level

sumatriptan (IMITREX) Migraine any Eagle Level

SUSTIVA (efavirenz) HIV/AIDS any Eagle Guaranteed

SYMBICORT (budesonide/formoterol) Asthma any Eagle Level

SYMBICORT (budesonide/formoterol) Chronic obstructive pulmonary


p. 36



SYMBYAX (fluoxetine/olanzapine) Depression/bipolar disorder any Eagle Level

SYMLIN (pramlintide) Diabetes any Eagle Level (with no diabetic complications)

SYMMETREL (amantadine HCl) Parkinson’s disease any Eagle Level

SYMMETREL (amantadine HCl) Drug-induced movement disorders any Eagle Level

SYNTHROID Thyroid any Eagle Level

SYNVISC Osteoarthritis any Eagle Level

SYSTANE Eye drops any Eagle Level

TACLONEX Dermatological treatment any Eagle Level

tacrolimus (PROGRAF) Organ transplant rejection any Eagle Guaranteed

tadalafil (CIALIS) Erectile dysfunction any Eagle Level

TAGAMET (cimetidine) Heartburn any Eagle Level

TAMBOCOR (flecainide) Heart arrhythmia any Eagle Level

TAMIFLU Influenza any Eagle Level

tamoxifen (SOLTAMOX) Breast cancer/cancer remission


tamsulosin (FLOMAX) Benign prostatic hypertrophy any Eagle Level

TANDEM Iron supplementation any Eagle Level

TARKA (trandolapril/verapamil) Hypertension any Eagle Level

TAXOTERE (docetaxel) Cancer 24 months Eagle Guaranteed

TEBAMIDE Nausea/vomiting any Eagle Level

TEGRETOL (carbamazepine) Epilepsy any Eagle Level

TEGRETOL (carbamazepine) Facial nerve disorder any Eagle Level

TEKTURNA (aliskiren) Hypertension any Eagle Level

TEKTURNA HCT (aliskiren/hydrochlorothiazide) Hypertension any Eagle Level

temazepam (RESTORIL) Insomnia any Eagle Level

TENEX (guanfacine) Hypertension any Eagle Level

tenofovir (VIREAD) Hepatitis B 24 months Eagle Guaranteed

tenofovir (VIREAD) HIV/AIDS any Eagle Guaranteed

TENORETIC (atenolol/chlorthalidone) Hypertension any Eagle Level

TENORMIN (atenolol) Hypertension any Eagle Level

TENORMIN (atenolol) Angina 12 months Eagle Guaranteed

TENORMIN (atenolol) Heart attack 12 months Eagle Guaranteed

TENUATE (diethylpropion) Obesity any Eagle Level (refer build chart)

terazosin (HYTRIN) Benign prostatic hypertrophy any Eagle Level

terbutaline (BRETHINE, BRICANYL) Asthma/bronchitis any Eagle Level

terbutaline (BRETHINE, BRICANYL) Emphysema any Eagle Guaranteed

TERCONAZOLE Fungal infection any Eagle Level

TESTOSTERONE CYPIONATE Hormonal treatment any Eagle Level

TESTOSTERONE PROPIONATE Hormonal treatment any Eagle Level

TESTRED (methyltestosterone) Males: hormonal treatment any Eagle Level

TESTRED (methyltestosterone) Females: Inoperable breast cancer 24 months Eagle Guaranteed

TETRACAINE HCL Eye drops any Eagle Level

TETRACYCLINE HCL Antibiotic any Eagle Level

p. 37




THALITONE (chlorthalidone) Hypertension any Eagle Level

THALITONE (chlorthalidone) Congestive heart failure any Eagle Guaranteed

THALITONE (chlorthalidone) Liver cirrhosis any Eagle Guaranteed

THALITONE (chlorthalidone) Edema related to estrogen therapy any Eagle Level

THALOMID Cancer 24 months Eagle Guaranteed

THEOPHYLLINE Asthma any Eagle Level

THEOPHYLLINE Emphysema any Eagle Guaranteed

THIAMINE HCL Vitamin supplement any Eagle Level

THIORIDAZINE HCL Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49

THIOTHIXENE Schizophrenia 24 months Eagle Level; decline 40-49

THORAZINE (chlorpromazine HCl) Schizophrenia/psychotic disorder 24 months Eagle Level; decline 40-49

tiagabine (GABITRIL) Seizures any Eagle Level

TIAZAC (diltiazem) Hypertension any Eagle Level

TIAZAC (diltiazem) Angina 12 months Eagle Guaranteed

TICLID (ticlopidine) Stroke 12 months Eagle Guaranteed

TICLID (ticlopidine) Clot prevention after heart stent


ticlopidine (TICLID) Stroke 12 months Eagle Guaranteed

ticlopidine (TICLID) Clot prevention after heart stent


TIKOSYN (dofetilide) Heart arrhythmia any Eagle Level

TIMOLOL MALEATE OPHTHALMIC GEL FORMING Eye drops any Eagle Level

TINDAMAX Antibiotic any Eagle Level

tiotropium (SPIRIVA) Chronic obstructive pulmonary


TIZANIDINE HCL Muscle relaxer any Eagle Level

TOBI Antibiotic any Eagle Level

TOBRADEX Eye drops any Eagle Level

TOBRAMYCIN SULFATE Eye drops any Eagle Level

TOFRANIL (imipramine) Depression any Eagle Level

TOLNAFTATE Dermatological treatment any Eagle Level

TOPAMAX (topiramate) Epilepsy any Eagle Level

TOPAMAX (topiramate) Migraine any Eagle Level

topiramate (TOPAMAX) Epilepsy any Eagle Level

topiramate (TOPAMAX) Migraine any Eagle Level

TOPROL-XL (metoprolol) Hypertension any Eagle Level

TOPROL-XL (metoprolol) Angina 12 months Eagle Guaranteed

TOPROL-XL (metoprolol) Congestive heart failure any Eagle Guaranteed

torsemide (DEMADEX) Hypertension any Eagle Level

torsemide (DEMADEX) Liver disease any Eagle Guaranteed

torsemide (DEMADEX) Congestive heart failure any Eagle Guaranteed

torsemide (DEMADEX) Kidney disease any Eagle Guaranteed

TOVIAZ Overactive bladder any Eagle Level

TRAMADOL HCL Moderate to severe pain - narcotic any Eagle Level

p. 38



TRANDATE (labetalol) Hypertension any Eagle Level

trandolapril (MAVIK) Hypertension any Eagle Level

trandolapril (MAVIK) Congestive heart failure any Eagle Guaranteed

trandolapril/verapamil (TARKA) Hypertension any Eagle Level

TRANSDERM-SCOP Nausea/vomiting any Eagle Level

TRANXENE (clorazepate dipotassium) Anxiety disorder any Eagle Level

TRANXENE (clorazepate dipotassium) Seizures any Eagle Level

TRANXENE (clorazepate dipotassium) Alcohol withdrawal 24 months Eagle Guaranteed

TRAVATAN Eye drops any Eagle Level

trazodone (DESYREL) Depression any Eagle Level

TRENTAL (pentoxifylline) Circulation disorder any Eagle Level

TRETINOIN Dermatological treatment any Eagle Level

TREXIMET Migraine any Eagle Level

TRIAMCINOLONE ACETONIDE Dermatological treatment any Eagle Level

triamcinolone oral inhalation (AZMACORT) Asthma any Eagle Level

triamterene/hydrochlorothiazide (DYAZIDE, MAXZIDE) Hypertension any Eagle Level

triamterene/hydrochlorothiazide (DYAZIDE, MAXZIDE) Edema any Eagle Level

triazolam (HALCION) Insomnia any Eagle Level

TRICOR (fenofibrate) Elevated cholesterol/triglycerides any Eagle Level

TRIFLUOPERAZINE HCL Schizophrenia/anxiety 24 months Eagle Level; decline 40-49

TRIFLURIDINE Eye drops any Eagle Level

trihexyphenidyl (ARTANE) Parkinson’s disease any Eagle Level

TRILEPTAL (oxcarbazepine) Seizures any Eagle Level

TRILIPIX Elevated cholesterol/triglycerides any Eagle Level

TRI-LUMA Dermatological treatment any Eagle Level

TRILYTE Constipation any Eagle Level

TRIMETHOBENZAMIDE HCL Nausea/vomiting any Eagle Level

TRIMETHOPRIM Antibiotic any Eagle Level

TRIPLE ANTIBIOTIC Dermatological treatment any Eagle Level

TRIXAICIN HP Dermatological treatment any Eagle Level

TROPICAMIDE Eye drops any Eagle Level

TRUSOPT Eye drops any Eagle Level

TRUVADA (emtricitabine/tenofovir) HIV/AIDS any Eagle Guaranteed

TUSNEL-HC Cough/cold/allergies any Eagle Level

TUSSI-12D Cough/cold/allergies any Eagle Level

TUSSIONEX PENNKINETIC EXTENDED RELEASE Cough/cold/allergies any Eagle Level

TYGACIL Antibiotic any Eagle Level

TYLENOL WITH CODEINE #3 (acetaminophen with Pain relief - narcotic any Eagle Level

codeine #3)

UDAMIN SP Vitamin supplement any Eagle Level

ULORIC Gout any Eagle Level

ULTRACET Pain relief - narcotic any Eagle Level

UMECTA PD Dermatological treatment any Eagle Level

p. 39




UNIRETIC (hydrochlorothiazide/moexipril) Hypertension any Eagle Level

UNIVASC (moexipril) Hypertension any Eagle Level

UREA Dermatological treatment any Eagle Level

URISED Urinary antibiotic any Eagle Level

UROQID #2 Urinary antibiotic any Eagle Level

UROXATRAL Benign prostatic hypertrophy any Eagle Level

URSO (ursodiol) Gallstones any Eagle Level

URSO (ursodiol) Liver cirrhosis any Eagle Guaranteed

ursodiol (ACTIGALL, URSO) Gallstones any Eagle Level

ursodiol (ACTIGALL, URSO) Liver cirrhosis any Eagle Guaranteed

UTA Urinary antibiotic any Eagle Level

VALCYTE (valganciclovir) Cytomegalovirus-AIDS any Eagle Guaranteed

VALCYTE (valganciclovir) Cytomegalovirus-organ transplant any Eagle Guaranteed

valganciclovir (VALCYTE) Cytomegalovirus-AIDS any Eagle Guaranteed

valganciclovir (VALCYTE) Cytomegalovirus-organ transplant any Eagle Guaranteed

VALIUM (diazepam) Anxiety disorder any Eagle Level

VALIUM (diazepam) Convulsive disorder/muscle spasms any Eagle Level

VALIUM (diazepam) Alcohol withdrawal 24 months Eagle Guaranteed

VALPROIC ACID Seizures any Eagle Level

valsartan (DIOVAN) Hypertension any Eagle Level

valsartan (DIOVAN) Congestive heart failure any Eagle Guaranteed

valsartan (DIOVAN) Treatment after heart attack 12 months Eagle Guaranteed

VALTREX Cold sores/herpes/chickenpox any Eagle Level

VALTURNA Hypertension any Eagle Level

VANCOCIN HCL Antibiotic any Eagle Level

VANIQA Dermatological treatment any Eagle Level

varenicline (CHANTIX) Smoking cessation 12 months smoking rates (Eagle Guaranteed)

VASERETIC (enalapril/hydrochlorothiazide) Hypertension any Eagle Level

VASOTEC (enalapril) Hypertension any Eagle Level

VASOTEC (enalapril) Congestive heart failure any Eagle Guaranteed

VAZOTAN Cough/cold/allergies any Eagle Level

VAZOTUSS HC Cough/cold/allergies any Eagle Level

venlafaxine (EFFEXOR) Depression/anxiety any Eagle Level

VENTOLIN (albuterol) Asthma any Eagle Level

VERAMYST Nasal allergy symptoms any Eagle Level

verapamil (CALAN, COVERA-HS, ISOPTIN, VERELAN) Hypertension any Eagle Level

verapamil (CALAN, COVERA-HS, ISOPTIN, VERELAN) Angina 12 months Eagle Guaranteed

verapamil (CALAN, COVERA-HS, ISOPTIN, VERELAN) Arrhythmia any Eagle Level

VERELAN (verapamil) Hypertension any Eagle Level

VERELAN (verapamil) Angina 12 months Eagle Guaranteed

VERELAN (verapamil) Arrhythmia any Eagle Level

VERTIGOHEEL Vertigo any Eagle Level

VESICARE Overactive bladder any Eagle Level

p. 40



VFEND Fungal infection any Eagle Level

VIAGRA Erectile dysfunction any Eagle Level

VICKS NYQUIL Cough/cold/allergies any Eagle Level

VICTOZA (liraglutide) Diabetes any Eagle Level (with no diabetic complications)

VIGAMOX Eye drops any Eagle Level

VIMOVO Pain relief- anti-inflammatory any Eagle Level

VIREAD (tenofovir) Hepatitis B 24 months Eagle Guaranteed

VIREAD (tenofovir) HIV/AIDS any Eagle Guaranteed

VIVITROL (naltrexone) Alcohol dependence/opiate

24 months Eagle Guaranteed dependence

VYTORIN Elevated cholesterol any Eagle Level

VYVANSE ADHD any Eagle Level

warfarin (COUMADIN) Clot prevention after heart valve


warfarin (COUMADIN) Atrial fibrillation any Eagle Level

WELCHOL (colesevelam) Elevated cholesterol any Eagle Level

WELCHOL (colesevelam) Diabetes any Eagle Level (with no diabetic complications)

WELLBUTRIN (bupropion) Depression any Eagle Level

XALATAN Eye drops any Eagle Level

XELODA (capecitabine) Cancer 24 months Eagle Guaranteed

XENADERM Dermatological treatment any Eagle Level

XENICAL Obesity any Eagle Level

XERAC AC Dermatological treatment any Eagle Level

XIBROM Eye drops any Eagle Level

XIFAXAN Antibiotic any Eagle Level

XOPENEX Asthma any Eagle Level

XPECT-AT Cough/cold/allergies any Eagle Level

XYZAL Antihistamine any Eagle Level

ZADITOR Eye drops any Eagle Level

zafirlukast (ACCOLATE) Asthma any Eagle Level

zaleplon (SONATA) Insomnia any Eagle Level

ZAROXOLYN (metolazone) Hypertension any Eagle Level

ZAROXOLYN (metolazone) Congestive heart failure any Eagle Guaranteed

ZAROXOLYN (metolazone) Kidney disease any Eagle Guaranteed

ZEGERID (omeprazole/sodium bicarbonate) Ulcers/GERD/esophagitis any Eagle Level

ZELAPAR (selegiline) Parkinson’s disease any Eagle Level

ZEMPLAR (paricalcitol) Kidney disease any Eagle Guaranteed

ZESTORETIC (lisinopril/hydrochlorothiazide) Hypertension any Eagle Level

ZESTRIL (lisinopril) Hypertension any Eagle Level

ZESTRIL (lisinopril) Congestive heart failure any Eagle Guaranteed

ZESTRIL (lisinopril) Heart attack 12 months Eagle Guaranteed

ZETIA (ezetimibe) Elevated cholesterol any Eagle Level

ZIAGEN (abacavir) HIV/AIDS any Eagle Guaranteed

p. 41




zidovudine (RETROVIR) HIV/AIDS any Eagle Guaranteed

ZINC SULFATE Mineral supplementation any Eagle Level

ziprasidone (GEODON) Schizophrenia/bipolar disorder 24 months Eagle Level; decline 40-49

ZOCOR (simvastatin) Elevated cholesterol any Eagle Level

ZOFRAN (ondansetron) Nausea/vomiting related to


zoledronic acid (RECLAST, ZOMETA) Osteoporosis any Eagle Level

ZOLOFT (sertraline) Depression any Eagle Level

zolpidem tartrate (AMBIEN) Insomnia any Eagle Level

ZOMETA (zoledronic acid) Osteoporosis any Eagle Level

ZOMIG Migraine any Eagle Level

ZONEGRAN (zonisamide) Epilepsy any Eagle Level

zonisamide (ZONEGRAN) Epilepsy any Eagle Level

ZOTANE HC External ear infection any Eagle Level

ZOVIRAX Herpes any Eagle Level

ZOVIRAX (acyclovir) Shingles/chickenpox/genital herpes any Eagle Level

ZYBAN (bupropion) Smoking cessation 12 months Eagle Level

ZYLET Eye drops any Eagle Level

ZYMAR Eye drops any Eagle Level

ZYPREXA (olanzapine) Schizophrenia/bipolar disorder any Eagle Level

ZYRTEC Antihistamine any Eagle Level

ZYRTEC-D Cough/cold/allergies any Eagle Level

ZYVOX Antibiotic any Eagle Level

p. 42

Field Prescription Drug Guide

The following Guide is designed to assist you when writing a SIMPL Preferred,

SIMPL Standard or Modified Whole Life application. It discloses the most

widely used prescriptions and usage. It is not uncommon for applicants to be

on medication or multiple medications and this is an underwriting

consideration.

Prescribed medications “obtained or increased in the last 2 years” are used in the underwriting process for SIMPL Preferred, SIMPL Standard OR MWL.

PLEASE NOTE:

When multiple Rxs are used for one disorder it may be a sign that the disease/illness may be at

an uninsurable stage and this can be reason for a decline. Please call or check with Underwriter. LBL/CLICO may investigate any medication (or combination of) which may suggest treatment for

a condition that may be life threatening.

If you see an unlisted drug or have any questions, please call our Underwriting Department at

1-800-731-4300 prior to submitting the application. BPH = Benign prostate hypertrophy HTN = Hypertension or High Blood Pressure CHF = Congestive Heart Failure MS = Multiple Sclerosis COPD = Chronic Obstructive RA = Rheumatoid Arthritis

Pulmonary Disease RLS = Restless Leg Syndrome • (dot) = “Yes” approved for plan SIMPL SIMPL

List of Medications PREF. STD. MWL Medical Condition Underwriting Decision

3TC HIV treatment

Abarelix Prostate cancer

Accupril • • • HTN/CHF/Renal failure Yes if for HTN only

Aggrenox • • Circulatory disorders/Stroke/TIA Stroke/TIA MWL only

Akineton • • Parkinson's Disease

Aldactone • • • HTN/CHF/Renal Failure prevention Yes if for HTN only

Aldesleukin Cancer treatment

Alglucerase Gaucher's genetic disease

Altace • • • HTN/CHF/Kidney Failure prevention Yes if for HTN only

Altretamine Cancer treatment

Amantadine Severe Parkinson's Disease

Ambrisentan Pulmonary HTN/CHF

Amicar • • Anemia/Cirrhosis SIMPL Std if Cirrhosis only

Amiodarone • CHF/Irregular heart beat

LBL-FPDG-05-02-2016 1

SIMPL SIMPL


Amlodipine Besylate • • • HTN/CHF/Kidney Failure prevention Yes if for HTN only

Anakinra • Rheumatoid Arthritis

Anastrozole • Cancer treatment Yes Testosterone only

Aplenzin • • • Major Depression/Depression

Aromasin • Breast cancer

Arimidex • Breast cancer

Aricept Dementia, Alzheimer’s Dementia

Atenolol • • • HTN/Migraines

Atripla AIDS, HIV treatment

Avinza • Moderate to Severe pain

Avastin Chemotherapy for cancer treatment

Avonex Multiple Sclerosis (MS)

Azasan Anti-rejection for organ transplant

Azathioprine Anti-rejection for organ transplant

AZT HIV/AIDS treatment

Baclofen • Anti-spasmodic/MS/Nerve Damage

Benztropine • Severe Parkinson's Disease

Betaseron Multiple Sclerosis (MS)

Bicalutamide Cancer treatment

BiDil • Angina/Heart Disease

Bocerevir • Hepatitis C

Bumetanide CHF/Kidney disease

Bumex CHF/Kidney disease

Buprenex • Moderate to severe chronic pain

Buprenorphine • Moderate to severe chronic pain

Butrans • Moderate to severe chronic pain

Byetta • • • Diabetes Only if controlled

Caduet • • • HTN/CHF/Kidney Failure prevention Yes if for HTN only

Calcitriol Kidney Dialysis

Captopril • • • HTN/CHF Yes if for HTN only

Carbidopa Parkinson's Disease

Carboplatin Cancer

Cardizem • • • HTN/Angina/Abnormal Heart Rhythms Yes if for HTN only

Carvedilol • • • Heart failure/Hypertension Yes if for HTN only

Cellcept Anti-rejection for organ transplant

Certolizumab pegol • Crohn’s/Rheumatoid,Psoriatic Arthritis

Cilostazol • Claudication/Clogged arteries

Cimzia • Crohn’s/Rheumatoid,Psoriatic Arthritis

Cognex Dementia/Alzheimer's Dementia

Combivent • COPD/Emphysema

Copaxone Multiple Sclerosis (MS)

Cordarone CHF/ Heart failure

Coreg • • • Heart failure/Hypertension Yes if for HTN only

Coumadin • • Blood thinner If for Stroke MWL only

Cozaar • • • HTN

Creon • Pancreatic insufficiency

Cyclosporine Autoimmune disorders

Cymbalta • • • Depression

LBL-FPDG-05-02-2016 2

SIMPL SIMPL


DALIResp • Severe Respiratory disorder(s)

Digoxin • • Irregular heart beat

Dilaudid • Moderate to severe pain

Diltiazem • • • HTN/Angina/Cardiac Yes if for HTN only

Dimethyl fumarate Multiple Sclerosis/Brain Lesions

Disulfiram Alcoholism

Donepezil Alzheimer's dementia

Dopamine • Circulatory problems

Dopar • Severe Parkinson's Disease

Dronabinol Cancer, AIDS treatment Dronedarone • Anti-arrhythmic

Droperidol • Tranquilizer, sedative, anti-nausea

Droxia Leukemia/Cancer/Sickle Cell Anemia

Dynacirc CR • • • HTN/High Blood Pressure

Effient • CAD/stent - angioplasty history If current use only MWL

Enalapril • • • HTN/Hypertension/CHF Yes if for HTN only

Eldepryl • Severe Parkinson's Disease

Entresto Chronic heart failure

Eliquis • Blood thinner

Enbrel • Arthritis/Ankylosing Spondylitis

Emcyt Cancer

Entacapone Severe Parkinson’s Disease

Enzalutamide Cancer

Erbitux Cancer treatment

Ergoloid Dementia

Erythropoietin • Anemia of Renal or Kidney origin

Etanercept • Arthritis/Ankylosing Spondylitis

Etopophos Cancer

Eulexin Cancer

Evzio Narcotic overdose

Exelon Dementia

Exemestane • Breast cancer

Extavia Multiple Sclerosis (MS)

Femara Cancer

Fentanyl • Severe Pain

Fentanyl Patch • Severe Pain

Flecainide • Arrhythmias/Abnormal Heart Rhythms No CHF,Cardiomyopathy

Fluphenazine • Psychotic Disorders

Formoterol • COPD

Furosemide • • • Fluid/HTN/CHF Yes if for HTN only

Gabapentin • • • Pain/Neuropathy SMP Pref or Std < 900 mg

Galantamine Alzheimer's dementia

Glatiramer Multiple Sclerosis (MS)

Gleevec Cancer

Goserelin Cancer

Gilenya Multiple Sclerosis (MS)

HCTZ • • • Fluid/HTN/CHF/Kidney failure Yes if for HTN only

LBL-FPDG-05-02-2016 3

SIMPL SIMPL


Hectoral Kidney Disorder

Hexalen Cancer

Hydergine Alzheimer's dementia

Hydrea • Leukemia (CLL)

Hydromorphone • Moderate to severe pain

Hydroxychloroquine • Autoimmune disorders

Hydroxyurea • Leukemia (CLL)

Humira • Rheumatoid

Idarubicin Leukemia

Ifosfamide Cancer

Imatinib Cancer

Imdur • Angina/Heart disease

Imuran Organ transplant/blood disorders

Incivek • • Hepatitis C

Inderal • • • Tremor/HTN/Angina Yes if for HTN only

Insulin • • • Diabetes Only if controlled

Interferon • Cancer, HIV/AIDS, Hepatitis C Yes if Hepatitis C only

Isosorbide • Angina/Heart disease

Jakafi Organ transplant/blood disorders

Kemadrin • Severe Parkinson's Disease

Kineret • Rheumatoid Arthritis

Lamivudine HIV/AIDS treatment

Lanoxin • Heart/A Fib If used for CHF, decline

Lantus • • • Diabetes Only if controlled

Larodopa • Severe Parkinson's Disease

Lasix • • • Fluid/HTN/CHF Yes if for HTN only

Letrozole • Cancer/Breast Cancer

Levodopa • Severe Parkinson's Disease

Lisinopril • • • HTN/Heart Yes if for HTN only

Lloperidone • Schizophrenia

Lopressor • • • HTN/Heart Yes if for HTN only

Lopinavir HIV/AIDS treatment

Lupron • Cancer

Megace • Cancer/HIV/AIDS treatment MWL only if for appetite

Megestrol • Cancer/HIV/AIDS treatment MWL only if for appetite

Memantine Alzheimer's dementia

Mercaptopurine Leukemia

Mesna Cancer

Methadone Severe pain/Drug addiction

Methotrexate • • Cancer/MS/Rheumatoid Arthritis (RA) MWL if for Cancer

Metoprolol • • • HTN/Angina/Heart Yes if for HTN only

Mitomycin Cancer

Modafinil • • • Daytime sleepiness/Narcolepsy/OSA

Morphine • Moderate to Severe pain

Mycophenolate Anti-rejection Organ transplant

Multaq • Anti-arrhythmic

Naloxone Narcotic overdose

LBL-FPDG-05-02-2016 4

SIMPL SIMPL


Naltrexone Drug Addiction

Namenda Alzheimer's dementia

Narcan Narcotic overdose

Neurontin • • • Pain/Neuropathy SMP if < 900 mg daily

Nifedipine • • • HTN/Angina/Heart SMP PREF for HTN only

Nitrobid • Angina/chest pains/Heart

Nitroglycerine • Angina/chest pains/Heart

Nitroquick • Angina/chest pains/Heart

Nivolumab Advanced Cancer

Norfloxacin • • • Infections

Norvir HIV/AIDS treatment

Nucynta • • • Pain/Neuropathy

Nuvigil • • • Narcolepsy, Excessive sleepiness

Octreotide • Cancer treatment

Olysio • • Hepatitis C

Opdivo Advanced Cancer

Oxycontin • Severe pain

Paclitaxel Cancer

Parlodel Severe Parkinson's Disease

Permex • Severe Parkinson's Disease

Plaquenil • Autoimmune disorders, Lupus

Plavix • Blood thinner

Pradaxa • Blood thinner

Pramipexole • RLS/Mild Parkinson's Disease

Prasugrel • CAD/stent - angioplasty history If current use only MWL

Procrit • Kidney Disorder

Procylidine • Severe Parkinson's Disease

Prograf Organ transplant rejection

Provigil • • • Excessive sleepiness/Narcolepsy/OSA

Ranexa • Chronic Angina

Ranolazine • Chronic Angina

Rasagiline • Severe Parkinson's Disease

Renagel Kidney Dialysis

Remeron • • • Depression/Tremors/Panic disorder

Remicade • Rheumatoid

Reminyl Alzheimer's/Dementia

Requip • • • Parkinson's/Restless Leg Syndrome SMPL Pref./Std if RLS only

Ribavirin • • Hepatitis C

Rifaximin Liver Failure

Ritonavir HIV/AIDS treatment

Rivastigmine Alzheimer's/Dementia

Ropinirole • • • RLS/Parkinson's Disease

Ruxolitinib Organ transplant/blood disorders

Sandostatin • Cancer treatment

Selegiline • • • RLS/Dementia SMP Pref./STD If RLS only

Simeprevir • • Hepatitis C

Sinemet Parkinson’s Disease

LBL-FPDG-05-02-2016 5

SIMPL SIMPL


Spiriva • COPD/Emphysema

Spironolactone • • • Fluid/HTN/CHF Yes if for HTN only

Szofosburvir • • Hepatitis C

Solvadi • • Hepatitis C

Stalevo • Severe Parkinson's Disease

Stribild HIV/AIDS treatment

Suboxone Drug and Alcohol treatment

Sunitinib Malate Advanced Renal Cancer & GIST

Sutent Advanced Renal Cancer & GIST Symmetrel • • Parkinson's Disease

Tacrolimus Organ transplant rejection

Tamoxifen • Breast cancer

Taiazac • • • HTN/Angina Yes if for HTN only

Tapentadol • • • Pain/Neuropathy

Tecfidera Multiple Sclerosis/Brain Lesions

Telaprevir • • Hepatitis C

Tenofovir HIV treatment

Tizanidine • MS/Spinal cord disorders No, if for MS

Thorazine • Psychotic Disorders

Tolcapone • • Parkinson's Disease

Toprol • • • HTN/Angina/Heart Yes if for HTN only

Torsemide CHF/Kidney or Liver Disease

Toremifene Cancer

Triamterene • • • Fluid/HTN/CHF Yes if for HTN only

Trifluoperazone • Psychotic Disorders

Trihexyphenidyl • • Parkinson's Disease

Vasotec • • • HTN/Angina/CHF SMPL for HTN only

Viread HIV treatment

Vicodin • Chronic Pain

Victrelis • Hepatitis C

Warfarin • Blood thinner

Xarelto • Blood thinner

Xifaxan Brain function loss

Xtandi Cancer

ZDV HIV treatment

Zenpep • Pancreatic insufficiency

Zidovudine HIV treatment

Zoladex Cancer

Zometa Cancer/Multiple Myeloma

LifeVue Whole Life

Field Underwriting Guide Introduction: This product has three underwriting classes; Level Death Benefit, Graded Death Benefit and Decline. There are a series

of knock-out questions that will be asked upfront by the agent to determine the applicant’s product eligibility. If knock-out

requirements are met, the applicant will then answer a series of risk questions that are confirmed with an MIB check and

Prescription (Rx) Database check during the decision process. The decision is then reported to the agent and applicant.

Prescription (Rx) Database: The Rx scoring is based on medical conditions rather than directly on the drugs or therapeutic categories. Scoring cut

offs for each underwriting class are established both for the highest single condition score and for all conditions found

combined on a weighted basis. **A combination of medications could result in a higher score**.

Class Max Max Risk Tolerance Smoking Criteria Notes Single Combined

Score Score

No distinct classes

Allow 2 conditions scoring 299 or one No equiv to

299 and two lower scoring conditions

Level DB 299

479

but may play role in

"yes" on Part C conditions selection

Anything worse than above but not

No equiv to

HIV or terminal illness. Allows up to Graded DB 300

599

No distinct classes

two 300 scores plus a 299 but not

"yes" on Part A

three 300 scores

Worse than above

Decline 998 none none

999 score limited to MIB conditions

When und

such as HIV code needing underwriting referral rather than particular class or

RTU

none

none

referral, not a

none

decline action. class, is desired

Prescription Drugs Scored 299 & 300: This Prescription Drug Guide is used in conjunction with North American’s Underwriting guidelines and does not reflect all

prescription drugs considered by North American. This guide provides a list of common drugs scored at 299 and 300 that

combined and/or alone can eliminate an applicant from receiving a Level and/or Graded Death Benefit. Any prescription

drug used in combination with a related or unrelated prescription drug could result in a decline. Both this guide and the

full underwriting guidelines used by North American are subject to change.

The Prescriptions listed below have a “linked condition” that is associated with the medication. This may not be the only

condition that is treated by this prescription drug.

Scores at 299 if applicant is taking 3 or more severe uncontrolled hypertension medications.

Scores as 25 by itself.

• Scores at 299 if prescription information indicates chronic use. Scores lower than 299 otherwise.

*** Scores 300 if prescribed within last 24 months and 299 if 25 months or longer.

Label Name Linked Condition

Scor

e

ABILIFY Schizophrenia 300

ACETYLCYSTEINE Acetaminophen Toxicity 299

ACITRETIN Severe Recalcitrant Psoriasis 299

AGGRENOX Prevention of Cerebral Thrombosis 300

AMANTADINE Dementia associated with Parkinson's Disease 300

AMIODARONE Ventricular Fibrillation 300

AMLODIPINE BESYLATE Severe Uncontrolled Hypertension 299*

AMLODIPINE-BENAZEPRIL Severe Uncontrolled Hypertension 299*

AMPHETAMINE SALTS Narcolepsy Syndrome 299

AMPYRA ER Walking Impairment due to Multiple Sclerosis 300

AMRIX ER Muscle Spasticity of Spinal Origin 299

ANASTROZOLE Hormone Receptor Positive Breast Cancer 300***

ANDRODERM Male Hypogonadism 299

ANDROGEL Male Hypogonadism 299

ARANESP Anemia in Chronic Kidney Disease 300

ARICEPT Diffuse Lewy Body Disease 300

ARIMIDEX Hormone Receptor Positive Breast Cancer 299

ARIPIPRAZOLE Schizophrenia 300

AROMASIN Advanced Breast Cancer Progression Post-Antiestrogen Therapy 300

ASACOL EC Ulcerative Colitis 299

ASACOL HD Ulcerative Colitis 299

ASPIRIN EC Myocardial Infarction Prevention 300

ATENOLOL Severe Uncontrolled Hypertension 299*

ATENOLOL-CHLORTHALIDONE Severe Uncontrolled Hypertension 299*

ATROVENT HFA INHALER Prevention of Bronchospasms with Emphysema 300

AUBAGIO Multiple Sclerosis 299

AVINZA Pain, severe, long 299**

AXIRON Male Hypogonadism 299

AZATHIOPRINE Prevention of Kidney Transplant Rejection 300

AZILECT Idiopathic Parkinsonism 300

BACLOFEN Muscle Spasticity of Spinal Origin 299

BENAZEPRIL HCL Severe Uncontrolled Hypertension 299*

BENICAR Severe Uncontrolled Hypertension 299*

BENICAR HCT Severe Uncontrolled Hypertension 299*

BENZTROPINE Extrapyramidal Disease 300

BETASERON Multiple Sclerosis 299

BETHANECHOL Urinary Retention 299

BIDIL Chronic Heart Failure 300

BISOPROLOL-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*

BRILINTA Myocardial Reinfarction Prevention 299

BUDESONIDE EC Crohn's Disease 299

BUPRENORPHINE-NALOXONE Opioid Dependence 300

BUPROPION SR Smoking Cessation 299

BUTRANS Pain, severe, long 299**

BYSTOLIC Severe Uncontrolled Hypertension 299*

CARBAMAZEPINE Manic Bipolar Disorder 299

CARBIDOPA-LEVO ER Parkinsonism 300

CARISOPRODOL Muscle Spasticity of Spinal Origin 299

CARTIA XT Severe Uncontrolled Hypertension 299*

CARVEDILOL Chronic Heart Failure 300

CHLORPROMAZINE Schizophrenia 300

CILOSTAZOL Intermittent Claudication 300

CLONIDINE Severe Uncontrolled Hypertension 299*

CLOPIDOGREL Myocardial Reinfarction Prevention 300***

CLOZAPINE Treatment-Resistant Schizophrenia 300

COMBIVENT INHALER Chronic Obstructive Pulmonary Disease with Bronchospasms 300

COPAXONE Multiple Sclerosis 299

COREG CR Chronic Heart Failure 300

COZAAR Severe Uncontrolled Hypertension 299*

CREON DR Pancreatic Insufficiency 300

CVS ASPIRIN EC Myocardial Infarction Prevention 300

CYCLOBENZAPRINE Muscle Spasticity of Spinal Origin 299

DALIRESP Prevention of Bronchospasm with Chronic Bronchitis 300

D-AMPHETAMINE ER Narcolepsy Syndrome 299

DEPO-TESTOSTERONE Male Hypogonadism 299

DEXAMETHASONE Autoimmune Disease 300

DEXTROAMPHETAMINE Narcolepsy Syndrome 299

DIGITEK Chronic Heart Failure 300

DIGOX Chronic Heart Failure 300

DILANTIN Epilepsy 299

DILAUDID Pain, severe, long 299**

DILT XR Severe Uncontrolled Hypertension 299*

DILTIAZEM Severe Uncontrolled Hypertension 299*

DIOVAN Severe Uncontrolled Hypertension 299*

DIVALPROEX SOD ER Manic Bipolar Disorder 299

DONEPEZIL HCL Diffuse Lewy Body Disease 300

DOXAZOSIN MESYLATE Severe Uncontrolled Hypertension 299*

EFFIENT Myocardial Reinfarction Prevention 299

ELIQUIS Thromboembolism with Chronic Atrial Fibrillation 300

EMBEDA ER Chronic Pain 299**

EMEND Prevention of Cancer Chemotherapy-Induced Nausea and Vomiting 299

ENBREL Rheumatoid Arthritis 299

ENOXAPARIN Thromboembolic Disorder 300

EPLERENONE Chronic Heart Failure Following Myocardial Infarction 300

EXALGO ER Pain, severe, long 299**

EXELON Dementia associated with Parkinson's Disease 300

EXFORGE Severe Uncontrolled Hypertension 299*

FENTANYL Pain, severe, long 299**

FLECAINIDE ACETATE Cardioversion of Atrial Fibrillation 299

FLUDROCORTISONE Adrenogenital Disorder 299

FLUPHENAZINE Schizophrenia 300

FORTESTA Male Hypogonadism 299

GILENYA Multiple Sclerosis 299

HALOPERIDOL Schizophrenia 300

HARVON Chronic Hepatitis C - Genotype 1 300

HEPARIN SODIUM Acute ST Elevation Myocardial Infarction 299

HM ASPIRIN Myocardial Reinfarction Prevention 299

HUMALOG Type 1 Diabetes Mellitus 299

HUMALOG MIX Type 1 Diabetes Mellitus 299

HUMIRA Crohn's Disease 299

HUMULIN Type 1 Diabetes Mellitus 299

HYDRALAZINE Severe Uncontrolled Hypertension 299*

HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*

HYDROCODONE-ACETAMINOPHEN Pain, severe, long 299**

HYDROMORPHONE Pain, severe, long 299**

HYDROXYCHLOROQUINE Systemic Lupus Erythematosus 299

HYZAAR Severe Uncontrolled Hypertension 299*

INCIVEK Chronic Hepatitis C - Genotype 1 299

INNOPRAN XL Severe Uncontrolled Hypertension 299*

IPRATROPIUM BR Prevention of Bronchospasms with Emphysema 300

ISOSORBIDE Chronic Angina Pectoris 299

KRISTALOSE Hepatic Encephalopathy 300

LABETALOL HCL Severe Uncontrolled Hypertension 299*

LAMICTAL Bipolar Disorder in Remission 299

LAMOTRIGINE Bipolar Disorder in Remission 299

LANTUS Type 1 Diabetes Mellitus 299

LEFLUNOMIDE Rheumatoid Arthritis 299

LETROZOLE Ovarian Carcinoma 300

LEVEMIR Type 1 Diabetes Mellitus 299

LISINOPRIL Severe Uncontrolled Hypertension 299*

LITHIUM CARBONATE Bipolar Disorder 299

LITHIUM CARBONATE ER Bipolar Disorder 299

LORCET Pain, severe, long 299**

LOSARTAN POTASSIUM Severe Uncontrolled Hypertension 299*

LOSARTAN-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*

LOTREL Severe Uncontrolled Hypertension 299*

MEGESTROL Hormone Receptor Positive Breast Cancer 300

MEPERIDINE Pain, severe, long 299**

MEPERITAB Pain, severe, long 299**

MESALAMINE Ulcerative Colitis 299

METHADONE HCL Pain, severe, long 299**

METHOCARBAMOL Muscle Spasticity of Spinal Origin 299

METHOTREXATE 2.5 MG TABLET Rheumatoid Arthritis 299

METHOTREXATE 250 MG/10 ML VIAL Osteosarcoma of Bone 300

METHYLDOPA Severe Uncontrolled Hypertension 299*

METHYLIN Narcolepsy Syndrome 299

METHYLPHENIDATE Narcolepsy Syndrome 299

METHYLPREDNISOLONE Autoimmune Disease 300

METOCLOPRAMIDE Diabetic Gastroparesis 299

METOLAZONE Severe Uncontrolled Hypertension 299*

METOPROLOL Severe Uncontrolled Hypertension 299*

MICARDIS Severe Uncontrolled Hypertension 299*

MINOXIDIL Severe Uncontrolled Hypertension 299*

MIRAPEX Dementia associated with Parkinson's Disease 300

MODAFINIL Narcolepsy Syndrome 299

MORPHINE Pain, severe, long 299**

MULTAQ Prevention of Recurrent Atrial Fibrillation 299

NALTREXONE Alcoholism 299

NAMENDA Moderate to Severe Alzheimer's Type Dementia 300

NEUPRO Dementia associated with Parkinson's Disease 300

NIFEDICAL XL Severe Uncontrolled Hypertension 299*

NIFEDIPINE ER Severe Uncontrolled Hypertension 299*

NITROGLYCERIN 0.4 MG TABLET SL Angina 300***

NITROQUICK 0.4 MG TABLET SL Angina 300***

NITROSTAT 0.4 MG TABLET SL Angina 300***

NOVOLIN Type 1 Diabetes Mellitus 299

NOVOLOG Type 1 Diabetes Mellitus 299

NUEDEXTA Pseudobulbar Affect 299

NUVIGIL Sleepiness Due To Obstructive Sleep Apnea 299

OLANZAPINE Mixed Bipolar I Disorder 299

OPANA Pain, severe, long 299**

OXYBUTYNIN Neurogenic Bladder 299

OXYCODONE Pain, severe, long 299**

OXYCONTIN Chronic Pain 299**

OXYMORPHONE Chronic Pain 299**

OYSTER SHELL CALCIUM-VIT D TAB Hypocalcemia Prevention 299

PACERONE Ventricular Fibrillation 300

PANCREAZE DR Pancreatic Insufficiency 299

PCCA LIPODERM BASE Severe Uncontrolled Hypertension 299*

PEGINTRON REDIPEN Chronic Hepatitis C - Genotype 1 299

PERFOROMIST Prevention of Bronchospasm with Chronic Bronchitis 299

PERPHENAZINE Schizophrenia 300

PHENOBARBITAL Seizure Disorder 299

PHENYTOIN Epilepsy 299

PILOCARPINE HCL Xerostomia Secondary to Sjogren's Syndrome 299

PLAQUENIL Systemic Lupus Erythematosus 299

PLAVIX Myocardial Reinfarction Prevention 300

PRAMIPEXOLE Dementia associated with Parkinson's Disease 300

PRAZOSIN Severe Uncontrolled Hypertension 299*

PREDNISOLONE AC 1% EYE DROP Severe Ocular Inflammation 299

PREDNISONE Autoimmune Disease 300***

PROPANTHELINE Urinary Incontinence 299

PROPRANOLOL Severe Uncontrolled Hypertension 299*

PROVIGIL Narcolepsy Syndrome 299

PYRIDOSTIGMINE BR Myasthenia Gravis 299

QUETIAPINE FUMARATE Mixed Bipolar I Disorder 299

QUINAPRIL Severe Uncontrolled Hypertension 299*

QUINIDINE SULF ER Cardioversion of Atrial Fibrillation 299

ASPIRIN EC Myocardial Infarction Prevention 300

RANEXA ER Chronic Angina Pectoris 299

REGRANEX Diabetic Neuropathic Ulcer of Lower Extremities 300

RELION NOVOLIN Type 1 Diabetes Mellitus 299

RENVELA Renal Osteodystrophy with Hyperphosphatemia 300

REQUIP Dementia associated with Parkinson's Disease 300

RIBASPHERE RIBAPAK Chronic Hepatitis C - Genotype 1 299

RIFAMPIN Acute Tuberculosis 300***

RISPERIDONE Mixed Bipolar I Disorder 299

ROPINIROLE HCL Dementia associated with Parkinson's Disease 300

ROXICODONE Pain, severe, long 299**

RYZOLT ER Chronic Pain 299**

SANTYL OINTMENT Severe Burns 299

SAPHRIS Mixed Bipolar I Disorder 299

SENSIPAR Hyperparathyroidism Secondary to Chronic Renal Failure with Dialysis 300

SEREVENT DISKUS Bronchospasm Prevention with COPD 300

SEROQUEL Mixed Bipolar I Disorder 299

SIMPONI Rheumatoid Arthritis 299

SKELAXIN Muscle Spasticity of Spinal Origin 299

SM CALCIUM Hypocalcemia Prevention 299

SORIATANE Severe Recalcitrant Psoriasis 299

SOTALOL Life-Threatening Ventricular Tachycardia 300

SPIRIVA Bronchospasm Prevention with COPD 300

SPIRONOLACTONE Severe Uncontrolled Hypertension 299*

SULFASALAZINE Ulcerative Colitis 299

SULFAZINE EC Ulcerative Colitis 299

SYMBYAX Depression associated with Manic Depressive Disorder 299

TAMOXIFEN Hormone Receptor Positive Breast Cancer 300***

TECFIDERA DR Multiple Sclerosis 299

TEGRETOL Manic Bipolar Disorder 299

TEKTURNA Severe Uncontrolled Hypertension 299*

TEKTURNA HCT Severe Uncontrolled Hypertension 299*

TERAZOSIN Severe Uncontrolled Hypertension 299*

TESTIM Male Hypogonadism 299

TESTOSTERONE Male Hypogonadism 299

THEOPHYLLINE ER Chronic Obstructive Pulmonary Disease with Bronchospasms 300

TOPAMAX Simple-Partial Epilepsy 299

TOPIRAMATE Simple-Partial Epilepsy 299

TOPROL XL Severe Uncontrolled Hypertension 299*

TRIAMTERENE-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*

TRIHEXYPHENIDYL Idiopathic Parkinsonism 300

TROKENDI XR Simple-Partial Epilepsy 299

TRUVADA HIV Infection 900

TUDORZA PRESSAIR Bronchospasm Prevention with COPD 300

VALPROIC ACID Bipolar Disorder 299

VALSARTAN Severe Uncontrolled Hypertension 299*

VALSARTAN-HYDROCHLOROTHIAZIDE Severe Uncontrolled Hypertension 299*

VANCOMYCIN HCL Pseudomembranous Enterocolitis 299

VERAPAMIL Severe Uncontrolled Hypertension 299*

VYVANSE Binge Eating Disorder 300

WARFARIN Thromboembolic Disorder 300

XARELTO Thromboembolism with Chronic Atrial Fibrillation 300

XELJANZ Rheumatoid Arthritis 299

ZYPREXA Mixed Bipolar I Disorder 299

Build Chart: Our build chart is a unisex chart which applies to males and females. Any height/weight combination that is outside

of the published guidelines is not eligible for level death benefit.

Weight Limits - LBS

Height

Minimum

Maximum

4' 8" 74 198

4' 9" 77 205

4'10" 79 212

4'11" 82 220

5' 0" 85 227

5' 1" 88 235

5' 2" 91 243

5' 3" 94 251

5' 4" 97 259

5' 5" 100 267

5' 6" 103 275

5' 7" 106 284

5' 8" 109 292

5' 9" 112 301

5'10" 115 310

5'11" 119 319

6' 0" 122 328

6' 1" 126 337

6' 2" 129 346

6' 3" 133 356

6' 4" 136 365

6' 5" 140 375

6' 6" 143 386

6' 7" 147 395

6' 8" 151 405

6' 9" 154 415

Medical Conditions Not Considered:

Terminal Illness HIV, AIDS, AIDS related complex (ARC) Individual confined to nursing facility, assisted living facility, hospice or psychiatric facility, or have a felony or misdemeanor.

master prescription drug list

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