Medications and UnderwritingDecisions

Effective 05/2019

AbacavirHIV Decline Decline Decline DeclineAbbokinaseIschaemic Heart Disease Modified Limited Decline MIBAbilifyBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBAcarbosDiabetes Preferred Special Decline MIBAccupril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAccuretic

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAcebutolol Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Ventricular Arrhythmia Modified Limited Decline MIBAceon

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAcetaminophenPain Preferred Select Icare MIBAcetohexamideDiabetes Preferred Special Decline MIBActiqSevere Pain Modified Limited Decline MIBActivaseTopical Cream - Acne Preferred Select Icare MIB

Stroke Modified ≤ 2 years Decline, 2+ Limited Decline MIB

TIA Modified ≤ 2 years Decline, 2+ Limited Decline MIB

Actoplus MetDiabetes Preferred Special Decline MIB

Use this chart to choose how medications should be rated at on your new applications. Disclosures:1. This list is not all inclusive and is intended as a guide only. All cases subject to review.2. This list only identifies some uses for the medications. There may be other uses that could positively or

negatively impact the final classification of the case being reviewed. 3. If a medication is being taken for a reason other than what is listed, please document the medication and

reason taking on the Application as well as the duration and dosage information.

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

3

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

ActosDiabetes Preferred Special Decline MIBAdcetrisHodgkin's Lymphoma Decline Decline Decline DeclineAdcirca

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Adlyxin

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started be-fore age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

Advair Diskus Asthma Preferred Special Decline MIBCOPD Modified Special Decline MIBAdvicorCholesterol Preferred Select Decline MIBAfinitor

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBAfstylaHemophilia A Decline Decline Decline MIBAgeneraseHIV Decline Decline Decline DeclineAggrenox

Stroke Modified ≤ 2 years Decline, 2+ Limited Decline MIB

AgrylinThrombocythemia Decline Decline Decline MIBAkinetonParkinson’s Disease Modified Limited Decline MIBAlbuterolAsthma Preferred Special Decline MIBBronchitis Preferred Select Decline MIBCOPD Modified Special Decline MIBAldactone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAldoclor

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Aldomet

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Alecensa

Lung Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Lung Cancer 91+ days free Modified 2 - 5 years free Special Decline MIB

4

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Lung Cancer 2+ years free Preferred 5+ years free Select Decline MIBAlkeran

Ovarian Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Ovarian Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBOvarian Cancer 2+ years free Preferred 5+ years free Select Decline MIBAllopurinolGout Preferred Select Decline MIBAlprazolamAnxiety Disorder Preferred Select Icare MIBAlprolixHemophilia B Decline Decline Decline MIBAltace

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAlupentAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBAmantadine HclParkinson’s Disease Modified Limited Decline MIBAmarylDiabetes Preferred Special Decline MIBAmiloride Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAmiloride/Hydrochlorothia

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

AminophyllineAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBAmiodarone HclVentricular Arrhythmia Modified Limited Decline MIBAmitriptyline HclDepression Preferred Select Decline MIBAmlodipine Besylate

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Amphetamine/DextroamphetamineAttention Deficit Disorder Preferred Special Icare MIBNarcolepsy Preferred Select Decline MIBAmpyraMultiple Sclerosis Modified Limited Decline MIBAmturnide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Amyl Nitrite

5

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Heart Disease Modified Limited Decline MIBAnastrozole

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBAnoro ElliptaCOPD Modified Special Decline MIBAntabuse

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Apidra

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started before age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

AplenzinDepression Preferred Select Decline MIBApokynParkinson’s Disease Modified Limited Decline MIBApresoline

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAptiom

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

AptivusHIV Decline Decline Decline DeclineAquatensen

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Disease Modified Limited Decline MIBAralastCOPD Modified Special Decline MIBAranespKidney Disease Modified Limited Decline MIBArcapta NeohalerCOPD Modified Special Decline MIBArgatrobanCirculatory Disorder Modified Limited Decline MIBAriceptAlzheimer's/Dementia Decline Decline Decline MIBArimidex

Breast Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Breast Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBBreast Cancer 2+ years free Preferred 5+ years free Select Decline MIBAristadaSchizophrenia Modified Limited Decline MIBArixtra

6

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Deep Vein Thrombosis (DVT) Modified Limited Decline MIB

Aromasin

Breast Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Breast Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBBreast Cancer 2+ years free Preferred 5+ years free Select Decline MIBArzerraChronic Lymphocytic Leukemia Decline Decline Decline MIB

Atacand

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBAtametParkinson’s Disease Modified Limited Decline MIBAtaraxAllergies Preferred Select Icare MIBAnxiety Disorder Preferred Select Icare MIBAtenolol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

AtgamOrgan Transplant Rejection Decline Decline Decline MIBAtivanAnxiety Disorder Preferred Select Icare MIBAtorvastatin CalciumCholesterol Preferred Select Decline MIBAtriplaHIV/AIDS Decline Decline Decline DeclineAtrovent/ Atrovent HfaCOPD Modified Special Decline MIBAubagioMultiple Sclerosis Modified Limited Decline MIBAutoplex THemophilia B Decline Decline Decline MIBAvalide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

AvandametDiabetes Preferred Special Decline MIBAvandarylDiabetes Preferred Special Decline MIBAvandiaDiabetes Preferred Special Decline MIBAvapro

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Nephropathy Modified Limited Decline MIBAvastin

7

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBAvonexMultiple Sclerosis Modified Limited Decline MIBAzasanRhumatoid Arthritis Preferred Select Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBAzathioprineRhumatoid Arthritis Preferred Select Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBAzilectParkinson’s Disease Modified Limited Decline MIBAzmacortAsthma Preferred Select Decline MIBAzor

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

BaracludeLiver Disorder Modified Limited Decline MIBBeleodaqHodgkin's Lymphoma Decline Decline Decline DeclineNon-Hodgkin's Lymphoma Decline Decline Decline DeclineBenazepril Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBBendroflumethiazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Benicar

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

BenlystaLupus Modified Limited Decline MIBBenztropine MesylateParkinson’s Disease Modified Limited Decline MIBBetaseronMultiple Sclerosis Modified Limited Decline MIBBetaxolol Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Bevespi AerosphereChronic Bronchitis Modified Special Decline MIBCOPD Modified Special Decline MIBEmphysema Modified Special Decline MIBBicalutamide

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIB

8

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Cancer 2+ years free Preferred 5+ years free Select Decline MIBBicnuHodgkin's Lymphoma Decline Decline Decline DeclineNon-Hodgkin's Lymphoma Decline Decline Decline DeclineBidilCongestive Heart Failure Modified Limited Decline MIBBisoprolol Fumarate/Hydro

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

BosulifLeukemia Decline Decline Decline DeclineBreo ElliptaAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBBretylium TosylateHeart Modified Limited Decline MIBBrevibloc

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Tachycardia Modified Limited Decline MIBBrilinta

Acute Coronary Syndrome Modified ≤ 2 years Decline, 2+ Limited Decline MIB

BrintellixMajor Depressive Disorder Modified Limited Decline MIBBriviact

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

BromocriptineDiabetes Preferred Special Decline MIBParkinson’s Disease Modified Limited Decline MIBBumetanide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBBumex

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBBuprobanNicotine Dependence Preferred Select Icare MIBBuspirone HclAnxiety Disorder Preferred Select Icare MIBBydureonDiabetes - Non Insulin Injectable Preferred Special Decline MIB

Diabetes - Non Insulin Injectable Preferred Special Decline MIB

ByettaDiabetes - Non Insulin Injectable Preferred Special Decline MIB

9

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Diabetes - Non Insulin Injectable Preferred Special Decline MIB

Bystolic

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Byvalson

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Caduet

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Calan

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Arrhythmia Modified ≤ 2 years Decline, 2+ Special Decline MIB

Campral

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Drug Addiction Modified ≤ 5 years Decline, 5+ Special Decline MIB

Capozide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBCaprelsa

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBCapsaicinNephropathy Modified Limited Decline MIBCaptopril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBCaptopril/Hydrochlorothiazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBCarbamazepine

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Carbidopa/Levodopa/EntacaParkinson’s Disease Modified Limited Decline MIBCardene

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

10

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Cardiovid Plus

Cardiovascular Disease Modified ≤ 2 years Decline, 2+ Limited Decline MIB

Cardizem Cd

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Arrhythmia Modified ≤ 2 years Decline, 2+ Special Decline MIB

Cardura

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

CarnitorKidney Disease Modified Limited Decline MIBLiver Disorder Modified Limited Decline MIBCartia

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Arrhythmia Modified ≤ 2 years Decline, 2+ Special Decline MIB

Cartrol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Carvedilol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBCasodex

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBCatapres

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

CaystonCystic Fibrosis Decline Decline Decline MIBCeenuHodgkin's Lymphoma Decline Decline Decline DeclineCelebrexArthritis Preferred Select Decline MIBCelexaDepression Preferred Select Decline MIBCellceptLupus Modified Limited Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBCelontin

11

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Cerebyx

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

CeredaseGaucher's Disease Decline Decline Decline MIBCerezymeGaucher's Disease Decline Decline Decline MIBChantixSmoking Cessation Preferred Select Decline MIBChlorambucilLeukemia Decline Decline Decline DeclineChlordiazepoxideAnxiety Disorder Preferred Select Icare MIBChlorothiazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBChlorpromazine HclSchizophrenia Modified Limited Decline MIBChlorpropamideDiabetes Preferred Special Decline MIBChlorthalidone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBCilostazolCirculatory Disorder Modified Limited Decline MIBCitalopram HydrobromideDepression Preferred Select Decline MIBCleviprex

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

ClonazepamPanic Disorder Preferred Select Icare MIB

Epilepsy Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤2 years Decline, 2+ Limited Decline MIB

Clonidine Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Clopidogrel

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

Clorpres

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

ClozapineSchizophrenia Modified Limited Decline MIBCogentinParkinson’s Disease Modified Limited Decline MIB

12

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

CognexAlzheimer's/Dementia Decline Decline Decline MIBCombiventAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBCombivirHIV Decline Decline Decline DeclineCompleraHIV Decline Decline Decline DeclineComtanParkinson’s Disease Modified Limited Decline MIBConzipPain Preferred Select Icare MIBCopaxoneMultiple Sclerosis Modified Limited Decline MIBCopegusLiver Disorder Modified Limited Decline MIBCoreg

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBCorgard

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBCorlanorCongestive Heart Failure Modified Limited Decline MIBCorlopam

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

CorvertHeart Modified Limited Decline MIBCoumadinBlood Thinner Modified Special Decline MIBCovera-Hs

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Arrhythmia Modified ≤ 2 years Decline, 2+ Special Decline MIB

Cozaar

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBCreonPancreatic Insufficiency Modified Limited Decline MIBCrestorCholesterol Preferred Select Decline MIBCrixivanHIV Decline Decline Decline Decline

13

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Cyclobenzaprine HclMuscle Spasm Preferred Select Decline MIBCyclosporineOrgan Transplant Rejection Decline Decline Decline MIBCyclosporine AOrgan Transplant Rejection Decline Decline Decline MIBCyclosporine ModifiedOrgan Transplant Rejection Decline Decline Decline MIBCymbaltaDepression Preferred Select Decline MIBCystagonKidney Disease Modified Limited Decline MIBCytogamOrgan Transplant Rejection Decline Decline Decline MIBCytoveneOrgan Transplant Rejection Decline Decline Decline MIBDacarbazineSkin Cancer Preferred Select Decline MIBHodgkin's Lymphoma Decline Decline Decline DeclineDacogenMyelodysplastic Syndromes (MDS) Decline Decline Decline MIB

DaklinzaHepatitis C Decline Decline Decline MIBDalirespCOPD Modified Special Decline MIBDemadex

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBKidney Disease Modified Limited Decline MIBLiver Disorder Modified Limited Decline MIBDepacon

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Depade

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Drug Addiction Modified ≤ 5 years Decline, 5+ Special Decline MIB

Depakene

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

DepakoteBipolar Disorder Preferred Select Decline MIBMigraine Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

DescovyHIV Decline Decline Decline DeclineDesvenlafaxine Er

14

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Major Depressive Disorder Modified Limited Decline MIBDiabetaDiabetes Preferred Special Decline MIBDiazepamAnxiety Disorder Preferred Select Icare MIBDicyclomine HclIrritable Bowel Syndrome Preferred Select Decline MIBDidanosineHIV Decline Decline Decline DeclineDigitekHeart Modified Limited Decline MIBDigox

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBDigoxin

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBDilantin

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Dilatrate SrAngina Modified ≤ 2 years Decline, + Special Decline MIB

Coronary Artery Disease Modified ≤ 2 years Decline, 2+ Limited Decline MIB

Diltiazem

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Diovan

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Dipyridamole

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

Disopyramide PhosphateVentricular Arrhythmia Modified Limited Decline MIBDisulfiram

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Drug Addiction Modified ≤ 5 years Decline, 5+ Special Decline MIB

Diuril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Divalproex Bipolar Disorder Preferred Select Decline MIBMigraine Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Dobutamine Hcl

15

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Cardiac Failure Modified ≤ 2 years Decline, 2+ Limited Decline MIB

Dolophine

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Donepezil HclAlzheimer's/Dementia Decline Decline Decline MIBDroxiaSickle Cell Anemia Decline Decline Decline MIBDuetactDiabetes Preferred Special Decline MIBDulaglutideDiabetes - Non Isulin Injectable Preferred Special Declined MIB

Diabetes - Non-Isulin Injectable Preferred Special Declined MIB

DuleraAsthma Preferred Special Decline MIBDuonebCOPD Modified Special Decline MIBDuragesicSevere Pain Modified Limited Decline MIBDyazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Edarbi

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Edarbyclor

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Edecrin

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBEdurantHIV Decline Decline Decline DeclineEffexorAnxiety Disorder Preferred Select Icare MIBDepression Preferred Select Decline MIBEffient

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

ElavilDepression Preferred Select Decline MIBEldeprylParkinson’s Disease Modified Limited Decline MIBEligard

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIB

16

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

EliquisBlood Thinner Modified Special Decline MIBEmcyt

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBEmend

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBEmtrivaHIV Decline Decline Decline DeclineEnalapril Maleate

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBEnalaprilat

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBEnduron

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBLiver Disorder Modified Limited Decline MIBEnduronyl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

EntacaponeParkinson’s Disease Modified Limited Decline MIBEntresto

Cardiac Failure Modified ≤ 2 years Decline, 2+ Limited Decline MIB

EpclusaChronic Hepatitis C Decline Decline Decline MIBEphedrine Hcl

Hypotension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

COPD Modified Special Decline MIBEpivirHIV Decline Decline Decline DeclineEplerenone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBEptifibatide

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

EpzicomHIV Decline Decline Decline Decline

17

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

EquetroBipolar Disorder Preferred Select Decline MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

EsbrietIdiopathic Pulmonary Fibrosis Decline Decline Decline MIB

Escitalopram Oxalate Depression Preferred Select Decline MIBEskalithBipolar Disorder Preferred Select Decline MIBEthmozineVentricular Arrhythmia Modified Limited Decline MIBEthosuximide

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

EtopophosLeukemia Decline Decline Decline DeclineEulexin

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBEvistaOsteoporosis Preferred Select Icare MIBEvotazHIV Decline Decline Decline DeclineExelonAlzheimer's/Dementia Decline Decline Decline MIBExemestane

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBExenatideDiabetes - Non Insulin Injectable Preferred Special Decline MIB

Diabetes - Non Insulin Injectable Preferred Special Decline MIB

Exforge

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Exondys 51Muscular Dystrophy Modified Limited Decline MIBExtaviaMultiple Sclerosis Modified Limited Decline MIBFanaptSchizophrenia Modified Limited Decline MIBFareston

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

18

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBFarxigaDiabetes Preferred Special Decline MIBFelbamate

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Felbatol

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Felodipine

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

FentanylSevere Pain Modified Limited Decline MIBFetzimaMajor Depressive Disorder Modified Limited Decline MIBFlecainide Acetate

Arrhythmia Modified ≤ 2 years Decline, 2+ Special Decline MIB

FlomaxEnlarged Prostate Preferred Select Decline MIBFloventAsthma Preferred Special Decline MIBFluoxetineAnxiety Disorder Preferred Select Icare MIBFluphenazine HclPsychosis Modified Limited Decline MIBSchizophrenia Modified Limited Decline MIBFlutamide

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBForadil AerolizerAsthma Preferred Special Decline MIBBronchitis Preferred Select Decline MIBCOPD Modified Special Decline MIBFortametDiabetes Preferred Special Decline MIBFortovaseHIV Decline Decline Decline DeclineFosamax Plus DOsteoporosis Preferred Select Icare MIBFosinopril Sodium

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBFosphenytoin Sodium

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

19

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Fragmin

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Deep Vein Thrombosis (DVT) Modified Limited Decline MIB

Furosemide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBFuzeonHIV Decline Decline Decline DeclineFycompa

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 3+ Limited Decline MIB

GabapentinPain Preferred Select Icare MIBNeuropathy Modified Limited Decline MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Gabitril

Epilepsy Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤2 years Decline, 2+ Limited Decline MIB

GablofenMultiple Sclerosis Modified Limited Decline MIBGalantamineAlzheimer's/Dementia Decline Decline Decline MIBGemfibrozilCholesterol Preferred Select Decline MIBGengraf Organ Transplant Rejection Decline Decline Decline MIBGenvoyaHIV Decline Decline Decline DeclineGeodonBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBGilenyaMultiple Sclerosis Modified Limited Decline MIBGilotrif

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBGlassiaCOPD Modified Special Decline MIBGleevecLeukemia Decline Decline Decline DeclineGleostineHodgkin's Lymphoma Decline Decline Decline DeclineGlimepirideDiabetes Preferred Special Decline MIBGlipizide

20

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Diabetes Preferred Special Decline MIBGlucophageDiabetes Preferred Special Decline MIBGlyburideDiabetes Preferred Special Decline MIBGranisetron Hcl

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBGranixNeutropenia Decline Decline Decline DeclineGuanabenz Acetate

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Guanfacine Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

HaldoSchizophrenia Modified Limited Decline MIBHaloperidolSchizophrenia Modified Limited Decline MIBHarvoniHepatitis C Decline Decline Decline MIBHctz

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

HecoriaOrgan Transplant Rejection Decline Decline Decline MIBHectorolKidney Disease Modified Limited Decline MIBHeparin Blood Thinner Modified Limited Decline MIBHepseraChronic Hepatitis B Modified Limited Decline MIBHexalen

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBHorizantRestless Leg Syndrome Preferred Select Decline MIBHumalog

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started before age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

Humulin 70/30

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & started after age 40, Special Decline MIB

21

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Diabetes - Injectable 100+ units or started be-fore age 40, Modified

100+ units or started before age 40, Limited Decline MIB

Hycamtin

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBHydralazine

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Hydralazine Heart Failure Modified Limited Decline MIBHydrea

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBLeukemia Decline Decline Decline DeclineHydrochlorothi

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Hydrochlorothiazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

HydrocodonePain Preferred Select Icare MIBHydromorphone HclModerate To Severe Pain Modified Limited Decline MIBHydroxychloroquine SulfateRheumatoid Arthritis Preferred Select Decline MIBLupus Modified Limited Decline MIBHydroxyurea

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBLeukemia Decline Decline Decline DeclineHydroxyzine Allergies Preferred Select Icare MIBAnxiety Disorder Preferred Select Icare MIBHytrinEnlarged Prostate Preferred Select Decline MIB

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Hyzaar

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Ibutilide FumarateHeart Modified Limited Decline MIBIclusigLeukemia Decline Decline Decline Decline

22

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

IdelvionHemophilia B Decline Decline Decline MIBImatinibLeukemia Decline Decline Decline DeclineImbruvicaLeukemia Decline Decline Decline DeclineImuranRhumatoid Arthritis Preferred Select Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBInamrinoneHeart Modified Limited Decline MIBIncivekLiver Disorder Modified Limited Decline MIBIncruse ElliptaCOPD Modified Special Decline MIBIndapamide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Inderal

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBInfergenLiver Disorder Modified Limited Decline MIBInlyta

Kidney Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Kidney Cancer 91+ days free Modified 2- 5 years free Special Decline MIBKidney Cancer 2+ years free Preferred 5+ years free Select Decline MIBInnopran Xl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

InspraHeart Modified Limited Decline MIBInsulin

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started be-fore age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

IntelenceHIV Decline Decline Decline DeclineInvegaSchizophrenia Modified Limited Decline MIBInviraseHIV Decline Decline Decline DeclineInvokametDiabetes Preferred Special Decline MIBInvokanaDiabetes Preferred Special Decline MIBIpratropium BromideCOPD Modified Special Decline MIB

23

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Irbesartan Avapro

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Kidney Disease Modified Limited Decline MIBNephropathy Modified Limited Decline MIBIrbesartan/Hydrochlorothi

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Iressa

Lung Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Lung Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBLung Cancer 2+ years free Preferred 5+ years free Select Decline MIBIsentressHIV Decline Decline Decline DeclineIsochron Heart Modified Limited Decline MIBIsoniazidTuberculosis Modified Special Decline MIBIsoptin

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBIsosorbide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Heart Modified Limited Decline MIBIsradipine

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

JantovenHeart Modified Limited Decline MIBJantoven (Warfarin)

Stroke Modified ≤ 2 years Decline, 2+ Limited Decline MIB

JanumetDiabetes Preferred Special Decline MIBJanuviaDiabetes Preferred Special Decline MIBJardianceDiabetes Preferred Special Decline MIBKaletraHIV Decline Decline Decline DeclineKalydecoCystic Fibrosis Decline Decline Decline MIBKemadrinParkinson’s Disease Modified Limited Decline MIBKeppra

24

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Kerlone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

KlonopinAnxiety Disorder Preferred Select Icare MIBKlonopin WafersAnxiety Disorder Preferred Select Icare MIBKombiglyze XrDiabetes Preferred Special Decline MIBLabetalol Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

LamictalBipolar Disorder Preferred Select Decline MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

LamivudineHIV Decline Decline Decline DeclineLamotrigineBipolar Disorder Preferred Select Decline MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

LanoxinHeart Modified Limited Decline MIBLantus

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started before age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

Lasix

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBLatudaSchizophrenia Modified Limited Decline MIBLemtradaMultiple Sclerosis Modified Limited Decline MIBLetrozole

Breast Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Breast Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBBreast Cancer 2+ years free Preferred 5+ years free Select Decline MIBLeuprolide AcetateEndometriosis Preferred Select Decline MIBLevatol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Levemir Flexpen

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

25

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Diabetes - Injectable 100+ units or started before age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

Levetiracetam

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

LevocarnitineLiver Disorder Modified Limited Decline MIBLevodopaParkinson’s Disease Modified Limited Decline MIBLexaproAnxiety Disorder Preferred Select Icare MIBDepression Preferred Select Decline MIBLexivaHIV Decline Decline Decline DeclineLexxel

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBLipitorCholesterol Preferred Select Decline MIBLisinopril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Lithium CarbonateBipolar Disorder Preferred Select Decline MIBLodosynParkinson’s Disease Modified Limited Decline MIBLopidCholesterol Preferred Select Decline MIBLopressor

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBLorazepamAnxiety Disorder Preferred Select Icare MIBLosartan Potassium

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBLovastatinCholesterol Preferred Select Decline MIBLovenoxBlood Thinner Modified Special Decline MIBLoxapine Schizophrenia Modified Limited Decline MIBLoxapine SuccinateSchizophrenia Modified Limited Decline MIBLoxitaneSchizophrenia Modified Limited Decline MIBLozol

26

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

LupronEndometriosis Preferred Select Decline MIBLyricaFibromyalgia Syndrome Preferred Select Decline MIBNeuropathy Modified Limited Decline MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Megace OralMenopausal Symptoms Preferred Select Icare MIBNausea Preferred Select Icare MIB

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBCachexia/Wasting Syndrome Decline Decline Decline MIB

MegestrolMenopausal Symptoms Preferred Select Icare MIBNausea Preferred Select Icare MIB

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBCachexia/Wasting Syndrome Decline Decline Decline MIB

MellarilSchizophrenia Modified Limited Decline MIBMepronAIDS Decline Decline Decline DeclineMercaptopurineLeukemia Decline Decline Decline DeclineMetforminDiabetes Preferred Special Decline MIBMethadone

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Drug Overdose Modified ≤ 5 years Decline, 5+ Special Decline MIB

Moderate To Severe Pain Modified Limited Decline MIBMethotrexateArthritis Preferred Select Decline MIBRheumatoid Arthritis Preferred Select Decline MIB

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBMethyclothiazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIB

27

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Methyldopa

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBMetolazone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBMetoprolol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Metoprolol Succinate ErHeart Modified Limited Decline MIBMexiletine HclVentricular Arrhythmia Modified Limited Decline MIBMicardis

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBMicrozide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBMigranalMigraine Preferred Select Icare MIBMilrinone Heart Modified Limited Decline MIBMinitranHeart Modified Limited Decline MIBMinizide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Minoxidil

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

MirapexRestless Leg Syndrome Preferred Select Decline MIBParkinson’s Disease Modified Limited Decline MIBMirceraRenal Failure Modified Limited Decline MIBMirtazapineDepression Preferred Select Decline MIBMajor Depressive Disorder Modified Limited Decline MIBMitomycin

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBMobanSchizophrenia Modified Limited Decline MIBMoexipril Hcl

28

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBMonopril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBMorphine Sulfate ErModerate To Severe Pain Modified Limited Decline MIBMultaq

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

MustargenHodgkin's Lymphoma Decline Decline Decline DeclineMycobutinAIDS Decline Decline Decline DeclineMycophenolate MofetilLupus Modified Limited Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBMyforticLupus Modified Limited Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBMykrox

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBMyleranLeukemia Decline Decline Decline DeclineMylocel

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBLeukemia Decline Decline Decline DeclineMysoline

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

NadololHeart Modified Limited Decline MIBNaloxone HclDrug Overdose Preferred Select Decline MIBNaltrexone

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Drug Overdose Preferred Select Decline MIBNamendaAlzheimer's/Dementia Decline Decline Decline MIBNamzaricAlzheimer's/Dementia Decline Decline Decline MIBNateglinideDiabetes Preferred Special Decline MIB

29

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

NatrecorHeart Modified Limited Decline MIBNavane Schizophrenia Modified Limited Decline MIBNembutalAnxiety Disorder Preferred Select Icare MIBInsomnia Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

NeoralPsoriasis Preferred Select Icare MIBRheumatoid Arthritis Preferred Select Decline MIBOrgan Transplant Rejection Decline Decline Decline MIBNeosarLeukemia Decline Decline Decline DeclineNeuproRestless Leg Syndrome Preferred Select Decline MIBParkinson’s Disease Modified Limited Decline MIBNeurontinModerate To Severe Pain Modified Limited Decline MIBNeuropathy Modified Limited Decline MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

NevirapineHIV Decline Decline Decline DeclineNexavar

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBNexiclon Xr

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Nicardipine Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBNifedical Xl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Nifedipine

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Nilandron

Prostate Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Prostate Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBProstate Cancer 2+ years free Preferred 5+ years free Select Decline MIB

30

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

NimodipineIschemic Heart Disease Modified Limited Decline MIB

Brain Aneurysm Decline ≤ 2 years Decline, 2+ Special Decline MIB

Nisoldipine Er

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

NitrekHeart Modified Limited Decline MIBNitro-Bid

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Nitroglycerin

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Nitropress

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Nitrostat

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Normodyne

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBNortriptyline HclDepression Preferred Select Decline MIBNorvasc

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Heart Modified Limited Decline MIBNorvirHIV Decline Decline Decline DeclineNovantroneMultiple Sclerosis Modified Limited Decline MIBNovolin

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started be-fore age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

Novolog

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started be-fore age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

NulojixOrgan Transplant Rejection Decline Decline Decline MIBNuplazidParkinson’s Disease Modified Limited Decline MIBPsychosis Modified Limited Decline MIBOdefseyHIV Decline Decline Decline Decline

31

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

OlanzapineAnxiety Disorder Preferred Select Icare MIBBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBOlysioHepatitis C Decline Decline Decline MIBOndansetron Nausea Preferred Select Icare MIBOnglyzaDiabetes Preferred Special Decline MIBOrenitramPulmonary Hypertension Modified Limited Decline MIBOretic

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

OrkambiCystic Fibrosis Decline Decline Decline MIBOrlaam

Opioid Dependence Modified ≤ 5 years Decline, 5+ Special Decline MIB

Orthoclone Okt3Organ Transplant Rejection Decline Decline Decline MIBOxcarbazepine

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Oxtellar Xr

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Oxycodone HclModerate To Severe Pain Modified Limited Decline MIBPapaverine Hcl

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Peripheral Vascular Disease Modified Limited Decline MIBParlodelParkinson’s Disease Modified Limited Decline MIBParoxetine HclAnxiety Disorder Preferred Select Icare MIBPaserTuberculosis Modified Special Decline MIBPaxilDepression Preferred Select Decline MIBPaxipamAnxiety Disorder Preferred Select Icare MIBPeganone

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

PegasysHepatitis B Modified Limited Decline MIBHepatitis C Decline Decline Decline MIBPeg-Intron

32

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Hepatitis C Decline Decline Decline MIBPentoxifylline ErIntermittent Claudication Modified Limited Decline MIBPerforomistAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBPergolide MesylateParkinson’s Disease Modified Limited Decline MIBPerindopril Erbumine

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Coronary Artery Disease Modified ≤ 2 years Decline, 2+ Limited Decline MIB

PermaxParkinson’s Disease Modified Limited Decline MIBPerphenazinePsychosis Modified Limited Decline MIBSchizophrenia Modified Limited Decline MIBPhenobarbital

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Phenurone

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Phenytoin Sodium

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Pindolol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Pioglitazone HclDiabetes Preferred Special Decline MIBPlaquenilRheumatoid Arthritis Preferred Select Decline MIBLupus Modified Limited Decline MIBPlavix

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

PlegridyMultiple Sclerosis Modified Limited Decline MIBPlendil

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

PletalIntermittent Claudication Modified Limited Decline MIBPradaxaBlood Thinner Modified Special Decline MIBPramipexole DihydrochloriRestless Leg Syndrome Preferred Select Decline MIB

33

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Parkinson’s Disease Modified Limited Decline MIBPravacholCholesterol Preferred Select Decline MIBPravastatin SodiumCholesterol Preferred Select Decline MIBPrazosin Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

PremarinMenopausal Symptoms Preferred Select Icare MIB

Breast And Prostate Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Breast And Prostate Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBBreast And Prostate Cancer 2+ years free Preferred 5+ years free Select Decline MIBPrestalia

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

PrezcobixHIV Decline Decline Decline DeclinePrezistaHIV Decline Decline Decline DeclinePriftinTuberculosis Modified Special Decline MIBPrimacorHeart Disease Modified Limited Decline MIBPrimidone

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Prinzide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

PriscolinePulmonary Hypertension Modified Limited Decline MIBProair HfaAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBProcainamide HclVentricular Arrhythmia Modified Limited Decline MIBPrografOrgan Transplant Rejection Decline Decline Decline MIBProlastinCOPD Modified Special Decline MIBProlixinPsychosis Modified Limited Decline MIBSchizophrenia Modified Limited Decline MIBPropafenone Hcl

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

Ventricular Arrhythmia Modified Limited Decline MIBPropranolol

34

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Propranolol Hcl

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

Protriptyline HclDepression Preferred Select Decline MIBProventilAsthma Preferred Special Decline MIBBronchitis Preferred Select Decline MIBCOPD Modified Special Decline MIBProzacAnxiety Disorder Preferred Select Icare MIBPanic Disorder Preferred Select Icare MIBPulmozymeCystic Fibrosis Decline Decline Decline MIBPurinetholLeukemia Decline Decline Decline DeclinePyrazinamideTuberculosis Modified Special Decline MIBQuetiapine FumarateBipolar Disorder Preferred Select Decline MIBManic Depression Modified Limited Decline MIBSchizophrenia Modified Limited Decline MIBQuinapril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBQuinaretic

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBQuinidine Gluconate Cr

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

Ventricular Arrhythmias Modified Limited Decline MIBQvarAsthma Preferred Special Decline MIBRamipril

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBRanexa

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

RapamuneOrgan Transplant Rejection Decline Decline Decline MIBRazadyne ErAlzheimer's/Dementia Decline Decline Decline MIB

35

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

RebetronChronic Hepatitis C Decline Decline Decline MIBRelpaxMigraine Preferred Select Icare MIBReminylAlzheimer's/Dementia Decline Decline Decline MIBRemodulinPulmonary Hypertension Modified Limited Decline MIBRenagelRenal Disease With Dialysis Patients Decline Decline Decline MIB

Renese

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

RenvelaDialysis Decline Decline Decline MIBRequipRestless Leg Syndrome Preferred Select Decline MIBParkinson’s Disease Modified Limited Decline MIBRescriptorHIV Decline Decline Decline DeclineReserpine

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

RetavaseHeart Modified Limited Decline MIBRevia

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

Drug Addiction Modified ≤ 5 years Decline, 5+ Special Decline MIB

RexultiMajor Depressive Disorder Modified Limited Decline MIBSchizophrenia Modified Limited Decline MIBReyatazHIV Decline Decline Decline DeclineRibasphereHepatitis C Decline Decline Decline MIBRifamateTuberculosis Modified Special Decline MIBRilutekALS (Lou Gherig's Disease) Decline Decline Decline MIBRiluzoleALS (Lou Gherig's Disease) Decline Decline Decline MIBRisperdalBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBRisperidoneBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIB

36

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

RituxanRheumatoid Arthritis Preferred Select Decline MIBChronic Lymphocytic Leukemia Decline Decline Decline MIB

Non-Hodgkin's Lymphoma Decline Decline Decline DeclineRivastigmine TartrateAlzheimer's/Dementia Decline Decline Decline MIBRopiniroleRestless Leg Syndrome Preferred Select Decline MIBParkinson’s Disease Modified Limited Decline MIBRybix OdtModerate To Severe Pain Modified Limited Decline MIBRyzoltModerate To Severe Pain Modified Limited Decline MIBSabril

Epilepsy Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤2 years Decline, 2+ Limited Decline MIB

Saluron

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

SaphrisBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBSavaysa

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

SavellaFibromyalgia Syndrome Preferred Select Decline MIBSelegiline Parkinson’s Disease Modified Limited Decline MIBSelzentryHIV/AIDS Decline Decline Decline DeclineSerevent DiskusAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBEmphysema Modified Special Decline MIBSeromycinTuberculosis Modified Special Decline MIBSeroquelBipolar Disorder Preferred Select Decline MIBDepression Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBSertraline Depression Preferred Select Icare MIBSertraline HclPanic Disorder Preferred Select Icare MIBSimulectOrgan Transplant Rejection Decline Decline Decline MIBSimvastatinCholesterol Preferred Select Decline MIB

37

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

SinemetParkinson’s Disease Modified Limited Decline MIBSirturoTuberculosis Modified Special Decline MIBSoltamox

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBSotalol HclVentricular Arrhythmia Modified Limited Decline MIBSovaldiHepatitis C Decline Decline Decline MIBSpiriva HandihalerCOPD Modified Special Decline MIBSpiriva RespimatAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBSpironolactone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBStalevo Parkinson’s Disease Modified Limited Decline MIBStarlixDiabetes Preferred Special Decline MIBStavudineHIV Decline Decline Decline DeclineStiolto RespimatCOPD Modified Special Decline MIBStivarga

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBStribildHIV Decline Decline Decline DeclineStriverdi RespimatCOPD Modified Special Decline MIBSuboxone

Opioid Dependence Modified ≤ 5 years Decline, 5+ Special Decline MIB

SubsysSevere Pain Modified Limited Decline MIBSulfinpyrazoneGout Preferred Select Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Cardiovascular Disease Modified ≤ 2 years Decline, 2+ Limited Decline MIB

Sumatriptan

38

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Migraine Preferred Select Icare MIBSustivaHIV Decline Decline Decline DeclineSutent

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBSymbicortAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBSymbyaxBipolar Disorder Preferred Select Decline MIBDepression Preferred Select Decline MIBSymmetrelParkinson’s Disease Modified Limited Decline MIBSynthroidHypothyroidism Preferred Select Decline MIBSynriboChronic Myeloid Leukemia Decline Decline Decline MIBTabloidLeukemia Decline Decline Decline DeclineTacrolimusOrgan Transplant Rejection Decline Decline Decline MIBTagrisso

Lung Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Lung Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBLung Cancer 2+ years free Preferred 5+ years free Select Decline MIBTambocorHeart Disease Modified Limited Decline MIBTamoxifen Citrate

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBTamsulosin HclEnlarged Prostate Preferred Select Decline MIBTanzeumDiabetes - Non Insulin Injectable Preferred Special Decline MIB

Diabetes - Non Insulin Injectable Preferred Special Decline MIB

Tarceva

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBTarka

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

39

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

TasignaLeukemia Decline Decline Decline DeclineTasmarParkinson’s Disease Modified Limited Decline MIBTecfideraMultiple Sclerosis Modified Limited Decline MIBTechnivieHepatitis C Decline Decline Decline MIBTekamlo

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Tekturna

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

TeniposideAcute Lymphocytic Leukemia Decline Decline Decline Decline

Tenormin

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Terazosin Hcl

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Teveten

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Thalitone

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBTheophylline ErAsthma Preferred Special Decline MIBCOPD Modified Special Decline MIBEmphysema Modified Special Decline MIBThioridazineSchizophrenia Modified Limited Decline MIBThiothixeneSchizophrenia Modified Limited Decline MIBThorazineSchizophrenia Modified Limited Decline MIBTiagabine Hydrochloride

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Ticlid

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

Ticlopidine Hcl

40

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Blood Thinner ***See Blood Thinners at end of medication list Special Decline MIB

Tikosyn

Atrial Fibrillation Modified ≤ 2 years Decline, 2+ Special Decline MIB

Timolide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

TivicayHIV Decline Decline Decline DeclineTobiCystic Fibrosis Decline Decline Decline MIBTolazamideDiabetes Preferred Special Decline MIBTolbutamideDiabetes Preferred Special Decline MIBTolinaseDiabetes Preferred Special Decline MIBTonocardVentricular Arrhythmia Modified Limited Decline MIBTopamaxMigraine Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

TopiragenMigraine Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

TopiramateMigraine Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Toposar

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBToprol

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

Toprol XlCongestive Heart Failure Modified Limited Decline MIBTorsemide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBTracleerPulmonary Hypertension Modified Limited Decline MIBTradjentaDiabetes Preferred Special Decline MIB

41

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Trandate

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Trandolapril/Verapamil Hc

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Trazodone HclAnxiety Disorder Preferred Select Icare MIBMajor Depressive Disorder Modified Limited Decline MIBTreandaChronic Lymphocytic Leukemia Decline Decline Decline MIB

Tresiba Flextouch

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

Diabetes - Injectable 100+ units or started before age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

TretinoinTopical Cream - Eczema Preferred Select Icare MIBOral pill - Leukemia Decline Decline Decline DeclineTriamterene/Hydrochlorothiazide

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Tribenzor

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Trihexyphenidyl HclParkinson’s Disease Modified Limited Decline MIBTrileptal

Epilepsy Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤2 years Decline, 2+ Limited Decline MIB

TriumeqHIV Decline Decline Decline DeclineTrizivirHIV Decline Decline Decline DeclineTrulicityDiabetes - Non Insulin Injectable Preferred Special Decline MIB

Diabetes - Non Insulin Injectable Preferred Special Decline MIB

TruvadaHIV Decline Decline Decline DeclineTubersolTuberculosis Modified Special Decline MIBTudorza PressairCOPD Modified Special Decline MIBTwynsta

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

TybostHIV Decline Decline Decline Decline

42

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Tykerb

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2-5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBTyzekaHepatitis B Modified Limited Decline MIBUltramModerate To Severe Pain Modified Limited Decline MIBUniretic

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Univasc

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBUrsodiolGallstones Preferred Select Icare MIBPrimary Biliary Cirrhosis Decline Decline Decline MIBValproic AcidBipolar Disorder Preferred Select Decline MIBMigraine Preferred Select Icare MIB

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Valturna

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

VanatripDepression Preferred Select Decline MIBVandetanib

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBVascazen

Cardiovascular Disease Modified ≤ 2 years Decline, 2+ Limited Decline MIB

Vascor

Angina Modified ≤ 2 years Decline, 2+ Special Decline MIB

VasodilanCirculatory Disorder Modified Limited Decline MIBVasotec

Hypertension ≤ 5 medications Preferred, 6+ Modified

1- 2 medications Select, 3+ Special Decline MIB

Heart Disease Modified Limited Decline MIBVeletriPulmonary Hypertension Modified Limited Decline MIBVelosulin Br

Diabetes - Injectable ≤ 99 units & started after age 40, Standard

≤ 99 units & diagnosed after age 40, Special Decline MIB

43

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Diabetes - Injectable 100+ units or started be-fore age 40, Modified

100+ units or diagnosed before age 40, Limited Decline MIB

VelphoroRenal Insufficiency Modified Limited Decline MIBVemlidyChronic Hepatitis B Modified Limited Decline MIBVenclextaChronic Lymphocytic Leukemia Decline Decline Decline MIB

Venlafaxine Hcl ErAnxiety Disorder Preferred Select Icare MIBDepression Preferred Select Decline MIBMajor Depressive Disorder Modified Limited Decline MIBVentavisPulmonary Hypertension Modified Limited Decline MIBVerapamil

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

VesanoidLeukemia Decline Decline Decline DeclineVictozaDiabetes - Non Insulin Injectable Preferred Special Decline MIB

Diabetes - Non Insulin Injectable Preferred Special Decline MIB

VictrelisHepatitis C Decline Decline Decline MIBVidexHIV Decline Decline Decline DeclineViekira PakHepatitis C Decline Decline Decline MIBViibrydDepression Preferred Select Decline MIBVimpat

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

ViraceptHIV Decline Decline Decline DeclineViramuneHIV Decline Decline Decline DeclineVireadHepatitis B Modified Limited Decline MIBHIV Decline Decline Decline DeclineVisken

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

VitektaHIV Decline Decline Decline DeclineVivitrol

Alcoholism Modified ≤ 5 years Decline, 5+ Special Decline MIB

44

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Drug Overdose Preferred Select Decline MIBVraylarBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBWarfarin Blood Thinner Modified Special Decline MIBXalkori

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBXareltoBlood Thinner Modified Special Decline MIBXeloda

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBXenazineHuntington's Chorea Decline Decline Decline MIBXigduo XrDiabetes Preferred Special Decline MIBZafirlukastAsthma Preferred Special Decline MIBZarontin

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Zaroxolyn

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

Congestive Heart Failure Modified Limited Decline MIBZarxioNeutropenia Decline Decline Decline DeclineZavescaGaucher's Disease Decline Decline Decline MIBZelaparParkinson’s Disease Modified Limited Decline MIBZemairaCOPD Modified Special Decline MIBEmphysema Modified Special Decline MIBZemplarChronic Kidney Disease Modified Limited Decline MIBDialysis Decline Decline Decline MIBZenapaxOrgan Transplant Rejection Decline Decline Decline MIBZepatierHepatitis C Decline Decline Decline MIBZeritHIV Decline Decline Decline DeclineZestoretic

45

Medication/Indication Simple Security Plan Security Care Plan iCare MIB

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

ZetiaCholesterol Preferred Select Decline MIBZiac

Hypertension ≤ 5 medications Preferred, 6+ Modified

1-2 medications Select, 3+ Special Decline MIB

ZinbrytaMultiple Sclerosis Modified Limited Decline MIBZiprasidone HclBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBZocorCholesterol Preferred Select Decline MIBZofran

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIBZoloftDepression Preferred Select Decline MIBZonegran

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

Zonisamide

Seizure Seizure ≤ 30 days Decline, 31+ Modified

Seizure ≤ 2 years Decline, 2+ Limited Decline MIB

ZortressOrgan Transplant Rejection Decline Decline Decline MIBZyprexaBipolar Disorder Preferred Select Decline MIBSchizophrenia Modified Limited Decline MIBZytiga

Cancer Current or < 90 days free Decline

Current or ≤ 2 years free Decline Decline Decline

Cancer 91+ days free Modified 2 - 5 years free Special Decline MIBCancer 2+ years free Preferred 5+ years free Select Decline MIB

Underwriting Blood Thinner Maintenance Therapy (Simple Security Plan)We are accepting certain blood thinning medications available for immediate coverage on the preferred class with the following conditions:

Ailments: Atrial Fibrillation, Pulmonary Embolism, Stroke (including TIA’s), and StentsMedications: Aggrenox, Aspirin, Clopidogrel, Dipyridamole, Effient, Eptifibatide, Persantine, Plavix, Prasugrel, Ticlid, Ticlopidine

Underwriting:• If qualifying event was more than two years ago with no other ailments you may apply for a first day coverage plan

at the preferred rate.• If qualifying event was more than two years ago, they are on the maintenance medications, and are insulin

dependent diabetic, we will issue based on severity and any other complications. First day coverage will not be given.

• If the qualifying event is within two years we will issue based on severity and any other complications. First day coverage will not be given.

Medications Not Included:This list is not all inclusive and is intended as a guide only. If they are on any of these blood thinning medications, the best plan they can get is a modified plan: Cilostazol, Coumadin, Eliquis, Lovenox, Pentoxifylline, Pradaxa, Warfarin, and Xarelto.

Uninsurable Conditions:This list is not inclusive, but more comprehensive than the application. This lists conditions that we consider uninsurable.

• Addison Disease – Auto-Immune disorder/atrophy of the adrenal cortex• AIDS or AIDS related complex• ALS (Lou Gehrig’s Disease) – Disorder of the motor neurons• Alzheimer’s• Anemia(s) – Sickle Cell Anemia, Thalassemia Major, Pernicious,• Sickle Cell trait• Anorexia• Ascites – Edema of the peritoneal space effecting the liver, heart, and kidneys• Cancer of the blood or bone marrow, not insurable at any time• Cirrhosis – Liver disorder• Cystic Fibrosis – Normal tissue is replaced with fibrous tissue• Dementia• Dialysis• Hepatitis C• HIV+• Hodgkin’s lymphoma, Non Hodgkin’s lymphoma, Hodgkin’s disease• Leukemia• Lupus Erythematosus – Blood disorder with renal and brain involvement• Organ Transplant• Sarcoidosis (If in Stage 3 or 4)• Suicidal behavior within 2 years• Need assistance or supervision with dressing, eating, personal hygiene (bathing or toilet), or transferring

to and from a bed or chair• Under hospice care or institutional care

P. O. Box 57220, Salt Lake City, UT 84157 5300 South 360 West, Suite 250, Salt Lake City, UT 84123

NON-DISCLOSURE AND NON-SOLICITATION AGREEMENT You acknowledge that all policyholder lists, applications for insurance, policyholder information, and all other business records, memoranda, and other materials and information contained herein are the property of Security National Life Insurance Company and its subsidiaries and are confidential, and that they and the information contained therein shall not be used or disclosed without the specific written authorization of the Company. You hereby agree to NOT induce or attempt to induce, or cause or aid in any manner whatsoever any other agent or other person to induce or attempt to induce, any policyholder to terminate any policy issued by SNLIC. You further agree to NOT solicit, or cause or aid any other person to solicit, any policyholders of SNLIC to purchase policies of another life insurance company. These restrictions shall continue for a period of two (2) years after the termination of Your authority. You agree that any engagement in activities described in the preceding four paragraphs will result in irreparable injury to SNLIC, for which there is no adequate remedy at law. Thus, You agree that in the event You breach any of said paragraphs, SNLIC may apply for and obtain immediate and continuing injunctive relief prohibiting further or continued breach of Your obligations, and You further agree to liquidated damages in the amount of two (2) years of annual premium for all policies which are terminated as a result of Your activities, and in the amount of the commissions for the preceding 365 days for any agents who terminate or reduce their activity as a result of Your activities.