new business underwriting guidelines and procedure manual · underwriting guidelines. 5 more...

New Business Underwriting Guidelines and Procedure Manual

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New Business Procedure Manual

Jennifer Golden, Manager [email protected]

Wendi Beauchaine, Assistant Manager [email protected]

Jennel Riggs, Supervisor [email protected]

Antonia Ebert, Underwriter [email protected]

Melanie Smith, Texas Contract Specialist [email protected]

Jamie Pettinger, Texas Contract Specialist [email protected]

Questions? Call us at 1-866-SNL-4SNL (Then press 1)

Sara Burke, Policy Issue Clerk/Texas Contract Specialist [email protected]

Annalise Sparkuhl, Policy Issue Clerk [email protected]

Erika Sanchez, Policy Issue Clerk/Spanish Specialist [email protected]

Morgan Cano, Pending Specialist [email protected]

Lashara Moreno, Assembly Clerk [email protected]

The New Business Team

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Common TermsProposed Insured Signature - Only the proposed insured may sign on the Proposed Insured signature line. No one else may sign the proposed insured’s name. The proposed insured must be able to sign their own name. A “mark” or “X” is not acceptable. Power of Attorney signatures are not acceptable.

Policy Owner Signature - Only the owner may sign on the Owner signature line. The policy owner signature is required if the policy owner is different than the proposed insured.

Payor Information - We need the payors full address and signature. If the insured has a representative payee, paperwork is required.

Replacements - State regulations require that applicable replacement forms be completed at the time of application and be submitted with the application.

Application Date - Applications must be dated the day the application is completed and signed by the proposed insured.

Policy Effective Date- The policy becomes effective on the issue date as long as underwriting approves the application, collects first premium and there are no changes in the proposed insured’s insurability between the applications signed date and the issue date. A future effective date of no more than 30 days in the future from the application may be requested.

Forms of Payment - EFT with completed information, personal check, credit or debit card (Visa, MC or AMEX), or money order. Cash is not acceptable and a check from the agent is not acceptable unless the agent check is for their own personal policy.

Bank Draft Date - A premium will be drafted on the same date each month. A draft date of the 1st through the 28th of each month is an acceptable draft date. If a specific draft date is not specified, SNL will draft immediately upon the approval of the application and the application date will be the future draft date each month. Initial draft date must be within 30 days of the application date.

Initial Premium - The initial draft may be drafted on any business day of the month as long as completed EFT information is filled out on the application. SNL requires a premium with applications OR completed EFT/CC information to draft the first premium within 30 days (We will run the bank account information through our Toolbox, if this comes back with “deny” or “insufficient information” we will require a voided check or a bank statement).

1035 Exchanges - SNL cannot accommodate 1035 exchanges for life insurance contracts.

Agent Splits - Split commissions between agents are acceptable. Both agents need to sign the application and write the percentage of the commission payable to each agent’s signature.

Social Security Numbers – The proposed insured’s Social Security Number is required for all applications.

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SNL Provides Three Methods to Submit Applications:

1. Website Upload (Preferred) This is the preferred method. You need to scan and save the application with any applicable documents to your computer. Next, log into our agent portal via www.SNLFinalExpense.com then the Agent Login button. Then click New Business Upload and select Secure Upload.

You should click on First Time Contract Submission then click Browse and go to the file you saved on your computer. Double click your file name. You may duplicate the file name as many times as needed to upload all documents (total of 15 megabyte limit on total submission). Lastly, click Submit to Underwriters and you will receive an email saying it was received successfully. The acceptable file types are png, jpg / jpeg, bmp, tif / tiff, pdf. (If you have problems logging into our agent portal please call our Marketing Department at 1-855-SNL-4SNL (Then press 4).

2. Mail You may mail applications via USPS to:Security National LifeNew BusinessPO Box 57220Salt Lake City, UT 84157

3. Overnight Via US Mail, UPS or FedExSecurity National Life5300 South 360 WestSalt Lake City, UT 84123

**Please note – we do not allow applications to be submitted via fax or email as this is not a secure way to transmit personal and confidential information.**

New Business must be received by 10:30 a.m. MST. Every piece of business that is received by 10:30 a.m. MST is guaranteed to be ENTERED and counted as received, but not necessarily issued.

• If you submit via UPS or FedEx, it is guaranteed to be ENTERED, but not necessarily issued.

• If it is submitted via express mail or priority mail through USPS, it is not guaranteed to be entered that day. It will depend on when it gets to the department.

• If you submit the application through secure online upload it is not necessary to mail in the originals. You may keep these for your records.

Corrections for policies that are pending due to problems must be received by 2:00 p.m. MST (12:00 p.m. (noon) MST on the last working day of the month) in order to issue the pending policy.

The preferred way to send corrections is through our secure online upload – this will help the business will be issued (IF the problem has been corrected).

Submitting New Business

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General Underwriting Guidelines1. All application sections must be completed correctly, signed and dated by the agent (agent number must be

written on application), proposed insured and the owner (if different than the applicant).

2. If the insured is a minor, we must have the parent or legal guardian sign for them. If there is a guardian, we will need a copy of the guardianship papers.

3. If the beneficiary is the estate or trustee, they must have an estate set up and we need copies of the estate papers or trust papers.

4. All applications are void 30 days after the written (signed) date; applications must be received by the home office before the 30-day deadline.

5. CWA (cash with application) must be submitted by the proposed insured/owner. No agent checks are allowed. We do allow COD business including credit/debit cards. When a credit/debit card is used for CWA the direct bill premium rate applies.

6. If the CWA is returned to us as non-sufficient funds (NSF) we will contact the agent to verify account information or collect different information to allow one additional attempt in collecting the CWA. The agent has 48 hours to provide us this information. We will cancel the policy as “rescinded” if we don’t hear from the agent.

7. If a policy is received by 10:30 a.m. MST it is guaranteed to be entered, but not guaranteed to be issued.

Medical Underwriting Guidelines

1. All Health questions on the application must be asked of the proposed insured and the complete information written on the application. Depending on how the health questions are answered will determine which coverage will be issued. By following the application guidelines in the health section of the application, the agent will easily be able to determine which plan to offer the proposed insured.

2. Medication for medical conditions means the applicant is being treated for that medical condition, which means that health questions for that condition must be marked “yes”. Refer to the Medical Guidelines section for additional information, or call the Underwriting Department with your questions.

3. All insured applications require Rx search as part of the underwriting process. We need the applicants SSN and signature on the application to complete this process. If this information is not on the application, the application will be held for 30 days (from the application date) to allow the agent to get the necessary information.

4. Applications that require an Rx search will be issued/amended/declined upon underwriting review. If amended/declined the agent and regional manager will be notified via email.

5. Applicant’s that are incarcerated in any type of facility cannot be issued on any type of plan. Do not submit an application.

6. Any phone verification calls or underwriting clarification calls will be made by the underwriting department directly to the applicant.

Underwriting Guidelines

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More Helpful Underwriting GuidelinesThese are helpful GUIDELINES for your assessment of the medical history on an application. Keep in mind that you actually visit with the insured, see them face to face and have an advantage over the Home Office. We rely on you for “field underwriting”.

Please remember that not all medical conditions are listed. If the condition was serious enough to seek medical attention and medications were given in aid of this condition, they may not qualify for the fully insured plan. Exceptions are minor acute conditions such as colds, flu, allergies, and other minor conditions from which the applicant has fully recovered. As individual situations vary, so do underwriting decisions. The primary insured must sign his/her own application. The only exception is for minor children. Insurance on those who cannot read or write and their signature is an “X”, must be witnessed by another person of legal age other than the agent. Make certain that all of the medical questions are asked and fully answered, as the application becomes a part of any policy issued.

If the primary insured has seen a doctor and they are currently running tests or are awaiting further news from the doctor this policy is to not be written. We need to postpone until either the doctor has given a clean bill of health or a diagnosis has been made.

4’10” 200 223 4’11” 207 229 5’0” 213 235 5’1” 219 241 5’2” 225 246 5’3” 231 251 5’4” 237 256 5’5” 243 262 5’6” 249 268 5’7” 255 274 5’8” 262 280 5’9” 270 287 5’10” 277 294 5’11” 285 301 6’0” 292 308 6’1” 299 316 6’2” 306 324 6’3” 313 332 6’4” 321 340 6’5” 329 348 6’6” 335 356 6’7” 341 365

Height Preferred/Standard Graded

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Underwriting Blood Thinner Maintenance Therapy (Simple Security Plan)Improved Underwriting:

We are now 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, Persantine, Plavix, Prasugrel, Ticlid, Ticlopidine

Underwriting:• If qualifying event was more than two years ago and they are on the maintenance medication with no

other ailments we will issue 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 type

one diabetic (insulin dependent) we will issue the graded plan.• 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:Warfarin and Coumadin will remain graded at all times. Please check our underwriting guide. Our Rx list has been updated.

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Afinitor Afinitor CancerGraded

Decline

Agenerase Agenerase AIDS Decline

Aggrastat Aggrastat Heart Graded

AgrylinAnagrelide Hy-

drochlorideCancer

Graded

Decline

Akineton Akineton Parkinson’s Disease Graded

Albuterol Albuterol Asthma COPDPreferred

Graded

Aldactone Spironolactone Heart Graded

Aldomet Methyldopa Hypertension heartPreferred

Graded

Alimta Alimta CancerGraded

Decline

Alkeran Alkeran CancerGraded

Decline

Allopurinol Allopurinol Gout Preferred

Aloxi Aloxi CancerGraded

Decline

Alprazolam AlprazolamAnxiety Panic Dis-

orderPreferred

Altace Alupent Hypertension CHFPreferred

Graded

Altace Alupent Hypertension CHFPreferred

Graded

Alupent Alupent Asthma COPDPreferred

Graded

Amantadine Hcl Amantadine Hcl Parkinson’s Disease Graded

Amaryl Glimepiride Type 2 Diabetes Preferred

Ambisome Ambisome AIDS Decline

Medical Guidelines

Abacavir Ziagen AIDS Decline

Abilify AbilifySchizophrenia Bipolar

DisorderGraded

Abraxane Abraxane CancerGraded

Decline

Acarbos Precose Type 2 Diabetes Preferred

Accupril Quinapril Hypertension heartPreferred

Graded

Accuretic Quinaretic Hypertension heartPreferred

Graded

Aceon Aceon Hypertension CHFPreferred

Graded

Acetaminophen Hydrocodone Pain Preferred

Acetohexamide Acetohexamide Type 2 Diabetes Preferred

Actiq Actiq CancerGraded

Decline

Activase Activase Stroke HeartPreferred

Graded

Actoplus Met Actoplus Met Type 2 Diabetes Preferred

Actos Actos Type 2 Diabetes Preferred

Adcetris Adcetris CancerGraded

Decline

Adriamycin Adriamycin CancerGraded

Decline

Adrucil Fluorouracil CancerGraded

decline

Advair Diskus Advair Diskus Asthma COPDPreferred

Graded

Advicor Advicor Cholesterol Preferred

Product Name Popular Name Indications Decision Product Name Popular Name Indications Decision

Use this chart to choose how medications should be graded 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. We only list the uses we are concerned about. For example, we don’t list elevated blood pressure because it is acceptable on the final expense application.

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.

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Aromasin Aromasin CancerGraded

Decline

Arranon Arranon CancerGraded

Decline

Arzerra Arzerra Cancer Graded

Asthmahaler Asthmahaler Lung DisorderPreferred

Graded

Atacand Atacand Hypertension HeartPreferred

Graded

AtametCarbidopa/

LevodopaParkinson’s Disease Graded

Atarax Hydroxyzine Allergies Anxiety Preferred

Atenolol Atenolol Hypertension Graded

Atgam Atgam Organ Transplant Decline

Ativan Lorazepam Anxiety Disorder Preferred

Atorvastatin

CalciumLipitor Cholesterol Preferred

Atripla Atripla AIDS Decline

AtroventIpratropium

BromideLung Disorder Graded

Atrovent Hfa Atrovent Hfa COPD Graded

Avalide Avalide Hypertension Preferred

Avandamet Avandamet Type 2 Diabetes Preferred

Avandaryl Avandaryl Type 2 Diabetes Preferred

Avandia Avandia Type 2 Diabetes Preferred

Avapro Avapro

Hypertension Diabetic

Nephropathy (Kidney

Problems)

Preferred

Graded

Avastin Avastin CancerGraded

Decline

Azasan Azathioprine

Organ Transplant

Rejection Rhumatoid

Arthritis

Please Call

Azathioprine Azathioprine

Organ Transplant

Rejection Rhumatoid

Arthritis

Please Call

Azilect Azilect Parkinson’s Disease Graded

Azmacort Azmacort Lung DisorderPreferred

Graded

Azor Azor Hypertension Preferred

Baraclude Baraclude Liver Disorder Graded

Benazepril Hcl Benazepril Hcl Hypertension HeartPreferred

Graded

Benicar Benicar Hypertension Preferred

Amifostine Amifostine CancerGraded

Decline

Amiloride Hcl Amiloride Hcl Hypertension CHFPreferred

Graded

Amiloride/Hydro-

chlorothia

Amiloride/Hydro-

chlorothiazideHypertension Preferred

Aminophylline Aminophylline Lung DisorderPreferred

Graded

Amitriptyline Hcl Amitriptyline Hcl DepressionPreferred

Graded

Amlodipine

Besylate

Amlodipine

BesylateHypertension Heart

Preferred

Graded

Amlodipine

Besylate/AtorvCaduet Hypertension Heart

Preferred

Graded

Ampyra Ampyra Multiple Sclerosis Graded

Amturnide Amturnide Hypertension Preferred

Amyl Nitrite Amyl Nitrite Heart Graded

Anagrelide Hy-

drochloride

Anagrelide Hy-

drochlorideCancer

Graded

Decline

Anastrozole Arimidex Cancer Graded

Angiomax Angiomax Circulatory Disorder Graded

Antabuse Antabuse Alcoholism Graded

Anzemet Anzemet Cancer Graded

Apidra Apidra Type 1 DiabetesStandard

Graded

Apidra Solostar Apidra Type 1 DiabetesStandard

Graded

Aplenzin AplenzinMajor Depressive

DisorderGraded

Apokyn Apokyn Parkinson’s Disease Graded

Apresoline Hydralazine Hypertension heartPreferred

Graded

Aptivus Aptivus AIDS Decline

Aquatensen Methyclothiazide Hypertension heartPreferred

Graded

Aralast Prolastin COPD Graded

Aranesp Aranesp Kidney Disease Graded

Arcapta Neohaler Arcapta Neohaler COPD Graded

ArediaPamidronate Diso-

diumCancer

Graded

Decline

Argatroban Argatroban Circulatory Disorder Graded

Aricept AriceptAlzheimer’s Disease

DementiaDecline

Arimidex Arimidex Cancer Graded


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Product Name Popular Name Indications Decision

Benztropine

Mesylate

Benztropine

MesylateParkinson’s Disease Graded

Betaseron Betaseron Multiple Sclerosis Graded

Betaxolol Hcl Betaxolol Hcl Hypertension Preferred

Bexxar Bexxar CancerGraded

Decline

Bicalutamide Casodex CancerGraded

Decline

Bicnu Bicnu CancerGraded

Decline

Bicnu W/Diluent

AbsoluteBicnu Cancer

Graded

Decline

Bidil Bidil Heart Graded

Bisoprolol Fuma-

rate/Hydro

Bisoprolol Fuma-

rate/Hydrochloro-

thiazide

Hypertension Preferred

Bitartrate Asthmahaler Lung DisorderPreferred

Graded

Blenoxane Bleomycin Sulfate CancerGraded

Decline

Bleomycin Sulfate Bleomycin Sulfate CancerGraded

Decline

Bosulif Bosulif CancerGraded

Decline

Bretylium Tosylate Bretylium Tosylate Heart Graded

Bromocriptine

Mesylate

Bromocriptine

Mesylate

Cancer Parkinson's

Disease Type 2 Dia-

betes

Please Call

Bumetanide Bumetanide Hypertension HeartPreferred

Graded

Bumex Bumetanide Hypertension HeartPreferred

Graded

Busulfex Myleran CancerGraded

decline

Bydureon Byetta Type 2 Diabetes Preferred

Byetta Byetta Type 2 Diabetes Preferred

Bystolic Bystolic Hypertension Preferred

Caduet Caduet Hypertension HeartPreferred

Graded

Calan Verapamil Hypertension heartPreferred

Graded

Calcium FolinateLeucovorin Cal-

ciumcancer

Graded

Decline

Campath Campath CancerGraded

Decline

Campral Campral Alcoholism drugs Graded

Camptosar Irinotecan Cancer Graded

Decline

CapozideCaptopril/Hydro-

chlorothiazideHypertension Heart

Preferred

Graded

Caprelsa Caprelsa CancerGraded

Decline

Captopril/Hydro-

chlorothia

Captopril/Hydro-

chlorothiazideHypertension Heart

Preferred

Graded

Carbidopa/

Levodopa/EntacaStalevo Parkinson’s Disease Graded

Carboplatin Carboplatin CancerGraded

Decline

Cardene Nicardipine Hcl Hypertension heartPreferred

Graded

Cardiosterol Cardiosterol Cholesterol HeartPreferred

Graded

Cardizem Cd Diltiazem Hypertension heartPreferred

Graded

CarduraDoxazosin

MesylateHypertension Preferred

Carnitor Carnitor Kidney Disease Graded

Carnitor Levocarnitine Liver Disorder Graded

Cartia Diltiazem Hypertension heartPreferred

Graded

Carvedilol Carvedilol Hypertension HeartPreferred

Graded

Casodex Casodex CancerGraded

Decline

Catapres Clonidine Hcl Hypertension Preferred

Ceenu Ceenu CancerGraded

Decline

Celebrex Celebrex Arthritis Preferred

CelexaCitalopram Hyd-

robromideDepression Preferred

Cellcept Cellcept Organ Transplant Decline

Celontin Celontin Seizure Graded

Cerebyx Cerebyx Seizure Graded

Cerubidine Cerubidine CancerGraded

Decline

Cesamet Cesamet CancerGraded

Decline

Chlorambucil Chlorambucil CancerGraded

Decline

Chlorothiazide Chlorothiazide Hypertension HeartPreferred

Graded

Chlorpromazine

Hcl

Chlorpromazine

HclMental Disorders Graded

Chlorthalidone Chlorthalidone Hypertension heartPreferred

Graded


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Cidofovir Vistide AIDS Decline

Cilostazol Cilostazol Circulatory Disorder Graded

Cisplatin Cisplatin CancerGraded

Decline

Cladribine Cladribine CancerGraded

Decline

Clolar Clolar CancerGraded

Decline

Clopidogrel Plavix Stroke heartPreferred

Graded

CogentinBenztropine

MesylateParkinson’s Disease Graded

Cognex CognexAlzheimer’s Disease

DementiaDecline

Combivir Combivir AIDS Decline

Complera Complera AIDS Decline

Conzip Tramadol Hcl Pain Preferred

Copaxone Copaxone Multiple Sclerosis Graded

Copegus Ribasphere Liver Disorder Graded

Coreg Carvedilol Hypertension HeartPreferred

Graded

Coreg Cr Coreg Cr Hypertension heartPreferred

Graded

Corgard Nadolol Hypertension heartPreferred

Graded

Corvert Corvert Heart Graded

Coumadin Warfarin Stroke heart Graded

Covera-Hs Verapamil Hypertension heartPreferred

Graded

Cozaar Cozaar Hypertension heartPreferred

Graded

Crestor Crestor Cholesterol Preferred

Crixivan Crixivan AIDS Decline

Cyclosporine Cylosporine Organ Transplant Decline

Cyclosporine A Cylosporine Organ Transplant Decline

Cyclosporine

ModifiedNeoral Organ Transplant Decline

Cymbalta Cymbalta Depression Preferred

Cystagon Cystagon Kidney Disease Graded

Cytogam Cytogam Organ Transplant Decline

Cytosar-U Cytarabine CancerGraded

Decline

CytoxanCyclophospha-

mideCancer

Graded

Decline

Dacarbazine Dacarbazine CancerGraded

Decline

Dacogen Dacogen CancerGraded

decline

Dactinomycin Cosmegen CancerGraded

Decline

Daliresp Daliresp Lung Disorder Graded

Daunoxome Daunoxome CancerGraded

Decline

Demadex Torsemide Hypertension heartPreferred

Graded

Depacon Valproic Acid Seizure Graded

Depade Naltrexone Alcoholism Drugs Graded

Depakene Valproic Acid Seizure Graded

Depakote Depakote Seizure Graded

Depocyt Depocyt CancerGraded

Decline

Diabeta Glyburide Type 2 Diabetes Preferred

Diazepam DiazepamAnxiety Panic Dis-

orderPreferred

Didanosine Didanosine AIDS Decline

Digitek Digoxin Heart Graded

Dilantin Dilantin Seizure Graded

Dilatrate Sr Isosorbide Heart Graded

Diltiazem Diltiazem Hypertension heartPreferred

Graded

Diovan Diovan Hypertension heartPreferred

Graded

Disulfiram Antabuse Alcoholism Graded

Diuril Chlorothiazide Hypertension HeartPreferred

Graded

Divalproex Depakote Seizure Graded

Docefrez Taxotere CancerGraded

Decline

Docetaxel Taxotere CancerGraded

Decline

Dolophine Methadone Alcoholism Drugs Graded

Donepezil Hcl AriceptAlzheimer’s Disease

DementiaDecline

Doxil Doxil CancerGraded

Decline


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Dtic-Dome Dacarbazine CancerGraded

Decline

Duetact Duetact Type 2 Diabetes Preferred

Duoneb Combivent Lung Disorder Graded

Duragesic Fentanyl CancerGraded

Decline

DyazideTriamterene/Hy-

drochlorothiazideHypertension heart

Preferred

Graded

Edecrin Edecrin Hypertension HeartPreferred

Graded

Edurant Edurant AIDS Decline

Effexor EffexorDepression Anxiety

DisorderPreferred

Elavil Amitriptyline Hcl DepressionPreferred

Graded

Eldepryl Selegiline Parkinson’s Disease Graded

Eligard Eligard CancerGraded

Decline

Eligard Lupron Depot CancerGraded

Decline

Eliquis Eliquis Stroke heart Graded

Elitek Elitek CancerGraded

Decline

Ellence Ellence CancerGraded

Decline

Eloxatin Eloxatin CancerGraded

Decline

Elspar Elspar CancerGraded

Decline

Emcyt Emcyt CancerGraded

Decline

Emend Emend CancerGraded

Decline

Eminase Eminase Heart Graded

Emtriva Emtriva AIDS Decline

Enalapril Maleate Enalapril Maleate Hypertension heartPreferred

Graded

Enalaprilat Enalaprilat Hypertension heartPreferred

Graded

Enduron Methyclothiazide Hypertension heartPreferred

Graded

Entacapone Comtan Parkinson’s Disease Graded

Epinephrine Asthmahaler Lung DisorderPreferred

Graded

Epirubicin Hcl Ellence CancerGraded

Decline

Epivir Epivir AIDS Decline

Epivir Hbv Epivir AIDS Decline

Eplerenone Eplerenone Heart Graded

Epzicom Epzicom AIDS Decline

Equetro EquetroBipolar Mood Dis-

orderGraded

Erbitux Erbitux CancerGraded

Decline

Erivedge Erivedge CancerGraded

Decline

Erwinaze Erwinaze CancerGraded

Decline

Escitalopram

Oxalate Lexapro Depression Preferred

Eskalith Lithium CarbonateBipolar Disorder Graded

Estrogens, Conju-

gatedPremarin

Menopausal Symp-

tomsPreferred

Ethosuximide Ethosuximide Seizures Graded

Etopophos Etopophos CancerGraded

Decline

Etoposide Etoposide Cancer Graded

Eulexin Flutamide CancerGraded

decline

Evista Evista Osteoporosis Please Call

Exelon ExelonAlzheimer’s Disease

DimentiaDecline

Exemestane Aromasin Cancer Graded

Exforge Exforge Hypertension heartPreferred

Graded

Extavia Betaseron Multiple Sclerosis Graded

Fanapt Fanapt Schizophrenia Graded

Fanapt Titration

PackFanapt Schizophrenia Graded

Fareston Fareston CancerGraded

Decline

Faslodex Faslodex CancerGraded

Decline

Felbamate Felbatol Seizure Graded

Felbatol Felbatol Seizure Graded

Felodipine Felodipine Hypertension HeartPreferred

Graded

Femara Femara CancerGraded

Decline

Fentanyl Fentanyl CancerGraded

Decline

Flecainide Acetate Flecainide Acetate Heart Graded

Flomax Flomax Enlarged Prostate Preferred

Flovent Flovent Diskus Asthma Lung Disor-

der

Preferred

Graded


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Flovent Diskus Flovent Diskus Asthma Lung Disor-

der

Preferred

Graded

Floxuridine Floxuridine CancerGraded

Decline

Fludarabine Phos-

phateFludara Cancer

Graded

Decline

Fluorouracil Fluorouracil CancerGraded

Decline

Fluoxetine FluoxetineAnxiety Panic Dis-

orderPreferred

Flutamide Flutamide CancerGraded

Decline

Folotyn Folotyn CancerGraded

Decline

Foradil Aerolizer Foradil AerolizerAsthma Lung Disor-

der

Preferred

Graded

Fortamet MetforminType 2 Diabetes

MellitusPreferred

Fortovase Fortovase AIDS Decline

Fosamax Plus D Fosamax Osteoporosis Preferred

Foscarnet Sodium Foscarnet Sodium AIDS Decline

Foscavir Foscarnet Sodium AIDS Decline

Fosinopril Sodium Fosinopril Sodium Hypertension heartPreferred

Graded

Fosphenytoin

SodiumCerebyx Seizure Graded

Fudr Floxuridine CancerGraded

Decline

Furosemide Furosemide Hypertension heartPreferred

Graded

Fusilev Fusilev CancerGraded

Decline

Fuzeon Fuzeon AIDS Decline

Gabapentin Gabapentin Seizure Neuropathy Please Call

Gabarone Gabapentin Seizure Neuropathy Please Call

Gablofen BaclofenMuscle Spasticity

Multiple SclerosisPlease Call

Galantamine Razadyne ErAlzheimer’s Disease

DimentiaDecline

Gemfibrozil Gemfibrozil Cholesterol Preferred

Gengraf Neoral Organ Transplant Decline

Geodon GeodonBipolar Mood Disor-

der schizphreniaGraded

Glassia Prolastin COPD Graded

Gliadel Wafer Gliadel Wafer CancerGraded

Decline

Glibenclamide Glyburide Type 2 Diabetes Preferred

Glimepiride Glimepiride Type 2 Diabetes Preferred

Glipizide Glipizide Type 2 Diabetes Preferred

Glucophage MetforminType 2 Diabetes

MellitusPreferred

Glyburide Glyburide Type 2 Diabetes Preferred

Glyset Glyset Type 2 Diabetes Preferred

Granisetron Hcl Kytril CancerGraded

Decline

Granisol Kytril CancerGraded

Decline

Halaven Halaven CancerGraded

Decline

HaldoHaloperidol Deca-

noateSchizophrenia Graded

Haloperidol

Decanoate

Haloperidol Deca-

noateSchizophrenia Graded

Hctz Hctz Hypertension Preferred

Hecoria Prograf Organ Transplant Decline

Hectorol Hectorol Kidney Disease Graded

Heparin Heparin Stroke heart Graded

Heparin Lock

FlushHeparin Stroke heart Graded

Herceptin Herceptin CancerGraded

Decline

Hexalen Hexalen CancerGraded

Decline

Hivid Hivid AIDS Decline

Horizant HorizantRestless Leg Syn-

dromePreferred

Humalog Humalog Type 1 DiabetesStandard

Graded

Humulin 70/30 Humulin 70/30 Type 1 Diabetes Standard

Graded

Hybolin Improved Hybolin Improved CancerGraded

Decline

Hycamtin Hycamtin CancerGraded

Decline

Hydralazine Hydralazine Hypertension heartPreferred

Graded

Hydralazine Hydralazine Hypertension heartPreferred

Graded

Hydralazine Hcl Hydralazine Hypertension heartPreferred

Graded

Hydralazine/Hy-

drochlorothHydralazine Hypertension heart

Preferred

Graded


13


Hydrea Hydroxyurea CancerGraded

Decline

Hydrochlorothi Lisinopril Hypertension Preferred

Hydrochlorothi-

azide

Hydrochlorothi-

azideHypertension heart

Preferred

Graded

Hydrocodone Hydrocodone Pain Preferred

Hydroxychloro-

quine Sulfate

Hydroxychloro-

quine SulfateCancer

Graded

Decline

Hydroxyurea Hydroxyurea CancerGraded

Decline

Hydroxyzine Hydroxyzine Allergies Anxiety Preferred

Hytrin Terazosin Hcl Hypertension heart Graded

Hyzaar Hyzaar Hypertension heart Preferred

Ibutilide Fumarate Corvert Heart Graded

Iclusig Iclusig CancerGraded

Decline

Idamycin Pfs Idarubicin Hcl CancerGraded

Decline

Idarubicin Hcl Idarubicin Hcl CancerGraded

Decline

Ifex Ifex CancerGraded

Decline

Ifex/Mesnex

Combo Pack

Ifex/Mesnex Com-

bo PackCancer

Graded

Decline

Ifosfamide Ifex CancerGraded

Decline

Ifosfamide/MesnaIfex/Mesnex Com-

bo PackCancer

Graded

Decline

Iletin I Lente Iletin I Lente Type 1 DiabetesGraded

Decline

Imuran Azathioprine

Organ Transplant

Rejection Rhumatoid

Arthritis

Please Call

Inamrinone Inamrinone Heart Graded

Incivek Incivek Liver Disorder Graded

Indapamide Indapamide Hypertension heartPreferred

Graded

Inderal Propranolol Hypertension heartPreferred

Graded

Infergen Infergen Liver Disorder Graded

Inlyta Inlyta CancerGraded

Decline

Innolet Humulin 70/30 Type 1 Diabetes Standard

Graded

Inspra Eplerenone Heart Graded

Insulin Insulin Type 1 DiabetesStandard

Graded

Intelence Intelence AIDS Decline

Intron-A W/

DiluentIntron-A Cancer

Graded

Decline

Invega Invega Schizophrenia Graded

Invirase Invirase AIDS Decline

Ipratropium

Bromide

Ipratropium

BromideLung Disorder Graded

Ipratropium Bro-

mide/AlbutCombivent Lung Disorder Graded

Irbesartan Avapro Avapro

Hypertension Diabetic

Nephropathy (Kidney

Problems)

Preferred

Graded

Irbesartan/Hydro-

chlorothiAvalide Hypertension Preferred

Iressa Iressa CancerGraded

Decline

Irinotecan Irinotecan Cancer Graded

Decline

Isentress Isentress AIDS Decline

Isochron Isosorbide Heart Graded

Isoptin Verapamil Hypertension heartPreferred

Graded

Isosorbide Isosorbide Heart Graded

Isoxsuprine Hcl Isoxsuprine Hcl Stroke heart Graded

Istodax Istodax CancerGraded

Decline

Jantoven Warfarin Stroke heart Graded

Janumet Janumet Type 2 Diabetes Preferred

Janumet Xr Janumet Type 2 Diabetes Preferred

Januvia Januvia Type 2 Diabetes Preferred

Jentadueto Jentadueto Type 2 Diabetes Preferred

Jevtana Jevtana CancerGraded

Decline

Kaletra Kaletra AIDS Decline

Kalydeco Kalydeco Cystic Fibrosis Graded

Kazano Kazano Type 2 Diabetes Preferred

Kemadrin Kemadrin Parkinson’s Disease Graded

Kepivance Kepivance CancerGraded

Decline

Keppra Keppra Seizures Graded

Kerlone Betaxolol Hcl Hypertension Preferred

Klonopin ClonazepamAnxiety Panic Dis-

orderPreferred

Klonopin Wafers ClonazepamAnxiety Panic Dis-

orderPreferred


14

Kombiglyze Xr Kombiglyze Xr Type 2 Diabetes Preferred

Kyprolis Kyprolis CancerGraded

Decline

Kytril Kytril CancerGraded

Decline

Labetalol Hcl Labetalol Hcl Hypertension heartPreferred

Graded

Lamictal Lamictal Seizure Graded

Lamivudine Epivir AIDS Decline

Lamivudine/Zid-

ovudineCombivir AIDS Decline

Lanoxicaps Digoxin Heart Graded

Lanoxin Digoxin Heart Graded

Lantus Lantus Type 1 DiabetesStandard

Graded

Lasix Furosemide Hypertension heartPreferred

Graded

Latuda Latuda Schizophrenia Graded

Letrozole Femara CancerGraded

Decline

Leucovorin

Calcium

Leucovorin Cal-

ciumcancer

Graded

Decline

Leukeran Leukeran CancerGraded

Decline

Leukine Leukine CancerGraded

Decline

Leuprolide

AcetateLupron Depot Cancer

Graded

Decline

Leustatin Cladribine CancerGraded

Decline

Levamisole Hcl Levamisole Hcl CancerGraded

Decline

Levetiracetam Levetiracetam Seizures Graded

Levetiracetam Keppra Seizures Graded

Levocarnitine Levocarnitine Liver Disorder Graded

Levodopa Larodopa Parkinson’s Disease Graded

Lexapro Lexapro Depression Preferred

Lexiva Lexiva AIDS Decline

Lexxel Lexxel Hypertension heartPreferred

Graded

Lioresal Intra-

thecalBaclofen

Muscle Spasticity

Multiple SclerosisPlease Call

Lipitor Lipitor Cholesterol Preferred

Lipodox Doxil CancerGraded

Decline

Lisinopril Lisinopril Hypertension Preferred

Lithium Carbon-

ateLithium CarbonateBipolar Disorder Graded

Lodosyn Lodosyn Parkinson’s Disease Graded

Lopid Gemfibrozil Cholesterol Preferred

LopressorMetoprolol

TartrateHypertension heart

Preferred

Graded

Lorazepam Lorazepam Anxiety Disorder Preferred

Losartan Potas-

siumCozaar Hypertension heart

Preferred

Graded

Losartan Potassi-

um/HydrocHyzaar Hypertension heart

Preferred

Graded

Lotensin Benazepril Hcl Hypertension HeartPreferred

Graded

Loxapine Loxapine Schizophrenia Graded

Loxapine Succi-

nateLoxapine Schizophrenia Graded

Loxitane Loxapine Schizophrenia Graded

Lozol Indapamide Hypertension heartPreferred

Graded

Lupron Depot Eligard CancerGraded

Decline

Lupron Depot Lupron Depot CancerGraded

Decline

Lyrica LyricaFibromyalgia Syn-

drome Seizures

Preferred

Graded

Lysodren Lysodren CancerGraded

Decline

Matulane Matulane CancerGraded

Decline

Megace Oral MegestrolMenopausal Symp-

toms cancerPlease Call

Megestrol MegestrolMenopausal Symp-


Megestrol AcetateMegestrolMenopausal Symp-


Mellaril Thioridazine Schizophrenia Graded

Mepron Mepron AIDS Graded

Mercaptopurine Mercaptopurine CancerGraded

Decline

Mesna Mesnex CancerGraded

Decline

Mesnex Mesnex CancerGraded

Decline

Metaglip Glipizide Type 2 Diabetes Preferred

Metformin Glipizide Type 2 Diabetes Preferred


15


Metformin MetforminType 2 Diabetes

MellitusPreferred

Methadone Methadone Alcoholism Drugs Graded

Methotrexate Methotrexate Rheumatoid Arthritis Preferred

Methyclothiazide Methyclothiazide Hypertension heartPreferred

Graded

Methyldopa Methyldopa Hypertension heartPreferred

Graded

Methyldopa

AnhydrousMethyldopa Hypertension heart

Preferred

Graded

Metolazone Metolazone Hypertension heartPreferred

Graded

Metoprolol Succi-

nate ErToprol Hypertension heart

Preferred

Graded

Metoprolol

Tartrate

Metoprolol

TartrateHypertension heart

Preferred

Graded

Micardis Micardis Hypertension heartPreferred

Graded

MicrozideHydrochlorothi-


Preferred

Graded

Milrinone Milrinone Heart Graded

Milrinone Lactate Milrinone Heart Graded

Minitran Nitrostat Heart Graded

Mirapex Mirapex

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Mithracin Mithracin CancerGraded

Decline

Mitomycin Mitomycin CancerGraded

Decline

Mitoxantrone Hcl Novantrone CancerGraded

Decline

Moban Moban Schizophrenia Graded

Moexipril Hcl Univasc Hypertension heartPreferred

Graded

Moexipril/Hydro-

chlorothiaUniretic Hypertension heart

Preferred

Graded

Monopril Fosinopril Sodium Hypertension heartPreferred

Graded

Mustargen Mustargen CancerGraded

Decline

Mutamycin Mitomycin CancerGraded

Decline

Mycobutin Mycobutin AIDS Decline

Myfortic Myfortic Organ Transplant Decline

Mykrox Metolazone Hypertension heartPreferred

Graded

Myleran Myleran CancerGraded

Decline

Mylocel Hydroxyurea CancerGraded

Decline

Mylotarg Mylotarg CancerGraded

Decline

Mysoline Primidone Seizure Graded

Nadolol Nadolol Hypertension heartPreferred

Graded

Naloxone Hcl Naloxone Hcl Alcoholism Drugs Graded

Naltrexone Naltrexone Alcoholism Drugs Graded

Naltrexone Hcl Naltrexone Alcoholism Drugs Graded

Namenda Titra-

tion PakNamenda

Alzheimer's Disease

DimentiaDecline

Narcan Naloxone Hcl Alcoholism Drugs Graded

Natrecor Natrecor Heart Graded

Navane Thiothixene Mental Disorder Graded

Navelbine Navelbine CancerGraded

Decline

Nebupent Nebupent AIDS Decline

Neonatal Naloxone Hcl Alcoholism Drugs Graded

Neoral Neoral Organ Transplant Decline

NeosarCyclophospha-

mideCancer

Graded

Decline

Nesina Nesina Type 2 Diabetes Preferred

Neulasta Neulasta CancerGraded

Decline

Neumega Neumega CancerGraded

Decline

Neupogen Neupogen Cancer Graded

Neupro Neupro

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Neurontin Gabapentin Seizure Neuropathy Please Call

Neutrexin Neutrexin AIDS Decline

Nevirapine Viramune AIDS Decline

Nexavar Nexavar Cancer Graded

Nexiclon Xr Clonidine Hcl Hypertension Preferred

Nicardipine Hcl Nicardipine Hcl Hypertension heartPreferred

Graded


16

Nifedipine Nifedipine Hypertension heartPreferred

Graded

Nilandron Nilandron CancerGraded

Decline

Nimodipine Nimodipine Stroke heart Graded

Nimotop Nimodipine Stroke heart Graded

Nitrek Nitrostat Heart Graded

Nitro-Bid Nitrostat Heart Graded

Nitroglycerin Nitroglycerin Heart Graded

Nitrostat Nitrostat Heart Graded

Nolvadex Tamoxifen Citrate CancerGraded

Decline

Normodyne Labetalol Hcl Hypertension heartPreferred

Graded

Norvasc Besylate heart Graded

Norvir Norvir AIDS Decline

Novantrone Novantrone CancerGraded

Decline

Novolin Humulin 70/30 Type 1 Diabetes Standard

Graded

Novolog Novolog Type 1 Diabetes Standard

Graded

Noxafil Noxafil CancerGraded

Decline

Octreotide

Acetate

Sandostatin Lar

DepotCancer

Graded

Decline

Oforta Fludara CancerGraded

Decline

Olanzapine Zyprexa Mental Disorder Graded

Olanzapine Odt Zyprexa Mental Disorder Graded

Olanzapine/Fluox-

etine Symbyax

Depression Bipolar

mood disorder

Preferred

Graded

Omontys Omontys Liver Disorder Graded

Oncaspar Oncaspar CancerGraded

Decline

Ondansetron Ondansetron CancerGraded

Decline

Ondansetron Hcl Ondansetron CancerGraded

Decline

Ondansetron Hcl Zofran CancerGraded

Decline

Ontak Ontak CancerGraded

Decline

Onxol Paclitaxel CancerGraded

Decline

OreticHydrochlorothi-


Preferred

Graded

Orthoclone Okt3 Orthoclone Okt3 Organ Transplant Decline

Oxaliplatin Eloxatin CancerGraded

Decline

Oxcarbazepine Trileptal Seizures Graded

Oxtellar Xr Trileptal Seizures Graded

Paclitaxel Paclitaxel CancerGraded

Decline

Pamidronate

Disodium

Pamidronate Diso-

diumCancer

Graded

Decline

Panretin Panretin AIDS Decline

Paraplatin Carboplatin CancerGraded

Decline

ParlodelBromocriptine

Mesylate

Cancer Parkinson's

Disease Type 2 Dia-

betes

Please Call

Paroxetine Hcl Paroxetine Hcl Depression Preferred

Paxil Paroxetine Hcl Depression Preferred

Peganone Peganone Seizures Graded

Pegasys Pegasys Liver Disorder Graded

Pegasys Proclick Pegasys Liver Disorder Graded

Peg-Intron Peg-Intron Liver Disorder Graded

Peg-Intron

RedipenPeg-Intron Liver Disorder Graded

Pentam 300 Nebupent AIDS Decline

Pentamidine

IsethionateNebupent AIDS Decline

Perforomist Foradil AerolizerAsthma Lung Disor-

der

Preferred

Graded

Pergolide

MesylatePergolide Mesylate Parkinson’s Disease Graded

Permax Pergolide Mesylate Parkinson’s Disease Graded

Perphenazine Perphenazine Mental Disorder Graded

Phenobarbital Phenobarbital Seizures Graded

Phenurone Phenurone Seizures Graded

Phenytoin Sodium Phenytoin Sodium Seizures Graded


17





Nicardipine Hcl Nicardipine Hcl Hypertension heartpreferred

graded

Nifedipine Nifedipine Hypertension heartpreferred

graded


decline

Nimodipine Nimodipine Stroke heart graded

Nimotop Nimodipine Stroke heart graded






decline

Normodyne Labetalol Hcl Hypertension heartpreferred

graded

Norvasc Besylate heart graded



decline


graded


graded


decline

Octreotide

Acetate

Sandostatin Lar

DepotCancer

Graded

decline


Decline



Olanzapine/Fluox-

etine Symbyax

Depression Bipolar

mood disorder

preferred

graded



decline


decline


decline


decline


decline


decline



preferred

graded

Orthoclone Okt3 Orthoclone Okt3 Organ Transplant Graded

decline


Decline




decline

Pamidronate

Disodium

Pamidronate Diso-

diumCancer

Graded

decline



Decline


Mesylate

Cancer Parkinson's

Disease Type 2 Dia-

betes

Please Call







Peg-Intron



Pentamidine


Perforomist Foradil AerolizerAsthma Lung Dis-

order

Preferred

graded

Pergolide

MesylatePergolide Mesylate Parkinson’s Disease Graded


Photofrin Photofrin CancerGraded

Decline

Pindolol Pindolol Hypertension heartPreferred

Graded

Pioglitazone

Hcl-GlimepirDuetact Type 2 Diabetes Preferred

PlaquenilHydroxychloro-

quine SulfateCancer

Graded

Decline

Platinol Aq Cisplatin CancerGraded

Decline

Plavix Plavix Stroke heartPreferred

Graded

Plenaxis Plenaxis CancerGraded

Decline

Plendil Felodipine Hypertension HeartPreferred

Graded

Pletal Cilostazol Circulatory Disorder Graded

Potiga Potiga Seizures Graded

Pramipexole

DihydrochloriMirapex

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Prandimet Prandimet Type 2 Diabetes Preferred

Prandin Prandin Type 2 Diabetes Preferred

PravacholPravastatin So-

diumCholesterol Preferred

Pravastatin

Sodium

Pravastatin So-


Pravigard Pac Pravigard Pac Heart Graded

Precose Precose Type 2 Diabetes Preferred

Prezista Prezista AIDS Decline

Primacor Milrinone Heart Graded

Primidone Primidone Seizure Graded

Prinzide Lisinopril Hypertension Preferred

Prolastin Prolastin COPD Graded

Proleukin Proleukin CancerGraded

Decline

Propranolol Propranolol Hypertension heartPreferred

Graded

Propranolol Hcl Propranolol Hypertension heartPreferred

Graded

Prozac FluoxetineAnxiety Panic Dis-

orderPreferred

Purinethol Mercaptopurine CancerGraded

Decline

Quetiapine Fu-

marateSeroquel Mental Disorder Graded

Quinapril Quinapril Hypertension heartPreferred

Graded

Quinapril Hcl Quinapril Hypertension heartPreferred

Graded

Quinapril/Hydro-

chlorothiaQuinaretic Hypertension heart

Preferred

Graded

Quinidine Gluco-

nate Cr

Quinidine Gluco-

nate CrHeart Graded

Ramipril Alupent Hypertension CHFPreferred

Graded

Ranexa Ranexa Heart Graded

Rapamune Rapamune Organ Transplant Decline

Razadyne Er Razadyne ErAlzheimer’s Disease

DimentiaDecline

Razadyne Er Razadyne ErAlzheimer’s Disease

DimentiaDecline

Rebetron Rebetron Liver Disorder Graded

Reclast Reclast CancerGraded

Decline

Relion Humulin 70/30 Type 1 Diabetes Standard

Graded

Reminyl Razadyne ErAlzheimer’s Disease

DimentiaDecline

Requip Requip

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Requip Xl Requip

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Rescriptor Rescriptor AIDS Decline

Retavase Retavase Heart Graded

Retavase Half-Kit Retavase Heart Graded

Retrovir Zidovudine AIDS Decline

Retrovir Iv Infu-

sionZidovudine AIDS Decline

Revex Revex Alcoholism Drugs Graded

Revia Naltrexone Alcoholism Drugs Graded

Revlimid Revlimid CancerGraded

Decline

18





graded


graded


decline








decline


graded




decline


graded


graded


decline

Octreotide

Acetate

Sandostatin Lar

DepotCancer

Graded

decline


Decline



Olanzapine/Fluox-

etine Symbyax

Depression Bipolar

mood disorder

preferred

graded



decline


decline


decline


decline


decline


decline



preferred

graded


decline


Decline




decline

Pamidronate

Disodium

Pamidronate Diso-

diumCancer

Graded

decline



Decline


Mesylate

Cancer Parkinson's

Disease Type 2 Dia-

betes

Please Call







Peg-Intron



Pentamidine



order

Preferred

graded








decline

Pindolol Pindolol Hypertension heartpreferred

graded

Pioglitazone



quine SulfateCancer

Graded

decline


Decline

Plavix Plavix Stroke heart graded


decline


Graded



Pramipexole


Restless Leg Syn-

drome Parkinson's

Disease

preferred

graded





Pravastatin

Sodium

Pravastatin So-









Reyataz Reyataz AIDS Decline

Ribasphere Ribasphere Liver Disorder Graded

Rilutek Rilutek

Amyotrophic Lateral

Sclerosis Lou Gherig's

Disease

Graded

Risperdal Risperdal Mental DisordersGraded

Decline

Risperdal M-Tab Risperdal Mental DisordersGraded

Decline

Risperidone Risperdal Mental DisordersGraded

Decline

Rituxan Rituxan CancerGraded

Decline

Roferon-A Roferon-A CancerGraded

Decline

Ropinirole Er Requip

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Ropinirole Hcl Requip

Restless Leg Syn-

drome Parkinson's

Disease

Preferred

Graded

Rybix Odt Tramadol Hcl Pain Preferred

Ryzolt Tramadol Hcl Pain Preferred

Sancuso Sancuso Cancer Graded

Sandostatin Sandostatin Lar

DepotCancer

Graded

Decline

Sandostatin Lar

Depot

Sandostatin Lar

DepotCancer

Graded

Decline

Saphris Saphris Mental Disorder Graded

Selegiline Selegiline Parkinson’s Disease Graded

Selzentry Selzentry AIDS Decline

Sensipar Sensipar Liver Disorder Graded

Serentil Serentil Mental Disorders Graded

Seroquel Seroquel Mental Disorder Graded

Sertraline Sertraline Depression Preferred

Sertraline Hcl Sertraline Depression Preferred

Simulect SimulectOrgan Transplant

RejectionDecline

Simvastatin Simvastatin Cholesterol Preferred

SinemetCarbidopa/

LevodopaParkinson’s Disease Graded

Soltamox Tamoxifen Citrate CancerGraded

Decline

Spiriva Spiriva Lung Disorder Graded

Spiriva Handihaler Spiriva Lung Disorder Graded

Spironolactone Spironolactone Heart Graded

Sprycel Sprycel CancerGraded

Decline

Stalevo Stalevo Parkinson’s Disease Graded

Stalevo 100 Stalevo Parkinson’s Disease Graded

Starlix Starlix Type 2 Diabetes Preferred

Stavudine Zerit AIDS Decline

Stilphostrol Stilphostrol CancerGraded

Decline

Stribild Stribild AIDS Decline

Subsys Fentanyl CancerGraded

Decline

Symbicort SymbicortAsthma Lung Disor-

der

Preferred

Graded

Symbyax SymbyaxDepression Bipolar

mood disorder

Preferred

Graded

Symlinpen Symlinpen Type 1 Diabetes Standard

Graded

Symlinpen 120 Symlinpen Type 1 Diabetes Standard

Graded

Symlinpen 60 Symlinpen Type 1 Diabetes Standard

Graded

Symmetrel Amantadine Hcl Parkinson’s Disease Graded

Synribo Synribo CancerGraded

Decline

Tabloid Tabloid CancerGraded

Decline

Tacrolimus Prograf Organ Transplant Decline

Tambocor Flecainide Acetate Heart Graded

Tamoxifen Citrate Tamoxifen Citrate CancerGraded

Decline

Tamsulosin Hcl Flomax Enlarged Prostate Preferred

Tarceva Tarceva CancerGraded

Decline

Targretin Targretin CancerGraded

Decline

Tarka Tarka Hypertension heartPreferred

Graded

19






graded


graded


decline








decline


graded




decline


graded


graded


decline

Octreotide

Acetate

Sandostatin Lar

DepotCancer

Graded

decline


Decline



Olanzapine/Fluox-

etine Symbyax

Depression Bipolar

mood disorder

preferred

graded



decline


decline


decline


decline


decline


decline



preferred

graded


decline


Decline




decline

Pamidronate

Disodium

Pamidronate Diso-

diumCancer

Graded

decline



Decline


Mesylate

Cancer Parkinson's

Disease Type 2 Dia-

betes

Please Call







Peg-Intron



Pentamidine



order

Preferred

graded








decline


graded

Pioglitazone



quine SulfateCancer

Graded

decline


Decline



decline


Graded



Pramipexole


Restless Leg Syn-

drome Parkinson's

Disease

preferred

graded





Pravastatin

Sodium

Pravastatin So-









Tasigna Tasigna CancerGraded

Decline

Tasmar Tasmar Parkinson’s Disease Graded

Taxol Paclitaxel CancerGraded

Decline

Taxotere Taxotere CancerGraded

Decline

Temodar Temodar CancerGraded

Decline

Tenormin Atenolol Hypertension Preferred

Terazosin Hcl Terazosin Hcl Hypertension heart Graded

Terazosin Hcl Terazosin Hcl Hypertension heart Graded

Teslac Teslac CancerGraded

Decline

Thalitone Chlorthalidone Hypertension heartPreferred

Graded

Thalomid Thalomid CancerGraded

Decline

Theracys Tice Bcg CancerGraded

Decline

Thioplex Thiotepa CancerGraded

Decline

Thioridazine Thioridazine Schizophrenia Graded

Thioridazine Hcl Thioridazine Schizophrenia Graded

Thiothixene Thiothixene Mental Disorder Graded

ThorazineChlorpromazine

HclMental Disorders Graded

Thorazine Thorazine Mental Disorders Graded

Thymoglobulin Thymoglobulin Organ TransplantGraded

Decline

Tiagabine Hydro-

chlorideGabitril Seizure Graded

Tice Bcg Tice Bcg CancerGraded

Decline

Ticlid Ticlopidine Hcl Stroke heartPreferred

Graded

Ticlopidine Hcl Ticlopidine Hcl Stroke heartPreferred

Graded

Tikosyn Tikosyn Heart Graded

Tnkase Tnkase Heart Graded

Tolazamide Tolazamide Type 2 Diabetes Preferred

Tolbutamide Tolbutamide Type 2 Diabetes Preferred

Tolinase Tolazamide Type 2 Diabetes Preferred

Topamax Topamax Migraine SeizuresPreferred

Graded

Topiragen Topamax Migraine SeizuresPreferred

Graded

Topiramate Topamax Migraine SeizuresPreferred

Graded

Toposar Etoposide Cancer Graded

Topotecan Hcl Hycamtin CancerGraded

Decline

Toprol Toprol Hypertension heartPreferred

Graded

Toprol Xl Toprol Hypertension heartPreferred

Graded

Torisel Torisel CancerGraded

Decline

Torsemide Torsemide Hypertension heartPreferred

Graded

Totect Dexrazoxane CancerGraded

Decline

Trandate Labetalol Hcl Hypertension heartPreferred

Graded

Trandolapril/Ver-

apamil HcTarka Hypertension heart

Preferred

Graded

Treanda Treanda CancerGraded

Decline

Tretinoin Tretinoin CancerGraded

Decline

Triamterene/Hy-

drochlorothiazide

Triamterene/Hy-

drochlorothiazideHypertension heart

Preferred

Graded

Trihexyphenidyl

Hcl

Trihexyphenidyl

HclParkinson’s Disease Graded

Trileptal Trileptal Seizures Graded

Trisenox Trisenox CancerGraded

Decline

Trizivir Trizivir AIDS Decline

Truvada Truvada AIDS Decline

Tykerb Tykerb CancerGraded

Decline

Tyzeka Tyzeka Liver Disorder Graded

Ultram Tramadol Hcl Pain Preferred

Uniretic Uniretic Hypertension heartPreferred

Graded

Univasc Univasc Hypertension heartPreferred

Graded

20





graded


graded


decline








decline


graded




decline


graded


graded


decline

Octreotide

Acetate

Sandostatin Lar

DepotCancer

Graded

decline


Decline



Olanzapine/Fluox-

etine Symbyax

Depression Bipolar

mood disorder

preferred

graded



decline


decline


decline


decline


decline


decline



preferred

graded


decline


Decline




decline

Pamidronate

Disodium

Pamidronate Diso-

diumCancer

Graded

decline



Decline


Mesylate

Cancer Parkinson's

Disease Type 2 Dia-

betes

Please Call







Peg-Intron



Pentamidine



order

Preferred

graded








decline


graded

Pioglitazone



quine SulfateCancer

Graded

decline


Decline



decline


Graded



Pramipexole


Restless Leg Syn-

drome Parkinson's

Disease

preferred

graded





Pravastatin

Sodium

Pravastatin So-









Valproic Acid Valproic Acid Seizure Graded

Valproic Sodium Valproic Acid Seizure Graded

Valstar Valstar CancerGraded

Decline

Valturna Valturna Hypertension heartPreferred

Graded

Vanatrip Amitriptyline Hcl DepressionPreferred

Graded

Vandetanib Caprelsa CancerGraded

Decline

Vantas Vantas CancerGraded

Decline

Vasodilan Isoxsuprine Hcl Stroke heart Graded

Vasotec Enalapril Maleate Hypertension heartPreferred

Graded

Velosulin Br Velosulin Br Type 1 Diabetes Standard

Graded

Vepesid Etoposide Cancer Graded

Verapamil Verapamil Hypertension heartPreferred

Graded

Vesanoid Tretinoin CancerGraded

Decline

Vesprin Vesprin Mental Disorder Graded

Victoza Victoza Type 2 Diabetes Preferred

Victrelis Victrelis Liver Disorder Graded

Vidaza Vidaza CancerGraded

Decline

Videx Didanosine AIDS Decline

Videx Ec Didanosine AIDS Decline

Vinblastine Sulfate Vinblastine Sulfate CancerGraded

Decline

Vincasar Pfs Vincristine Sulfate CancerGraded

Decline

Vinorelbine

TartrateNavelbine Cancer

Graded

Decline

Viracept Viracept AIDS Decline

Viramune Viramune AIDS Decline

Viramune Xr Viramune AIDS Decline

Viread Viread AIDS Decline

Visken Pindolol Hypertension heartPreferred

Graded

Vistide Vistide AIDS Decline

Vivitrol Vivitrol Alcoholism Drugs Graded

Vumon Vumon CancerGraded

Decline

Warfarin Warfarin Stroke heart Graded

Xalkori Xalkori CancerGraded

Decline

Xarelto Xarelto Stroke heart Graded

Xeloda Xeloda CancerGraded

Decline

Yervoy Yervoy CancerGraded

Decline

Zaltrap Zaltrap CancerGraded

Decline

Zanosar Zanosar CancerGraded

Decline

Zarontin Ethosuximide Seizures Graded

Zaroxolyn Metolazone Hypertension heartPreferred

Graded

Zelapar Selegiline Parkinson’s Disease Graded

Zelboraf Zelboraf CancerGraded

Decline

Zemaira Prolastin COPD Graded

Zemplar Zemplar Liver Disorder Graded

Zenapax Zenapax Organ Transplant Decline

Zerit Zerit AIDS Decline

Zestoretic Lisinopril Hypertension Preferred

Zetia Zetia Cholesterol Preferred

Zevalin In-111 Zevalin In-111 CancerGraded

Decline

Zevalin Y-90 Zevalin Y-90 CancerGraded

Decline

Ziac

Bisoprolol Fuma-

rate/Hydrochloro-

thiazide

Hypertension Preferred

Ziagen Ziagen AIDS Decline

Zidovudine Zidovudine AIDS Decline

Zinecard Dexrazoxane CancerGraded

Decline

Ziprasidone Hcl GeodonBipolar Mood Disor-

der schizphreniaGraded

21


Zocor Simvastatin Cholesterol Preferred

Zofran Ondansetron Cancer Graded Decline

Zofran Zofran Cancer Graded Decline

Zoladex Zoladex Cancer Graded Decline

Zolinza Zolinza Cancer Graded Decline

Zoloft Sertraline Depression Preferred

Zometa Reclast Cancer Graded Decline

Zonegran Zonisamide Seizure Graded

Zonisamide Zonisamide Seizure Graded

Zortress Zortress Organ Transplant Graded Decline

Zyprexa Zyprexa Mental Disorder Graded

Zytiga Zytiga Cancer Graded decline

22

Notes

23

Notes

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

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