Page 2 - Insurance-Declinable-Drugs
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X indicates that the drug will result in a decline. Make sure to list ALL medications on the application. Prescription
medications may be used for multiple reasons. ALWAYS determine how the medication is used. Insurability is based
on the conditions listed on the actual application. There may be additional medications and conditions not listed that
could result in a decline. If the applicant is currently taking, or has recently taken, a medication in this list for a use
that is NOT listed on this application, we will REQUIRE a SIGNED and DATED letter from the prescribing physician.
This letter MUST state the condition for which the medication is being taken AND must state that the applicant does
not have the declinable condition on this list. Failure to include this letter WITH the application may lead to the
declination of the application.
Please note that the Underwriter will make the final determination in all cases.
CANCER HEART OTHER RIDERS
Drug Name Use Flexible Choice Flexible Choice HI/ICU/HICU*
Cancer Treatment Heart
Abacavir AIDS X
Abatacept Rheumatoid Arthritis X X X
Abilify Schizophrenia X
Acamprosate Calcium Alcoholism X X
Acetate Megace Cancer X
Actemra Rheumatoid Arthritis X X
Actigall Cirrhosis, Liver Disease X X
Adalimumab Rheumatoid Arthritis, Crohn’s X X
Adcirca Pulmonary Hypertension XX X
Adriamycin Cancer X
Afinitor Cancer X X
Agenerase AIDS X X
Aggrastat Angina, Angioplasty X
Agrylin Myeloproliferative Disorders X X
Alfa Epogen Renal Failure, Dialysis X X
Alkeran Cancer X
Altretamine Cancer X X
Ambenonium Chloride Myasthenia Gravis X X
Ambrisentan Pulmonary Hypertension XX X
Amiodarone Hear,Ventricular Arrhythmia X X
Amprenavir AIDS X X
Anagrelide Myeloproliferative Disorders X X
Anagrelide Hydrochloride Myeloproliferative Disorders X
Anastrozole Cancer XX X
Antabuse Alcoholism X
Antagon Infertility Treatments X X
Aptivus HIV X
Aranesp Chronic Renal Failure X
Arformoterol Tartrate COPD X
Arimidex Cancer X
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel.
* HI = Hospital Indemnity Rider
ICU = Intensive Care Unit Rider
HICU = Hospital & Intensive Care Unit Rider
2
medications may be used for multiple reasons. ALWAYS determine how the medication is used. Insurability is based
on the conditions listed on the actual application. There may be additional medications and conditions not listed that
could result in a decline. If the applicant is currently taking, or has recently taken, a medication in this list for a use
that is NOT listed on this application, we will REQUIRE a SIGNED and DATED letter from the prescribing physician.
This letter MUST state the condition for which the medication is being taken AND must state that the applicant does
not have the declinable condition on this list. Failure to include this letter WITH the application may lead to the
declination of the application.
Please note that the Underwriter will make the final determination in all cases.
CANCER HEART OTHER RIDERS
Drug Name Use Flexible Choice Flexible Choice HI/ICU/HICU*
Cancer Treatment Heart
Abacavir AIDS X
Abatacept Rheumatoid Arthritis X X X
Abilify Schizophrenia X
Acamprosate Calcium Alcoholism X X
Acetate Megace Cancer X
Actemra Rheumatoid Arthritis X X
Actigall Cirrhosis, Liver Disease X X
Adalimumab Rheumatoid Arthritis, Crohn’s X X
Adcirca Pulmonary Hypertension XX X
Adriamycin Cancer X
Afinitor Cancer X X
Agenerase AIDS X X
Aggrastat Angina, Angioplasty X
Agrylin Myeloproliferative Disorders X X
Alfa Epogen Renal Failure, Dialysis X X
Alkeran Cancer X
Altretamine Cancer X X
Ambenonium Chloride Myasthenia Gravis X X
Ambrisentan Pulmonary Hypertension XX X
Amiodarone Hear,Ventricular Arrhythmia X X
Amprenavir AIDS X X
Anagrelide Myeloproliferative Disorders X X
Anagrelide Hydrochloride Myeloproliferative Disorders X
Anastrozole Cancer XX X
Antabuse Alcoholism X
Antagon Infertility Treatments X X
Aptivus HIV X
Aranesp Chronic Renal Failure X
Arformoterol Tartrate COPD X
Arimidex Cancer X
Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel.
* HI = Hospital Indemnity Rider
ICU = Intensive Care Unit Rider
HICU = Hospital & Intensive Care Unit Rider
2
