Page 3 - Insurance-Declinable-Drugs

CANCER HEART OTHER RIDERS

Drug Name Use Flexible Choice Flexible Choice HI/ICU/HICU*
Cancer Treatment Heart
Aripiprazole Schizophrenia X
Arixtra Blood Clots X X
X
Aromasin Cancer X X
Arsenic Trioxide Leukemia X X
X
Asenapine Schizophrenia, Bipolar Disorder X X X
Atripla AIDS X
X
Atrovent COPD (Nasal Spray OK for Allergies) X X
Avastin Cancer X
X
Avonex Multiple Sclerosis X
Azasan OrganTransplant, Rheumatoid Arthritis X

Azathioprine OrganTransplant, Rheumatoid Arthritis X X X
AZT AIDS X
X
Aztreonam Cystic Fibrosis X
Baclofen X
Multiple Sclerosis X
(OK for Restless Leg Syndrome) X
X
Betaseron Multiple Sclerosis X X
Bevacizumab Cancer X
X
Bicalutamide Oral Cancer X X
Blenoxane Cancer X X
X
Bleomycin Cancer X X
Boceprevir Hepatitis C X
X
Bortezomib Multiple Myeloma, Lymphoma X X
Bosentan Pulmonary Hypertension X
X X
X
Bravelle Infertility Treatments X
Brovana COPD X

Buprenorphine Opiate Addiction X
Busulfan Cancer

Campral Alcoholism X
Capecitabine Cancer

Casodex Cancer X
Cayston Cystic Fibrosis

Cellcept OrganTransplant, Rheumatoid Arthritis
Certolizumag Pegol Rheumatoid Arthritis, Crohn’s

Cetrorelix Infertility Treatments
Cetrotide Infertility Treatments

Chlorambucil Cancer X
Chlorotrianisene Cancer X

Chlorpromazine Antipsychotic

Confidential, unpublished property of Cigna.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
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