The Order of United Commercial Travelers of America • A Fraternal Benefit Society 1801 Watermark Drive, Suite 100, P.O. Box 159019, Columbus, OH 43215 Tel: 614.487.9680 • Toll-free: 800.848.0123 • Fax: 800.948.1039 • www.uct.org UCT Unacceptable Medications – Medicare Supplement Applicants taking any of the medications listed below will be declined if they are not in the open enrollment period. Do not submit their applications. This list is intended for use as a basic guide only. Due to the rapid advances being made in the medical field, it is not possible to include all unacceptable medications or to keep this list updated. UCT has the right to decline applications based on conditions indicated by other medications that are not on this list. Contact the Customer Service Department at (800) 848-1124, ext. 300, or at [email protected], with specific questions. A Azmacort (Triamcinolone) Cisplatin (Platinol) Abilify (Aripiprazole) AZT (Azidothymid) Clomipramine (Anafranil) Abacavir (Ziagen) Azulfidine (Sulfasalazine) Clozapine (Clozaril) Actraphane (Insulin) Clozaril (Clozapine) Actrapid (Insulin) B Cogentin (Benztropine) Adriamycin (Doxorubicin) Baclofen (Kemstro, Lioresal) Cognex (Tacrine) Adrucil (Flourouracil) Baphen Combivir (Zidovudine, Retrovir) Agenerase (Amprenavir) Bendopa (Dopa, Levodopa) Copaxone (Glatiramer) Akineton (Biperiden) Benztropine (Cogentin) Compazine (Prochlorperazine)–if Alfa Epogen (Epogen, Procrit, Beta interferon (Avonex, used for psychotic disorders Epoetin) Betaseron) Cortisone (Cortone)–if used for Alkeran (Melphalan) Betaseron (Beta interferon) arthritis or chronic lung Altretamine (Hexalen) Bicalutamide (Casodex) disorders Amantadine (Symadine, Biperiden (Akineton) Cosmegan (Dactinomycin) Symmetrel) Blenoxane (Bleomycin) Crixivan (Indinavir) Ambenonium Chloride (Mytelase) Bleomycin (Blenoxane) Cyclophosphamide (Cytoxan, Amprenavir (Agenerase) Bromocriptine (Parlodel)–if used Neosar) Anafranil (Clomipramine) for Parkinson’s Cycrimine (Pagitane) Anastrozole (Arimidex) Budesonide (Pulmicort) Cycrimine Hydrochloride Antabuse (Disulfiram) Busulfan (Myleran) (Kemadrin) Arava(Leflunomide) Byetta Cytarabine (Cytosar) Aricept (Donepezil) Cytosar (Cytarabine) Arimidex (Anastrozole) C Cytoxan (Cyclophosphamide, Aripiprazole (Abilify) Calcimar (Calcitonin) Neosar) Aromasin (Exemestane) – taking Calcitonin (Calcimar) for 5 years Capecitabine (Xeloda) D Arsenic Trioxide (Trisenox) Carbidopa (Lodosyn) Dactinomycin (Cosmegan) Artane (Trihexyphenidyl, Tremin) Carbidopa-levidopa (Sinemet) Dantrium (Dantrolene) Atamet (L-Dopa, Levodopa, Casodex (Bicalutamide) Dantrolene (Dantrium) Sinemet) CeeNu (Lomustine) Daunorubicin (Cerubidine) Auranofin (Ridaura, Oral Gold) Cellcept (Mycophenolate Mofetil) Deapril (Eegoloid Mesylates) Avinza (Morhine) Cerespan Delavirdine (Rescriptor) Avonex (Beta interferon, Cerubidine (Daunorubicin) Deponit (Minitran, Nitro Patch, Interferon Beta 1a, Rebif)) Chlorambucil (Leukeran) Nitroglycerin, Nitro-Dur, Azathioprine (Imuran) Chlorpromazine (Thorazine) Nitrostat) Azidothymid (AZT) Cilostazol (Pletal) Didanosine (Videx) ___________________________________________________________________________________________________________________________________ This list is not conclusive and is subject to change at any time without notice. We have the right to decline based on medications not on this list. We do not take anyone using opiate medication(s). Page 1 Rev. 12/13 The Order of United Commercial Travelers of America Didronel (Etidronate) if used for Fluphenazine Hydrochloride Idarubicin (Idamycin) Paget’s (Prolixin) Iletin (Insulin) Dihdroergotoxine (Niloric) Flutamide (Eulexin) Imdur (Isobid, Isordil, Isosorbide) Disulfiram (Antabuse) Fluvoxamine (Luvox) Imuran (Azathioprine) Dolophine (Methodone) Fortovase (Invirase, Saquinavir) Indinavir (Crixivan) Donepezil (Aricept) Foscarnet (Foscavir) Infliximab(Remicade) Dopar (Levadopa, Bendopa) Foscavir (Foscarnet) Initard (Insulin) Doxil (Doxorubicin) FUDR (Floxuridine, FDUR) Interferon Beta-1a (Avonex, Rebif) Doxorubicin (Adriamycin, Doxil, Fulvestrant (Faslodex) Insulin (Actraphane, Actrapid, Rubex) Humulin, Humalog, Hypurin, Dronabinol (Marinol) G Iletin, Initard, Isophane, D4T (Stavudine, Zerit) Galantamine (Razadyne, Reminyl) Isulatard, Lantus, Lentard, Gallium Nitrate (Granite) Lispro, Mixtard, Monotard, E Ganite (Gallium Nitrate) Novolin, Protophane, Pur-In Edophonium Chlorides Gemtuzumab Ozogamicin Mix, PZI, Semitard, Ultralente, Efavirenz (Sustiva) (Mylotarg) Ultratard, Velosulin) Efudex (Fluoroplex, Fluorouracil) Geodon (Ziprasidone) Intron Eldepryl (Selegiline) Gerimal (Salac) Invirase (Saquinavir, Fortovase) Emcyt (Estramustine) Glatiramer (Copaxone) Isobid (Imdur, Isordil, Isosorbide,) Enbrel (Etanercept) Gold Shots (Myochrysine) Isordil (Imdur, Isobid, Isosorbide) Enlon (Reversol, Tensilon) Goserelin (Zoladex) Isophane (Insulin) Epivir (Lamivudine) Isosorbide (Imdur, Isordil, Isobid) Epoetin (Epogen, Procrit, Alfa H Isulatard (Insulin) Epogen) Haldol (Haloperidol) Epogen (Alfa epogen, Procrit) Haloperidol (Haldol) K Ergamisol (Levamisole) Herceptin (Trastuzumab) Kaletra (Lopinavir, Ritonavir, Ergoloid Mesylates (Deapril) Hexalen (Altretamine) Norvir) Eskalith (Lithobid, Lithium) Hivid (Zalcitabine) Kemadrin (Procyclidine Estramustine (Emcyt) Humulin (Insulin) Hydrochloride, Hydrochloride Etanercept (Enbrel) Humalog (Insulin) Pagitane) Etidronate (Didronel) if used for Hydergine (Ergoloid Mesylates) Kemstro (Baclofen, Lioresal) Paget’s Hydrea (Hydroxyurea) Etoposide (VePesid) Hydrochloride Pagitane L Eulexin (Flutamide) (Kemadrin, Procyclidine Lamictal (Lamotrigine) Exelon (Rivastigmine) Hydrochloride) Lamivudine (Epivir) Exemestane (Aromasin) taking for Hydrocortisone (Hydrocortone)–if Lamotrigine (Lamictal) 5 years used for arthritis or chronic lung Lantus (Insulin) disorders Larodopa (L-dopa, Atamet, F Hydroxychloroquine (Plaquenil) Sinemet, Levodopa) Fareston (Toremifene) Hydroxyurea (Hydrea) L-Dopa (Levodopa, Atamet, Faslodex (Fulvestrant) Hyoscyamine (Levsin, Levbid, Sinemet, FDUR (Floxuridine, FUDR) Levsinex) – if used for Larodopa) Femara (Letrozole) Parkinson’s Leflunomide(Arava) Filgrastim (Neupogen) Hypurin (Insulin) Lentard (Insulin) Floxuridine (FUDR, FDUR) Letrozole (Femara) Fluoroplex (Efudex, Fluorouracil) I, J Leukeran (Chlorambucil) Fluorouracil (Efudex, Fluoroplex) Idamycin (Idarubicin) Leuprolide (Lupron) ___________________________________________________________________________________________________________________________________ This list is not conclusive and is subject to change at any time without notice. We have the right to decline based on medications not on this list. We do not take anyone using opiate medication(s). Page 2 Rev. 12/13 The Order of United Commercial Travelers of America Levamisole (Ergamisol) Minitran (Deponit, Nitro Dur, Nolvadex (Tamoxifen) taking for 5 Laviamsole Nitroglycerin, Nitro patch, years Levbid (Hyoscyamine, Levsin, Nitrostat) Norvir (Ritonavir, Kaletra, Levsinex – if used for Mirapex (Pramipexole Lopinavir) Parkinson’s Dihydrochloride) Novolin (Insulin) Levodopa (Bendopa, Dopar) Mithracin (Plicamycin) Levsin (Levbid, Levsinex) Mitomycin (Mutamycin) O (Hyoscyamine)– if used for Mitotane (Lysodren) Olanzapine (Zeprexa) Parkinson’s Moban (Molindone) Oncovin (Vincristine) Lioresal (Kemstro, Baclofen) Molindone (Moban) Oral gold (Ridaura, Auranofin) Lispro (Insulin) Monotard (Insulin) Oreton (Methyltestosterone) Lithane (Lithium) Morphine (Avinza) Oxycodone (Oxycontin) Lithium (Eskalith, Lithobid) Mustargen (Mechlorethamine) Oxycontin (Oxycondone) Lithobid (Eskalith, Lithium) Mutamycin (Mitomycin) Oxygen Lodosyn (Carbidopa) Myleran (Busulfan) Lomustine (CeeNu) Mycophenlote Mofetil (Cellcept) P Lopinavir (Kaletra, Ritonavir, Mylotarg (Gemtuzumab Parlodel (Bromocriptine)–if used Norvir) Ozogamicin) for Parkinson’s Loxapine (Loxitane) Myochrysine (Gold Shots) Parsidol–if used for Parkinson’s Loxitane (Loxapine) Mytelase (Ambenonium Parsitan (Profenamine Ludiomil (Maprotiline) Hydrochloride) Hydrochloride) Lupron (Leuprolide) Pavabid Lusadril N Pentam 300 (Nebupent, Luvox (Fluvoxamine) Namenda Pentamidine) Lysodren (Mitotane) Navane (Thiothixene) Pentamidine (Nebupent, Pentam Nebupent (Pentamidine, Pentam 300) M 300) Pentoxifylline (Trental) Maprotiline (Ludiomil) Nelfinavir (Viracept) Pergolide (Permax) Marinol (Dronabinol) Neoscar (Cyclophamide, Cytoxan) Permax (Pergolide) Matulane (Procarbazine) Neostigmine (Prostigmin) Perphenazine (Trilafon) Mechlorethamine (Mustargen) Neupogen (Filgrastim) Platinol (Cisplatin) Megace (Megestrol) Nevirapine (Viramune) Plaquenil (Hydroxchloroquine) Megestrol (Megace) Nilandron (Nilutamide) Pletal (Cilostazol) Mellaril (Thioridazine) Niloric (Dihydroergotoxine) Plicamycin (Mithracin) Melphalen (Alkeran) Nilutamide (Nilandron) Pramipexole Dihdrochloride Memantine Hydrochloride Nitro-Dur (Deponit, Minitran, (Mirapex) (Namenda) Nitroglycerin, Nitro patch, Prednisone–if used for arthritis or Mentane Nitrostat) chronic lung disorders Mercaptopurine (Purinethol) Nitroglycerin (Deponit, Minitran, Procarbazine (Matulane) Mesoridazine (Serentil) Nitro Dur, Nitro patch, Procrit (Epoetin Alfa Epogen, Mestinon (Pyridostigmine) Nitrostat) Epogen) Methadone (Dolophine) Nitro Patch (Deponit, Minitran, Prochlorperazine (Compazine)–if Methdose Nitro-Dur, Nitroglycerin, used for psychotic disorders Methotrexate (Rheumatrex) Nitrostat) Procyclidine Hydrochloride Mexate Nitrostat, (Deponit, Minitran, Nitro (Kemadrin, Hydrochloride Miacalcin (Calcitonin)–if