Please see the uninsurable medication and conditions list before continuing. Please note certain drop down selections will open additional fields. To proceed to the health pre-screen, select the health dropdown and choose “I would like to do a pre-screen”. If you have any questions regarding this form, please contact our office at (866) 605-7437.
Uninsurable Medications
*Generic versions also uninsurable
- Antabuse®
- Aricept®
- Artane®
- Avonex®
- Azilect
- Betaseron®
- Campral®
- Cogentin®
- Cognex®
- Comtan®
- Copaxone®
- Depade®
- Donepezil
- Eldepryl®
- Exelon®
- Fentanyl
- Galantamine
- Hydergine®
- Interferon®
- Larodope/L-Dopa
- Lucemyra
- Memantine
- Methadone
- Mirapex®
- Namenda®
- Namzaric®
- Parlodel®
- Permax®
- Razadyne®
- Reminyl®
- ReVia®
- Rivastigmine®
- Sinemet®
- Suboxone®
- Symmetrel®
- Vivitrol®
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Uninsurable Conditions
- Activity of daily living deficits (need help with any of the ADL’s)
- Alcoholism (active)
- Alzheimer’s/Dementia
- Amyotrophic Lateral Sclerosis (ALS)
- Balance disorder/ Gait impairment
- Cerebral palsy
- Cirrhosis
- Depression (severe or hospitalized in the last 5 years)
- Down syndrome
- Drug addiction/illicit drug use (within last ten years)
- HIV positive
- Huntington’s disease
- Intellectual disability
- Macular degeneration (progressive/wet)
- Memory loss
- Multiple myeloma
- Multiple sclerosis (MS)
- Muscular dystrophy
- Organ transplant (except kidney)
- Organic brain syndrome
- Osteoporosis with compression fracture
- Paralysis (paraplegia/quadriplegia)
- Parkinson’s disease
- Pregnancy (current)
- Stroke (multiple or residual affects)
- Surgery pending (will review after)
- Ventricular tachycardia
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