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List of Extra Covered Drugs

Extra Covered Drugs are part of your plan!See inside for details and a list of these drugs.

If you have questions, call us! Your Customer Service number is on your membership card.

Y0071_15_20278_I_010 07/28/2014 46574MUSENMUB_010_EBC_HECDH_2015_4

Your Senior Rx Plus PlanExtra Covered Drugs for 2015 ...

and what they mean for you

Your group-sponsored plan has chosen to give you an even wider variety of covered drugs.

Along with the list of covered Part D Drugs (also called the formulary) that comes with your plan, you also get "ExtraCovered Drugs." This booklet shows you which Extra Covered Drugs are included in your plan. For the full list of yourcovered Part D drugs, look at your formulary.

How do Extra Covered Drugs fit into your plan's prescription drug benefits?

Although these drugs are not normally covered in Medicre Prescription Drug plans, your Senior Rx Plus benefits offerthem to you. Like your covered Part D drugs, the cost you pay for Extra Covered Drugs is based on the tier each drug isin. You can find the tier number next to the drug name. And you can find the cost for each drug tier by checking thebenefit chart in your Evidence of Coverage (or your Certificate).

Because Extra Covered Drugs are separate from your Part D coverage, if you fill a prescription for one of them, the costdoes not count toward your Part D out-of-pocket limits. The cost also does not move you through the Part D coveragestages. If you are receiving Medicare's Extra Help to pay for your prescriptions, that will not apply for these drugs.

We're here to answer your questions.

Please call Customer Service at the number listed on your membership card.

Y0071_15_20278_I_010 07/28/2014 1 ECDH_2015_4

List of Extra Covered Drugs(keep with your formulary)

Requirements/Limits

DrugTierDrug Name

Antineoplastic / Immunosuppressant Drugs2IODOPEN

MO2SODIUM IODIDE (BULK)Autonomic / Cns Drugs, Neurology / Psych

MO1isometh-dichloral-acetaminophnMO1nodolorMO2PRODRIN ORAL TABLET 65-

20-325 MGCardiovascular, Hypertension / Lipids

MO2MEPHYTONMO1niacin oral capsule, extended

release 250 mg, 500 mgMO1niacin oral tablet 100 mg, 250

mg, 50 mgMO2NIACIN ORAL TABLET

EXTENDED RELEASE 1,000MG

MO1niacin oral tablet extended release250 mg, 500 mg, 750 mg

2NIACINAMIDE (BULK)CRYSTALS

MO2NIACINAMIDE (BULK)POWDER

MO1niacinamide oral tabletMO1nitro-timeMO1nitroglycerin oral capsule, extended

release 2.5 mg2PHYTONADIONE

INJECTIONMO2SLO-NIACIN ORAL TABLET

EXTENDED RELEASE 750MG

MO1vitamin k injectionMO2VITAMIN K ORALMO1vitamin k1 injection

Dermatologicals/Topical TherapyMO2ACLAROMO2ACLARO PD

1acne foaming face washMO2ALA-QUINMO2ALCORTIN A TOPICAL GEL

IN PACKET

Requirements/Limits

DrugTierDrug Name

MO2ALOQUINMO1alphaquin hpMO2AMINOBENZOIC ACID

(BULK)MO2AVAGEMO2BENZAC AC WASH

TOPICAL CLEANSER 10 %MO2BENZAC W WASH TOPICAL

CLEANSER 10 %MO1benzoyl peroxide topical cleanser

10 %, 5 %MO1bp 10-1MO1bp wash topical cleanser 10 %, 5

%MO1bp-50% urea

1bpo-101bpo-5

MO2CORTANE-B TOPICALMO1dermazeneMO2GRANULEXMO2HYDRO 40MO1hydrocortisone-pramoxine topical

creamMO1hydroquinoneMO1hydroquinone microspheresMO1iodoquinol-hcMO1latrixMO2LUSTRA-AFMO1lustra-ultraMO1melpaque hpMO1melquin hp

2MONSEL'SMO2NOVACORTMO1nuquin hp topical cream

2OVACE PLUS TOPICALCLEANSER,EXTENDEDRELEASE

MO2OVACE TOPICALCLEANSER

MO1panoxyl topical cleanser 10 %MO2PRAMOSONE TOPICAL

CREAM 2.5-1 %

2 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

MO2PRAMOSONE TOPICALOINTMENT

MO1refissaMO1remevenMO2RENOVA TOPICAL CREAM

0.02 %MO2SALEX TOPICAL

KIT,CLEANSER & CREAMER

MO2SALEX TOPICAL SHAMPOOMO1salicylic acid sr-ceramides topical

kit,cleanser & cream erMO1salicylic acid topical liquid 26 %MO1salicylic acid topical shampoo

1salicylic acid-ammon lact-aloeMO1salvaxMO1seb-prevMO1sulfacetamide sodium topical

cleanserMO1tretinoin (emollient)MO2TRI-LUMAMO2UMECTA PD TOPICAL

EMULSION, ADHESIVEMO2UMECTA TOPICAL

EMULSIONMO1umecta topical foamMO1urea (with la & sal acid)MO1urea 50%MO1urea nail stickMO1urea topical cream 40 %, 50 %MO2VANIQAMO1x-viate topical cream

Diagnostics / Miscellaneous Agents1central vite1central-vite performance oral tablet

MO1chromium picolinate oral capsule1chromium picolinate oral tablet

200 mcg1complete premium vitamin

MO2FERRLECITMO1finasteride oral tablet 1 mg

1multivital performanceMO2PROPECIA

2PROPECIA PRO-PAKMO1sodium ferric gluconat-sucrose

Requirements/Limits

DrugTierDrug Name

MO2ZINC SULFATE (BULK)POWDER 100 %Ear, Nose / Throat Medications

MO1cortane-b aqueousMO1cortane-b otic

1cough drops mucous membranelozenge 10 mg

2COUGH DROPS MUCOUSMEMBRANE LOZENGE 2.7MG, 5 MG, 5.4 MG, 5.8 MG,6.1 MG, 7 MG, 7.5 MG, 8 MG,9.1 MG

2FLANAX COUGH RELIEF(MENTHOL)

MO2HALLS COUGH DROPSMUCOUS MEMBRANELOZENGE 5.8 MG

2HALLS COUGH DROPSMUCOUS MEMBRANELOZENGE 7 MG, 7.6 MG, 9.1MG

2MENTHOL COUGHMUCOUS MEMBRANELOZENGE 6.1 MG

2NATURAL HERB MUCOUSMEMBRANE LOZENGE 4.8MG

MO1oto-end 102RICOLA MUCOUS

MEMBRANE LOZENGE 1.1-2.6-4.8 MG, 2-3.5-4.8 MG

1sore throat (hexylresorcinol)mucous membrane lozenge 2.4 mg

2SORE THROAT (MENTHOL)1throat drops mucous membrane

lozenge 2.8 mg2VICKS VAPODROPS

Endocrine/DiabetesMO2SSKI

GastroenterologyMO1anucort-hcMO2ANUSOL-HC RECTAL

SUPPOSITORYMO1chlordiazepoxide-clidiniumMO2DONNATAL ORAL ELIXIR

16.2-0.1037 -0.0194 MG/5 MLMO2DONNATAL ORAL TABLET

3 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

MO1hydrocortisone acetate rectalsuppository

MO1hydrocortisone-pramox-e-pram#1MO1hydrocortisone-pramoxine rectalMO2LIBRAX (WITH CLIDINIUM)MO1phenobarb-hyoscy-atropine-scop

oral tabletMO2PROCTOCORT RECTAL

SUPPOSITORYObstetrics / Gynecology

MO1covaryxMO1covaryx h.s.MO1eemtMO1eemt hsMO1estrogens-methyltestosteroneMO1isoxsuprine oral tablet 10 mgMO3OSPHENA

OphthalmologyMO2LATISSE

Respiratory And Allergy112 hour cold relief112 hour decongestant130pse-150gfn-15dm2ABATUSS DMX1adult robitussin m-s cold2ADULT ROBITUSSIN

NIGHT M-S CLD1adult robitussin peak cold m-s2ADVIL ALLERGY SINUS2ADVIL ALLERGY-

CONGESTION RLFMO2ADVIL COLD & SINUS

ORAL CAPSULE1advil cold & sinus oral

tablet+C10672ADVIL CONGESTION

RELIEFMO2ALA-HIST DM

2ALDEX GS2ALEVE COLD & SINUS2ALEVE SINUS & HEADACHE2ALEVE-D SINUS & COLD2ALEVE-D SINUS &

HEADACHE2ALKA-SELTZER PLUS C/

C(PE,DM)

Requirements/Limits

DrugTierDrug Name

2ALKA-SELTZER PLUS COLD(PE)

2ALKA-SELTZER PLUS COLD/COUGH

2ALKA-SELTZER PLUS DAY2ALKA-SELTZER PLUS DAY-

NIGHT2ALKA-SELTZER PLUS FLU2ALKA-SELTZER PLUS

NIGHT2ALKA-SELTZER PLUS SIN-

ALLG-CGH2ALKA-SELTZER PLUS SINUS-

COUGH2ALKA-SELTZER PLUS-D

SINUS-COLD2ALL DAY PAIN RELIEF

SINUS & CO2ALL-NITE COLD-FLU ORAL

LIQUID 6.25-15-325 MG/15ML

1allergy multi-symptom1allergy relief multi-symptom2ALLERGY RELIEF-SINUS

HEADACHE2ALLERGY SINUS

HEADACHE ORAL TABLET12.5-5-325 MG

2ALLERGY-SINUS ORALTABLET 25-10-650 MG

1allfenMO2AMBI 10PEH-4CPM-20DMMO2AMBI 20DM-4CPM

2AMBI 60PSE-4CPM-20DM2AMBIFED2AMBIFED DM1ap-hist dm

MO2BALAMINE DM (CHLOR-PE)MO1benzonatate

2BICLORA2BICLORA-D2BIO T PRES2BIO T PRES PEDIATRIC2BIODESP DM2BIONATUSS DXP2BIONEL PEDIATRIC2BIOSPEC DMX

4 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

MO2BROMFED DM1brompheniramin-phenylephrin-dm

oral liquid 2-5-10 mg/5 ml, 4-10-20 mg/5 ml

1brompheniramine-pseudoeph-dmoral liquid 4-20-20 mg/5 ml

1bronchial asthma relief2BRONCOTRON PED ORAL

DROPS2BRONCOTRON-S2BRONKIDS2BRONTUSS SF

MO2CAPCOFMO2CAPMIST DM

2CAPRON DM2CARBAPHEN CH2CARBAPHEN PED CH1cardec dm (phenyleph-chlorphn)2CCP CAFFEINE FREE2CERTUSS-D

MO1cheratussin acMO1cheratussin dac

1cherry cough drops1chest congestion relief + dm1chest congestion relief oral tablet1chest congestion relief pe1chest congestion-cough relief oral

tablet1chest-sinus congestion relief1child chest congestion + cough2CHILD COUGH & SORE

THROAT1child delsym cough+chest dm2CHILD DELSYM

COUGH+COLD1child mucinex chest congestion2CHILD MUCINEX

CONGESTION-COUGHMO2CHILD MUCINEX STUFFY

NOSE-COLD1child mucus relief cough1child mucus relief expectorant2CHILD MULTI-SYMPTOM

COLD/COUGH2CHILD PLUS COUGH &

RUNNY NOSE

Requirements/Limits

DrugTierDrug Name

1children's chest congestion oralliquid

1children's cold & cough1children's cold & cough dm2CHILDREN'S COLD-

COUGH-SORE2CHILDREN'S COUGH &

RUNNY NOSE1children's dibromm dm cold & c2CHILDREN'S MUCINEX

COLD-FEVER2CHILDREN'S MUCINEX

MULTI-SYMP2CHILDREN'S MUCINEX

NIGHT TIME2CHILDREN'S SUDAFED1children's sudafed pe cough2CHILDREN'S SUDAFED PE

NASAL1childrens plus cold oral suspension

1-2.5-5-160 mg/5 ml2CHILDS PLUS COLD &

ALLERGYMO2CHLO TUSS

2CHLO TUSS EXMO1chlorpheniramine-hydrocodone

1codeine-guaifenesin oral liquid 10-100 mg/5 ml

MO1codituss dm1cold & cough dm1cold & cough elixir2COLD HEAD CONGESTION

DAY/NITE2COLD HEAD CONGESTION

DAYTIME1cold head congestion nighttime1cold head congestion sever day1cold multi-symptom1cold multi-symptom (chlorphen)2COLD MULTI-SYMPTOM

DAY/NIGHT2COLD MULTI-SYMPTOM

DAYTIME1cold multi-symptom nighttime2COLD RELIEF M/S DAY/

NIGHT

5 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2COLD RELIEF ORALTABLET, EFFERVESCENT 2-7.8-325 MG

1cold relief plus1cold severe congestion2COLD-COUGH SINUS

RELIEF PE1cold-flu relief oral liquid 12.5-30-

1,000 mg/30 ml2COMPLETE SINUS RELIEF1congestac2CONTAC COLD-FLU DAY

AND NIGHT2CONTAC COLD-FLU MAX

STRENGTH2CONTAC COLD-FLU

NIGHT2CORICIDIN HBP2CORICIDIN HBP COLD-

MULTI SYMPTMO2CORICIDIN HBP COUGH &

COLD2CORICIDIN HBP DAY-

NIGHT1cough & cold oral liquid1cough & cold oral tablet2COUGH & RUNNY NOSE

ORAL LIQUID 1-5 MG/5 ML2COUGH & SEVERE COLD1cough & sore throat oral liquid

160-5 mg/5 ml1cough control dm oral syrup1cough dm er2COUGH DROPS (WITH

EUCALYPTUS) MUCOUSMEMBRANE LOZENGE 3.1MG

1cough drops (with eucalyptus)mucous membrane lozenge 6.5 mg,7 mg, 8 mg

1cough formula dm1cough relief1cough suppressant-expectorant1cough syrup1cough syrup dm1coughtab

Requirements/Limits

DrugTierDrug Name

MO1cpm-pseudoephed-hydrocodone2CREO-TERPIN (DM-

GUAIFENESIN)1day time pe1daytime2DAYTIME & NIGHTTIME

COLD2DAYTIME & NITETIME

SINUS2DAYTIME COLD & FLU

RELIEF ORAL CAPSULE 5-10-325 MG

1daytime cold & flu relief oralliquid

1daytime cold-flu1daytime cold-flu softgel1daytime mucus relief dm2DAYTIME SINUS1daytime-nighttime2DAYTIME-NIGHTTIME

COLD-FLU2DAYTIME-NIGHTTIME

COUGHMO2DECONEX DMXMO2DECONEX IR

2DECOREL FORTE PLUSMO2DELSYM 12 HOUR

2DELSYM COUGH+COLDDAYTIME

2DELSYM COUGH+COLDNIGHTTIME

2DELSYMCOUGH+SOOTHINGACTION

2DELTUSS DMX(DEXCHLORPHEN)

2DESGEN2DESGEN DM2DESPEC2DESPEC-DM2DEXCHLORPHEN-PSE-

CHLOPHEDIANOL1diabetic siltussin-dm2DIABETIC TUSSIN NIGHT

TIME2DIMETAPP LONG-ACTING

(CPM-DM)

6 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2DONATUSSINMO2DONATUSSIN PEDIATRICMO2DURAFLU

2DURAVENT DM2DURAVENT PE

MO1ed a-hist dm1effervescent cold relief plus1endacof-c1endacon2ENTEX LQ2ENTEX PAC

MO2ENTEX TMO1ephedrine sulfate injection solution

2EXACTUSS1expectorant oral liquid2FENESIN DM IR1fenesin pe ir2FLU & SEVERE COLD-

DAYTIME1flu & severe cold-nighttime2FLU & SORE THROAT2FLU & SORE THROAT

RELIEF1flu relief therapy daytime1flu relief therapy nighttime2FLU-SEVERE COLD-COUGH2G-SUPRESS DX2G-TRON PED2G-TUSICOF2G-ZYNCOF2GILPHEX TR2GILTUSS2GILTUSS PEDIATRIC2GILTUSS TR1guaiatussin ac2GUAICON DMS1guaifenesin ac

MO1guaifenesin dac1guaifenesin oral liquid

MO1guaifenesin oral tablet extendedrelease

1guaifenesin-dm1guiatuss ac2HEAD CONGESTION COLD

RELIEF ORAL TABLETS,SEQUENTIAL

Requirements/Limits

DrugTierDrug Name

2HISTEX DM1hot steam liquid1hydrocodone compound

MO1hydrocodone-homatropine oralsyrup 5-1.5 mg/5 ml

2HYDROCODONE-HOMATROPINE ORALSYRUP 5-1.5 MG/5 ML (5 ML)

MO1hydrocodone-homatropine oraltablet

MO1hydromet1ibuprofen cold1ibuprofen cold-sinus(with pse)2INTENSE COLD & FLU2INTENSE COUGH2INTENSE COUGH

RELIEVER ORAL LIQUID 20-300 MG/5 ML

MO1iophen c-nrMO1iophen dm-nrMO2J-MAXMO1liquibid d-rMO2LIQUIBID PD-R

2LIQUITUSS GG1lohist peb dm

MO2LORTUSS DM2LORTUSS EX

MO1m-clear wc2M-END DMX

MO2M-END MAX DMO2M-END PE

1mapap cold formula2MAR-COF BP

MO2MAR-COF CG2MAXIFED DM1maximum strength flu2MAXIPHEN DM1medi-phedrine2MEDI-PHENYL1medi-tussin dm1medi-tussin dm diabetic2MEDIKOFF1medikoff drops1menthol cough drops1menthol cough mucous membrane

lozenge 6.5 mg

7 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2MUCINEX COLD & SINUS2MUCINEX COLD-FLU &

SORE THROATMO2MUCINEX COUGH MINI-

MELTSMO1mucinex dMO1mucinex dm oral tablet extended

release 12 hrMO2MUCINEX DM ORAL

TABLET, ER MULTIPHASE12 HR

2MUCINEX FAST-MAXCOLD-FLU

2MUCINEX FAST-MAXCOLD-SINUS

MO2MUCINEX FAST-MAXCONGEST-COUGH ORALLIQUID

2MUCINEX FAST-MAXCONGEST-COUGH ORALTABLET

2MUCINEX FAST-MAX DAY-NITE COLD

1mucinex fast-max dm max2MUCINEX FAST-MAX NITE

COLD-FLU2MUCINEX FAST-MAX

SEVERE COLD2MUCINEX MINI-MELTS

ORAL GRANULES INPACKET 100 MG

MO2MUCINEX ORAL TABLET,ERBIPHASIC 12 HR 1,200 MG

2MUCINEX SINUS-MAX DAY-NIGHT

2MUCINEX SINUS-MAXPRESSUR-PAIN

2MUCINEX SINUS-MAX SEVCONGEST

1mucosa dm1mucus and cough relief2MUCUS RELIEF COLD &

SINUS2MUCUS RELIEF COLD-FLU-

SORE THR2MUCUS RELIEF

CONGESTION-COUGH

Requirements/Limits

DrugTierDrug Name

1mucus relief cough oral liquidMO1mucus relief dm

1mucus relief er1mucus relief oral tablet1mucus relief pe2MUCUS RELIEF SEV

CONGEST-COLD1multi-symptom cold (pe)1multi-symptom cold daytime1multi-symptom cold night time1multi-symptom cold-cough1nasal decongestant (pe) oral tablet

10 mg1nasal decongestant (pseudoeph) oral

tablet1nasal decongestant (pseudoeph) oral

tablet extended release2NASOHIST DM2NATURAL HERB COUGH

DROPS MUCOUSMEMBRANE LOZENGE 4.8MG

2NEOTUSS PLUS2NEOTUSS-D (IMPROVED

FORMULA)2NEXAFED1night time cold & flu relief1night time cold oral tablet1night time cold-flu oral capsule2NIGHT TIME COLD-FLU

ORAL LIQUID2NIGHT TIME COLD-FLU

RELIEF ORAL LIQUID 12.5-30-1,000 MG/30 ML

1night time cough & sore throat1nighttime cold-flu1nighttime cold-flu relief1nighttime cough1nighttime sinus1nite time cold-flu formula2NITE TIME COLD-FLU

ORAL LIQUID2NITE TIME COLD-FLU

RELIEF2NITE TIME COLD-FLU

RELIEF (PE)

8 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

1nite time cough1nite-time2NON-DRYING SINUS ORAL

TABLET2NON-PSEUDO COLD

RELIEFMO2NOREL AD

2NOREL CS1pain relief allergy sinus2PAIN RELIEF COLD &

COUGH2PAIN RELIEF SINUS PE1pain reliever pm oral tablet 30-

500 mg2PANATUSS PED2PANATUSS PED DROPS2PECGEN DMX2PEDIATEX TDM2PHENABID DM2PHENAGIL CH1phenylephrine-guaifenesin oral

tablet1phenylhistine

MO1phenylhistine dh2POLY HIST PD ORAL DROPS2POLY-HIST DM

(THONZYLAMINE)1poly-tussin1poly-tussin d2POLY-VENT DM ORAL

TABLET 60-20-380 MGMO2POLY-VENT IR ORAL

TABLET 60-380 MG2PRES GEN PEDIATRIC2PRESGEN B2PRESSURE & PAIN

MO2PRIMATENE ASTHMA2PRO-CHLO

MO2PRO-CLEAR ACMO2PRO-CLEAR CAPS

2PRO-RED AC (W/DEXCHLORPHENIR)

MO1promethazine vc-codeineMO1promethazine-codeineMO1promethazine-dm

1promethazine-phenyleph-codeine

Requirements/Limits

DrugTierDrug Name

2PSEUDOEPHED-CHLOPHEDIANOL-GG

MO1pseudoephedrine hcl oral tablet 30mg

1pseudoephedrine hcl oral tablet 60mg

MO1pseudoephedrine hcl oral tabletextended release

MO1q-tapp dm1refenesen oral tablet 400 mg1relcof c

MO2RESCON-DMMO2RESPA-ARMO2RESPAIRE-30MO2REZIRAMO1robafen cough

2ROBITUSSIN LONG-ACTING

2ROBITUSSIN MUCUS-CHEST CONGEST

2ROBITUSSIN NIGHTTIMECOUGH DM

MO1robitussin pediatric1rydex

MO2SAFE TUSSIN DM2SCOT-TUSSIN DIABETES CF1scot-tussin dm2SCOT-TUSSIN SENIOR2SEVERE ALLERGY-SINUS

HEADACHE1severe cold2SEVERE COLD (DIPHEN-PE-

ACETAM)1severe cold multi-symptom2SEVERE COLD PE2SEVERE CONGESTION &

COUGH MAX1siltussin-dm1sinus & allergy non-drowsy2SINUS & COLD-D1sinus congestion & pain2SINUS CONGESTION &

PAIN(GUAIF)1sinus congestion&pain(chlorph)

9 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2SINUS DAYTIME-NIGHTIME ORAL TABLETS,SEQUENTIAL

1sinus decongestant (pe)1sinus pain relief2SORBUTUSS

MO2SUDAFED 12 HOUR2SUDAFED PE

PRESSURE+PAIN+COUGHMO1sudogestMO1sudogest pe

1suphedrin 12 hour1suphedrin oral tablet1suphedrine1suphedrine 12 hour1suphedrine pe2SUPHEDRINE PE DAY-

NIGHT1suphedrine pe sinus headache2SUPRESS A2SUPRESS DM2SUPRESS-PE

MO2TESSALON PERLES2TG 10PEH-380GFN2THERAFLU DAYTIME

COLD-COUGH ORALPOWDER IN PACKET

2THERAFLU FLU-SORETHROAT ORAL PACKET 20-10-650 MG

2THERAFLU MAX-D SEVERECOLD-FLU

2THERAFLU MULTI-SYMPTOM COLD

2THERAFLU NIGHT SEVERECOLD-CGH

1throat lozengesMO2TREXBROM ORAL LIQUID

4-10-25 MG/5 ML2TRIACTIN2TRIAMINIC CHEST &NASAL

CONGEST2TRIAMINIC COLD &

COUGH (PE) ORAL LIQUID2TRIAMINIC COUGH-SORE

THROAT ORAL LIQUID 160-5 MG/5 ML

Requirements/Limits

DrugTierDrug Name

2TRISPEC DMX ORALLIQUID 10-187 MG/5 ML

2TRISPEC PSE ORAL LIQUID30-10-187 MG/5 ML

1trymine cg2TUSICOF1tusnel c2TUSNEL NEW FORMULA1tusnel pediatric oral drops2TUSNEL PEDIATRIC ORAL

LIQUID2TUSNEL-DM PEDIATRIC2TUSSI PRES-B ORAL LIQUID

4-10-30 MG/5 ML2TUSSI-PRES ORAL LIQUID

IN PACKET2TUSSI-PRES PEDIATRIC

MO2TUSSICAPSMO1tussigon

1tussin cf cough-cold2TUSSIN CF MAX

MO1tussin cf oral liquid1tussin cf oral syrup1tussin chest congestion1tussin cough &chest congestion1tussin cough (dm only)1tussin dm clear oral syrup1tussin dm cough1tussin dm cough & chest oral

liquid1tussin dm max1tussin dm oral syrup 10-100 mg/5

ml1tussin expectorant1tussin maximum strength cough1tussin oral liquid1tussin pe oral liquid

MO2TUSSIONEX PENNKINETICER

2TUSSLIN ORAL LIQUID 2.5-7.5-88 MG/ML

2TYLENOL COLD MULTI-SYMPT NIGHT ORALLIQUID

2TYLENOL COLD MULTI-SYMPTOM DAY

10 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2TYLENOL SINUSCONGESTION PAIN ORALTABLET 5-325-200 MG

MO2VANACOF2VANACOF DM2VANACOF DX2VANACOF-82VANATAB DX2VICKS CHILDREN'S

NYQUIL COLD&C1vicks dayquil cold&flu relief1vicks dayquil cough2VICKS DAYQUIL MUCUS

CONTROL DM2VICKS DAYQUIL SEVERE

COLD-FLU2VICKS DAYQUIL SINEX2VICKS DAYQUIL-NYQUIL2VICKS DAYQUIL-NYQUIL

COLD-FLU2VICKS DAYQUIL-NYQUIL

SEVERE2VICKS NATURE FUSION2VICKS NATURE FUSION

COLD & FLU2VICKS NATURE FUSION

COUGH & CH2VICKS NYQUIL COLD/FLU

(CPM)1vicks nyquil cold/flu liquicap2VICKS NYQUIL COUGH2VICKS NYQUIL NIGHTTIME

RELIEF2VICKS NYQUIL SEVERE

COLD-FLU2VICKS NYQUIL SINEX1vicks vaposteam1virtussin ac

MO2VITUZMO2Z-COF 12 DM

2Z-COF IMO2Z-TUSS AC

2ZEPHREX-D2ZODRYL AC 252ZODRYL AC 302ZODRYL AC 352ZODRYL AC 40

Requirements/Limits

DrugTierDrug Name

2ZODRYL AC 502ZODRYL AC 602ZODRYL AC 802ZODRYL DAC 252ZODRYL DAC 302ZODRYL DAC 352ZODRYL DAC 402ZODRYL DAC 502ZODRYL DAC 602ZODRYL DAC 802ZODRYL DEC 252ZODRYL DEC 302ZODRYL DEC 352ZODRYL DEC 402ZODRYL DEC 502ZODRYL DEC 602ZODRYL DEC 80

MO2ZONATUSSMO2ZUTRIPRO

2ZYNCOFUrologicals

2ALPROSTADIL (BULK)MO2CAVERJECTMO2CAVERJECT IMPULSEMO; QLL (6 per30 days)

3CIALIS

MO2EDEXMO; QLL (6 per30 days)

3LEVITRA

MO2MUSEMO; QLL (6 per30 days)

3STAXYN

MO; QLL (6 per30 days)

3STENDRA

MO; QLL (6 per30 days)

3VIAGRA

Vitamins, Hematinics / Electrolytes1a thru z1a thru z high potency oral tablet1a thru z select oral tablet1adults' daily formula

MO1advanced am-pm2AKEDAMINS1animal chews1animal shapes complete oral

tablet,chewable

11 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

1antioxidant vitamins oral tablet2ANTIOXIDANT VITAMINS

ORAL TABLET 1,000 UNIT-200 MG-60 UNIT-2 MG

MO2APATATE1apatate forte2APETEX2APETIGEN

MO2APETIGEN PLUS ORALTABLET

MO2AQUADEKS ORALTABLET,CHEWABLE

MO2AQUASOL A1ascorbate calcium oral2ASCORBATE SODIUM

(BULK) POWDER2ASCORBIC ACID (BULK)

GRANULESMO1ascorbic acid injectionMO2ASCORBIC ACID ORAL

GRANULES1ascorbic acid oral tablet 1,000 mg,

500 mgMO1ascorbic acid oral tablet extended

release 1,000 mg1ascorbic acid with rose hips1b complete

MO1b complex 100 injection1b complex 100 oral1b complex oral1b complex vitamins1b complex-folic acid oral tablet1b complex-vitamin b12

MO1b complex-vitamin c-folic acid1b-50 complex oral tablet extended

release1b-complex with vitamin c oral

tablet1b100 balanced1bal b-1002BALANCED B COMPLEX-

VIT C1balanced b-100 complex1balanced b-100 oral tablet 0.4 mg,

100 mg1balanced b-150

Requirements/Limits

DrugTierDrug Name

1balanced b-50MO1beta carotene oral capsule 25,000

unitMO2BIFERA RX

1biosupp1biotect plus2BIOTIN (BULK) POWDER

100 %1biotin oral capsule 5 mg

MO1biotin oral tablet 1 mgMO2BIOTIN ORAL TABLET 10

MG1biotin oral tablet 300 mcg1c-1000 oral tablet extended release1c-1000 with rose hips1c-500 oral tablet1c-500 oral tablet,chewable1calcidol1calcium carbonate-vit d3-min oral

tablet,chewable 600 mg (1,500mg)-200 unit

1calcium citrate + d with mag1calcium citrate plus (vit b6)

MO2CALCIUM PANTOTHENATE1calcium-magnesium-zinc oral

tablet 333-133-5 mgMO2CARDIOTEK-RX

(BIOPERINE)1centamin1central vite with lutein1central-vite cardio1central-vite select1central-vite with lycopene

MO1centratexMO1centrum oral liquid

2CENTRUM ORALTABLET,CHEWABLE

MO2CENTRUM SILVER ORALTABLET,CHEWABLE

2CENTRUM ULTRA MEN'S1century1century adults 50+1century cardio1century mature oral tablet 0.4-

300-250 mg-mcg-mcg

12 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2CENTURY ULTIMATEMEN'S ORAL TABLET 8 MGIRON- 200 MCG-600 MCG

MO2CEREFOLIN NAC (ALGALOIL)

1certa plusMO1certavite senior-antioxidantMO1certavite-antioxidantMO1chelated zinc

1chewable multi vitamin1chewable multivit-a,b,d,e,k,zn

MO1chewable-vite1child's chewable vitamins/iron1child's vitamin with vitamin c1children's chewable vitamin1children's chewable w/minerals

MO1chromium chlorideMO1cod liver oil oral capsuleMO1cod liver oil oral oil

1complete 50+2COMPLETE FORMULATION

MULTIVIT ORALTABLET,CHEWABLE

1complete multi1complete multi 50+1complete multivitamin oral tablet1complete multivitamin-mineral

oral tablet1complete oral tablet

MO1complete senior oral tablet 0.4-300-250 mg-mcg-mcg

MO1complex b-100 oral tablet extendedrelease

MO1corvitaMO1corvita 150MO2CORVITEMO2CORVITE FEMO2CUPRIC SULFATEMO2CYANOCOBALAMIN

(VITAMIN B-12) ORALLOZENGE

1cyanocobalamin (vitamin b-12)oral tablet 100 mcg, 250 mcg

1cyanocobalamin (vitamin b-12)oral tablet extended release 2,000mcg

Requirements/Limits

DrugTierDrug Name

2CYANOCOBALAMIN(VITAMIN B-12) POWDER

1daily energy1daily multi-vitamin1daily multi-vitamins/iron1daily multiple for men1daily multiple for men 50+2DAILY MULTIPLE FOR

WOMEN1daily multiple for women 50+1daily multiple oral tablet , 18-400

mg-mcg2DAILY MULTIPLE ORAL

TABLET 400-120 MCG-MG1daily multiple vitamins/iron1daily multivitamin with iron1daily multivitamin-minerals1daily teen multi-vitamin1daily vitamin1daily vitamin formula1daily vitamin formula-minerals1daily vitamin with iron

MO1daily vites/ironMO1daily-viteMO1dexferrumMO1dialyviteMO2DIALYVITE 3000MO2DIALYVITE 5000MO1dialyvite 800MO2DIALYVITE 800 WITH IRONMO2DIALYVITE 800 WITH ZINC

50MO2DIALYVITE SUPREME D

1dino-life1dino-life with extra c1dino-life with iron-zinc

MO2DRISDOL ORAL DROPS1ear health formula oral tablet 200-

100 mgMO2EFFER-K ORAL TABLET,

EFFERVESCENT 10 MEQ, 20MEQ

1ellis tonic2ERGOCALCIFEROL

(VITAMIN D2)

13 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

MO1ergocalciferol (vitamin d2) oralcapsule

1essential one daily2ESSENTIAL WOMAN 50+2ESTER-C WITH

BIOFLAVONOIDS ORALTABLET 500-200 MG

MO1fabb1fe 90 plus

MO1fe cMO2FEOSOL BIFERAMO1feosol oral tablet 325 mg (65 mg

iron)1fer-iron

MO2FERAHEMEMO1feroconMO1ferosul oral tabletMO2FERRALET 90 DUAL-IRON

DELIVERYMO2FERRETTS IPSMO2FERREX 150MO1ferrex 150 forteMO1ferrex 150 forte plus

2FERRIC SUBSULFATE(BULK) SOLUTION

MO1ferro-timeMO1ferrocite plusMO1ferrogels forteMO1ferrous fumarate oral tablet 324

mg (106 mg iron)MO1ferrous gluconate oral tablet 240

mg (27 mg iron)2FERROUS SULFATE

MO1ferrous sulfate oral liquidMO1ferrous sulfate oral solution

1ferrous sulfate oral syringe1ferrous sulfate oral tablet 134 mg

(27 mg iron)MO1ferrous sulfate oral tablet 325 mg

(65 mg iron)MO1ferrous sulfate oral tablet,delayed

release (dr/ec) 325 mg (65 mgiron)

2FERROUS SULFATE, DRIED(BULK)

2FLEXGEN

Requirements/Limits

DrugTierDrug Name

MO2FLINTSTONES COMPLETE(IRON) ORALTABLET,CHEWABLE

MO1folbeeMO1folbee plus oral tablet 5-1.5-25 mgMO1folbicMO2FOLGARD OSMO2FOLGARD RXMO2FOLIC ACID (BULK)MO1folic acid injectionMO1folic acid oral tabletMO1folic acid-vit b6-vit b12 oral tablet

2.2-25-0.5 mg1folic acid-vit b6-vit b12 oral tablet

2.5-25-1 mgMO1folitabMO1folivane-fMO1folivane-plusMO1folplex 2.2MO1foltabs 800MO1foltanxMO1foltanx rfMO2FOLTRATEMO1fosfreeMO2GALZINMO2GERITOL COMPLETE

2GERITOL TONIC WITHFERREX 18

1gummi bear multivitamin1gummy swirls2HAIR VITAMINS1hair,skin & nails oral tablet1healthy eyes

MO1hematinic plus vit/mineralsMO1hematinic/folic acidMO1hematogenMO1hematogen faMO1hematogen forte

2HEMATRONMO2HEMATRON-AFMO2HEMAXMO1hemetab

1high potency iron1honey bears1honey bears with iron-zinc

MO1hydroxocobalamin intramuscular

14 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

MO2I.L.X. B-12MO2ICAPS

1icaps plusMO2ICAR ORAL SUSPENSIONMO1iferex 150 forteMO1infed

2INFUVITE ADULT2INFUVITE PEDIATRIC

MO2INTEGRAMO2INTEGRA FMO2INTEGRA PLUS

1iron (dried)1iron (ferrous sulfate)1iron high potency1iron oral tablet 325 mg (65 mg

iron)MO2IROSPAN 24/6

1kid's vitamins + extra c1kid's vitamins + iron1kid's vitamins oral tablet,chewable

MO1l-methyl-b6-b12MO1l-methyl-mcMO1l-methyl-mc nac

1l-methylfolate ca p-5-p me-cbl1lipoflavovit

MO2LIQUI-E1little animals1little animals/iron1lmefol ca-acetyl-meb12-algal

MO1lugols oral1lumitene1m.v.i. adult2M.V.I. PEDIATRIC2M.V.I.-12 (WITHOUT

VITAMIN K)1macuvite

MO2MAGNESIUM CHLORIDECRYSTALS

1manganese chlorideMO1manganese sulfate intravenous

1men's daily formula1men's one daily oral tablet

MO2MERIBINMO1metafolbicMO1metafolbic plusMO1metafolbic plus rf

Requirements/Limits

DrugTierDrug Name

MO2METANX (ALGAL OIL)1milltrium senior2MTX SUPPORT

MO1multi-delyn1multi-delyn with iron1multi-vitamins with iron

MO2MULTICHEWMO1multigenMO1multigen folicMO1multilex-t&m

1multiple vitamin-minerals2MULTITRACE-4

MO2MULTITRACE-4CONCENTRATE

2MULTITRACE-4 NEONATAL1multitrace-4 pediatric2MULTITRACE-5

MO2MULTITRACE-5CONCENTRATE

1multivital oral tablet 0.4-162-18mg

1multivital platinum oral tablet1multivitamin with iron

MO1multivitamin with minerals oraltablet

MO1myferon 150 forte2MYKIDZ IRON1mynephrocaps

MO2NASCOBALMO1natalvirt fltMO1nephplex rxMO1nephro-vite rxMO2NEPHRON FA

1nephronexMO2NEURIN-SLMO1niacin flush free oral capsule 400

mg niacin (500 mg)MO2NO FLUSH NIACIN

2NUTRIVITMO2OCUVITE WITH LUTEIN

1omnicap1once daily1one daily 50 plus1one daily essential oral tablet , 0.4

mg1one daily for men

15 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

1one daily for women1one daily maximum1one daily maximum (with ca)1one daily men's 50+ oral tablet1one daily oral tablet , 0.4-600 mg-

mcg1one daily plus iron1one daily plus minerals2ONE DAILY WOMEN'S

METABOLISMMO2ONE-A-DAY CHOLESTEROL

PLUS1one-a-day maximum formula1one-a-day teen advantage2ONE-A-DAY WOMENS

FORMULA ORAL TABLET 18MG IRON-400 MCG-500 MG

MO2ONE-A-DAY WOMENSFORMULA ORAL TABLET 18MG IRON-400 MCG-500 MGCA

1opti-vitaminsMO2OPTISOURCE ORAL

TABLET,CHEWABLE 7.5-200MG-MCG

MO2ORAZINC ORAL TABLETMO2PERIDIN-CMO1poly-iron 150 forte

1poly-vitamin oral drops 1,500-35-400 unit-mg-unit/ml

1poly-vitamins2POLYSACCHARIDE IRON1polyvitamin/iron

MO2POTABA ORAL CAPSULEMO2PRO FEMO2PROFERRIN ESMO2PROFERRIN-FORTE

1prosight2PROTECT IRON

MO2PROTECT PLUSMO1purevit dualfe plusMO2PYRIDOXINE (BULK)

CRYSTALS2PYRIDOXINE (BULK)

POWDERMO1pyridoxine injection

Requirements/Limits

DrugTierDrug Name

1pyridoxine oral tablet 100 mg, 25mg

MO1rena-viteMO1rena-vite rxMO1renal capsMO1reno caps

1riboflavin oral tablet 100 mg1risanoid plus2SCOOBY-DOO ONE A DAY

MO1se-tan plusMO1selenium intravenousMO1selenium oral tablet 100 mcg

1selenium oral tablet 200 mcg2SENTRY ORAL TABLET 18-

400 MG-MCG1sentry senior1slow release iron oral tablet

extended release 142 mg (45 mgiron), 47.5 mg iron

MO1slow release iron oral tabletextended release 160 mg (50 mgiron)

1soothing pureway-cMO2SOURCECF MULTIVIT

WITH ZINC ORALTABLET,CHEWABLE

1spectravite advanced formula oraltablet 0.4-300-250 mg-mcg-mcg

1spectravite men's1spectravite oral tablet1spectravite oral tablet,chewable1spectravite senior oral tablet2SPECTRAVITE SENIOR W-

LYCOPENE1spectravite ultra women1strawberry c1stress 5001stress 500 plus zinc1stress b with zinc1stress formula advanced

MO1stress formula with zincMO1strong iodine oral

2SUPER B-50 COMPLEX1super b-50 complex plus2SUPER MULTIPLE ORAL

TABLET

16 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

2SUPER MULTIVITAMIN1superplex-t2SUPERVITE

MO2SUPERVITE (EC)MO1supportMO2SUPPORT-500MO1tab-a-viteMO2TANDEM DUAL ACTIONMO2TANDEM PLUSMO1taron forte

1thera1thera vitamin1thera-m oral tablet 27-0.4 mg

MO1thera-m oral tablet 9 mg iron-400mcg

1thera-tabs2THERAFLU COLD-SORE

THROAT (PE)2THERAFLU SINUS & COLD1therapeutic formula/hematinics1therapeutic-m vitamin/minerals

oral tablet 0.4-250 mg-mcg1theratrum complete 50 plus

MO1theremsMO1therems-mMO2THIAMINE HCL (BULK)MO1thiamine hcl injection

1thiamine hcl oral tablet 100 mg,50 mg

MO1tl g-fol osMO1tl gard rxMO1tl iconMO1tl-hem 150

1total b/c2TRACE ELEMENTS 4/

PEDIATRICMO2TRI-VI-SOL WITH IRONMO1tri-vitaminMO1triconMO1trigels-f forteMO1triphrocaps

2TROMBONEX2TYR COOLER ORAL

SUSPENSIONMO2UDAMIN SP

Requirements/Limits

DrugTierDrug Name

2ULTRA B-100 COMPLEXORAL TABLET

2VASOFLEX FORTE2VASOFLEX HD

MO2VASOFLEX ORAL TABLETMO2VENOFER INTRAVENOUS

SOLUTION 100 MG/5 MLIRON, 200 MG/10 ML IRON

2VENOFER INTRAVENOUSSOLUTION 50 MG/2.5 MLIRON

MO1virt-viteMO1virt-vite forte

1vision formula1vision formula (with lutein)

MO1vit 31vit a & d3 in cod liver oil

MO1vitabee/cMO1vitacel (with lutein)MO2VITAFOL ORAL TABLETMO2VITAL-D RXMO1vitamin a oral capsule 10,000 unit

1vitamin a oral capsule 8,000 unit2VITAMIN A PALMITATE

ORAL CAPSULEMO1vitamin b complex oral capsule

2VITAMIN B COMPLEXORAL TABLET 500 MG-400MCG- 18 MG IRON

1vitamin b complex with cMO1vitamin b-1

1vitamin b-1 (mononitrate)2VITAMIN B-12 ORAL

LOZENGE 50 MCG1vitamin b-12 oral lozenge 500

mcgMO1vitamin b-12 oral tablet

1vitamin b-12 oral tablet extendedrelease 2,000 mcg

MO1vitamin b-2MO1vitamin b-6 oral tablet 100 mg,

25 mgMO1vitamin c oral syrupMO1vitamin c oral tablet 1,000 mg,

250 mg, 500 mg1vitamin c oral tablet 100 mg

17 ECDH_2015_4

Requirements/Limits

DrugTierDrug Name

1vitamin c oral tablet extendedrelease 1,000 mg

MO1vitamin c oral tablet extendedrelease 500 mg

MO1vitamin c oral tablet,chewable 500mg

MO1vitamin c with rose hips oral tablet1vitamin c with rose hips oral tablet

extended releaseMO1vitamin d2MO1vitamin d3 oral tablet 400 unitMO1vitamin e oral capsule 100 unit

2VITAMIN E ORAL DROPS100 UNIT/0.25 ML

1vitamins & minerals2VITATRUM ORAL

TABLET,CHEWABLEMO1vol-care rxMO1vp-zel

1wee care2WOMEN'S DAILY CAPLET1women's daily formula oral tablet

18 mg iron-400 mcg-500 mg ca2WOMEN'S ONE DAILY

ORAL TABLET 18 MG IRON-400 MCG-500 MG CA

1women's one daily oral tablet 27-0.4 mg

1yelets1zinc

MO1zinc chlorideMO2ZINC CHLORIDE (BULK)

GRANULES2ZINC CHLORIDE (BULK)

POWDER1zinc gluconate oral tablet 30 mg

MO1zinc gluconate oral tablet 50 mg1zinc lozenges oral lozenge 23 mg2ZINC SULFATE (BULK)

POWDERMO1zinc sulfate intravenous solution 5

mg/mlMO1zinc sulfate oral capsuleMO2ZINC-15

1zinc-220

18 ECDH_2015_4

Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance maychange on January 1 of each year. Limitations, copayments and restrictions may apply. The benefitinformation provided is a brief summary, not a complete description, of benefits. For more information,contact the plan.

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licenseesof the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shieldplans.

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