List of Extra Covered Drugs

Transcription

1 List of Extra Covered s Extra Covered s 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. Y007_5_078_I_00 07/8/ MUSENMUB_00_ABC_H ECDH_05_4

2 Your Senior Rx Plus Plan Extra Covered s for 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 s (also called the formulary) that comes with your plan, you also get "Extra Covered s." This booklet shows you which Extra Covered s are included in your plan. For the full list of your covered Part D drugs, look at your formulary. How do Extra Covered s fit into your plan's prescription drug benefits? Although these drugs are not normally covered in Medicre Prescription plans, your Senior Rx Plus benefits offer them to you. Like your covered Part D drugs, the cost you pay for Extra Covered s is based on the tier each drug is in. You can find the tier number next to the drug name. And you can find the cost for each drug tier by checking the benefit chart in your Evidence of Coverage (or your Certificate). Because Extra Covered s are separate from your Part D coverage, if you fill a prescription for one of them, the cost does not count toward your Part D out-of-pocket limits. The cost also does not move you through the Part D coverage stages. 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. Y007_5_078_I_00 07/8/04 ECDH_05_4

3 List of Extra Covered s (keep with your formulary) Name Antineoplastic / Immunosuppressant s IODOPEN SODIUM IODIDE (BULK) Autonomic / Cns s, Neurology / Psych isometh-dichloral-acetaminophn nodolor PRODRIN ORAL TABLET MG Cardiovascular, Hypertension / Lipids MEPHYTON niacin oral capsule, extended release 50 mg, 500 mg niacin oral tablet 00 mg, 50 mg, 50 mg NIACIN ORAL TABLET EXTENDED RELEASE,000 MG niacin oral tablet extended release 50 mg, 500 mg, 750 mg NIACINAMIDE (BULK) CRYSTALS NIACINAMIDE (BULK) POWDER niacinamide oral tablet nitro-time nitroglycerin oral capsule, extended release.5 mg PHYTONADIONE INJECTION SLO-NIACIN ORAL TABLET EXTENDED RELEASE 750 MG vitamin k injection VITAMIN K ORAL vitamin k injection Dermatologicals/Topical Therapy ACLARO ACLARO PD acne foaming face wash ALA-QUIN ALCORTIN A TOPICAL GEL IN PACKET Name ALOQUIN alphaquin hp AMINOBENZOIC ACID (BULK) AVAGE BENZAC AC WASH TOPICAL CLEANSER 0 % BENZAC W WASH TOPICAL CLEANSER 0 % benzoyl peroxide topical cleanser 0 %, 5 % bp 0- bp wash topical cleanser 0 %, 5 % bp-50% urea bpo-0 bpo-5 CORTANE-B TOPICAL dermazene GRANULEX HYDRO 40 hydrocortisone-pramoxine topical cream hydroquinone hydroquinone microspheres iodoquinol-hc latrix LUSTRA-AF lustra-ultra melpaque hp melquin hp NSEL'S NOVACORT nuquin hp topical cream OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE OVACE TOPICAL CLEANSER panoxyl topical cleanser 0 % PRASONE TOPICAL CREAM.5- % ECDH_05_4

4 Name PRASONE TOPICAL OINTMENT refissa remeven RENOVA TOPICAL CREAM 0.0 % SALEX TOPICAL KIT,CLEANSER & CREAM ER SALEX TOPICAL SHAMPOO salicylic acid sr-ceramides topical kit,cleanser & cream er salicylic acid topical liquid 6 % salicylic acid topical shampoo salicylic acid-ammon lact-aloe salvax seb-prev sulfacetamide sodium topical cleanser tretinoin (emollient) TRI-LUMA UMECTA PD TOPICAL EMULSION, ADHESIVE UMECTA TOPICAL EMULSION umecta topical foam urea (with la & sal acid) urea 50% urea nail stick urea topical cream 40 %, 50 % VANIQA x-viate topical cream Diagnostics / Miscellaneous Agents central vite central-vite performance oral tablet chromium picolinate oral capsule chromium picolinate oral tablet 00 mcg complete premium vitamin FERRLECIT finasteride oral tablet mg multivital performance PROPECIA PROPECIA PRO-PAK sodium ferric gluconat-sucrose ZINC SULFATE (BULK) POWDER 00 % Name Ear, Nose / Throat Medications cortane-b aqueous cortane-b otic cough drops mucous membrane lozenge 0 mg COUGH DROPS MUCOUS MEMBRANE LOZENGE.7 MG, 5 MG, 5.4 MG, 5.8 MG, 6. MG, 7 MG, 7.5 MG, 8 MG, 9. MG FLANAX COUGH RELIEF (MENTHOL) HALLS COUGH DROPS MUCOUS MEMBRANE LOZENGE 5.8 MG HALLS COUGH DROPS MUCOUS MEMBRANE LOZENGE 7 MG, 7.6 MG, 9. MG MENTHOL COUGH MUCOUS MEMBRANE LOZENGE 6. MG NATURAL HERB MUCOUS MEMBRANE LOZENGE 4.8 MG oto-end 0 RICOLA MUCOUS MEMBRANE LOZENGE MG, MG sore throat (hexylresorcinol) mucous membrane lozenge.4 mg SORE THROAT (MENTHOL) throat drops mucous membrane lozenge.8 mg VICKS VAPODROPS Endocrine/Diabetes SSKI Gastroenterology anucort-hc ANUSOL-HC RECTAL SUPPOSITORY chlordiazepoxide-clidinium DONNATAL ORAL ELIXIR MG/5 ML DONNATAL ORAL TABLET hydrocortisone acetate rectal suppository 3 ECDH_05_4

5 Name hydrocortisone-pramox-e-pram# hydrocortisone-pramoxine rectal LIBRAX (WITH CLIDINIUM) phenobarb-hyoscy-atropine-scop oral tablet PROCTOCORT RECTAL SUPPOSITORY Obstetrics / Gynecology covaryx covaryx h.s. eemt eemt hs estrogens-methyltestosterone isoxsuprine oral tablet 0 mg OSPHENA Ophthalmology LATISSE Respiratory And Allergy hour cold relief hour decongestant 30pse-50gfn-5dm ABATUSS DMX adult robitussin m-s cold ADULT ROBITUSSIN NIGHT M-S CLD adult robitussin peak cold m-s ADVIL ALLERGY SINUS ADVIL ALLERGY- CONGESTION RLF ADVIL COLD & SINUS ORAL CAPSULE advil cold & sinus oral tablet+c067 ADVIL CONGESTION RELIEF ALA-HIST DM ALDEX GS ALEVE COLD & SINUS ALEVE SINUS & HEADACHE ALEVE-D SINUS & COLD ALEVE-D SINUS & HEADACHE ALKA-SELTZER PLUS C/ C(PE,DM) ALKA-SELTZER PLUS COLD (PE) 3 Name ALKA-SELTZER PLUS COLD/ COUGH ALKA-SELTZER PLUS DAY ALKA-SELTZER PLUS DAY- NIGHT ALKA-SELTZER PLUS FLU ALKA-SELTZER PLUS NIGHT ALKA-SELTZER PLUS SIN- ALLG-CGH ALKA-SELTZER PLUS SINUS- COUGH ALKA-SELTZER PLUS-D SINUS-COLD ALL DAY PAIN RELIEF SINUS & CO ALL-NITE COLD-FLU ORAL LIQUID MG/5 ML allergy multi-symptom allergy relief multi-symptom ALLERGY RELIEF-SINUS HEADACHE ALLERGY SINUS HEADACHE ORAL TABLET MG ALLERGY-SINUS ORAL TABLET MG allfen AMBI 0PEH-4CPM-0DM AMBI 0DM-4CPM AMBI 60PSE-4CPM-0DM AMBIFED AMBIFED DM ap-hist dm BALAMINE DM (CHLOR-PE) benzonatate BICLORA BICLORA-D BIO T PRES BIO T PRES PEDIATRIC BIODESP DM BIONATUSS DXP BIONEL PEDIATRIC BIOSPEC DMX BROMFED DM 4 ECDH_05_4

6 Name brompheniramin-phenylephrin-dm oral liquid -5-0 mg/5 ml, mg/5 ml brompheniramine-pseudoeph-dm oral liquid mg/5 ml bronchial asthma relief BRONCOTRON PED ORAL DROPS BRONCOTRON-S BRONKIDS BRONTUSS SF CAPCOF CAPMIST DM CAPRON DM CARBAPHEN CH CARBAPHEN PED CH cardec dm (phenyleph-chlorphn) CCP CAFFEINE FREE CERTUSS-D cheratussin ac cheratussin dac cherry cough drops chest congestion relief + dm chest congestion relief oral tablet chest congestion relief pe chest congestion-cough relief oral tablet chest-sinus congestion relief child chest congestion + cough CHILD COUGH & SORE THROAT child delsym cough+chest dm CHILD DELSYM COUGH+COLD child mucinex chest congestion CHILD MUCINEX CONGESTION-COUGH CHILD MUCINEX STUFFY NOSE-COLD child mucus relief cough child mucus relief expectorant CHILD MULTI-SYMPTOM COLD/COUGH CHILD PLUS COUGH & RUNNY NOSE children's chest congestion oral liquid Name children's cold & cough children's cold & cough dm CHILDREN'S COLD- COUGH-SORE CHILDREN'S COUGH & RUNNY NOSE children's dibromm dm cold & c CHILDREN'S MUCINEX COLD-FEVER CHILDREN'S MUCINEX MULTI-SYMP CHILDREN'S MUCINEX NIGHT TIME CHILDREN'S SUDAFED children's sudafed pe cough CHILDREN'S SUDAFED PE NASAL childrens plus cold oral suspension mg/5 ml CHILDS PLUS COLD & ALLERGY CHLO TUSS CHLO TUSS EX chlorpheniramine-hydrocodone codeine-guaifenesin oral liquid 0-00 mg/5 ml codituss dm cold & cough dm cold & cough elixir COLD HEAD CONGESTION DAY/NITE COLD HEAD CONGESTION DAYTIME cold head congestion nighttime cold head congestion sever day cold multi-symptom cold multi-symptom (chlorphen) COLD MULTI-SYMPTOM DAY/NIGHT COLD MULTI-SYMPTOM DAYTIME cold multi-symptom nighttime COLD RELIEF M/S DAY/ NIGHT COLD RELIEF ORAL TABLET, EFFERVESCENT MG 5 ECDH_05_4

7 Name cold relief plus cold severe congestion COLD-COUGH SINUS RELIEF PE cold-flu relief oral liquid.5-30-,000 mg/30 ml COMPLETE SINUS RELIEF congestac CONTAC COLD-FLU DAY AND NIGHT CONTAC COLD-FLU MAX STRENGTH CONTAC COLD-FLU NIGHT CORICIDIN HBP CORICIDIN HBP COLD- MULTI SYMPT CORICIDIN HBP COUGH & COLD CORICIDIN HBP DAY- NIGHT cough & cold oral liquid cough & cold oral tablet COUGH & RUNNY NOSE ORAL LIQUID -5 MG/5 ML COUGH & SEVERE COLD cough & sore throat oral liquid 60-5 mg/5 ml cough control dm oral syrup cough dm er COUGH DROPS (WITH EUCALYPTUS) MUCOUS MEMBRANE LOZENGE 3. MG cough drops (with eucalyptus) mucous membrane lozenge 6.5 mg, 7 mg, 8 mg cough formula dm cough relief cough suppressant-expectorant cough syrup cough syrup dm coughtab cpm-pseudoephed-hydrocodone CREO-TERPIN (DM- GUAIFENESIN) day time pe Name daytime DAYTIME & NIGHTTIME COLD DAYTIME & NITETIME SINUS DAYTIME COLD & FLU RELIEF ORAL CAPSULE MG daytime cold & flu relief oral liquid daytime cold-flu daytime cold-flu softgel daytime mucus relief dm DAYTIME SINUS daytime-nighttime DAYTIME-NIGHTTIME COLD-FLU DAYTIME-NIGHTTIME COUGH DECONEX DMX DECONEX IR DECOREL FORTE PLUS DELSYM HOUR DELSYM COUGH+COLD DAYTIME DELSYM COUGH+COLD NIGHTTIME DELSYM COUGH+SOOTHING ACTION DELTUSS DMX (DEXCHLORPHEN) DESGEN DESGEN DM DESPEC DESPEC-DM DEXCHLORPHEN-PSE- CHLOPHEDIANOL diabetic siltussin-dm DIABETIC TUSSIN NIGHT TIME DIMETAPP LONG-ACTING (CPM-DM) DONATUSSIN DONATUSSIN PEDIATRIC DURAFLU DURAVENT DM 6 ECDH_05_4

8 Name DURAVENT PE ed a-hist dm effervescent cold relief plus endacof-c endacon ENTEX LQ ENTEX PAC ENTEX T ephedrine sulfate injection solution EXACTUSS expectorant oral liquid FENESIN DM IR fenesin pe ir FLU & SEVERE COLD- DAYTIME flu & severe cold-nighttime FLU & SORE THROAT FLU & SORE THROAT RELIEF flu relief therapy daytime flu relief therapy nighttime FLU-SEVERE COLD-COUGH G-SUPRESS DX G-TRON PED G-TUSICOF G-ZYNCOF GILPHEX TR GILTUSS GILTUSS PEDIATRIC GILTUSS TR guaiatussin ac GUAICON DMS guaifenesin ac guaifenesin dac guaifenesin oral liquid guaifenesin oral tablet extended release guaifenesin-dm guiatuss ac HEAD CONGESTION COLD RELIEF ORAL TABLETS, SEQUENTIAL HISTEX DM hot steam liquid hydrocodone compound hydrocodone-homatropine oral syrup 5-.5 mg/5 ml Name HYDROCODONE- HOMATROPINE ORAL SYRUP 5-.5 MG/5 ML (5 ML) hydrocodone-homatropine oral tablet hydromet ibuprofen cold ibuprofen cold-sinus(with pse) INTENSE COLD & FLU INTENSE COUGH INTENSE COUGH RELIEVER ORAL LIQUID MG/5 ML iophen c-nr iophen dm-nr J-MAX liquibid d-r LIQUIBID PD-R LIQUITUSS GG lohist peb dm LORTUSS DM LORTUSS EX m-clear wc M-END DMX M-END MAX D M-END PE mapap cold formula MAR-COF BP MAR-COF CG MAXIFED DM maximum strength flu MAXIPHEN DM medi-phedrine MEDI-PHENYL medi-tussin dm medi-tussin dm diabetic MEDIKOFF medikoff drops menthol cough drops menthol cough mucous membrane lozenge 6.5 mg MUCINEX COLD & SINUS MUCINEX COLD-FLU & SORE THROAT MUCINEX COUGH MINI- MELTS mucinex d 7 ECDH_05_4

9 Name mucinex dm oral tablet extended release hr MUCINEX DM ORAL TABLET, ER MULTIPHASE HR MUCINEX FAST-MAX COLD-FLU MUCINEX FAST-MAX COLD-SINUS MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID MUCINEX FAST-MAX CONGEST-COUGH ORAL TABLET MUCINEX FAST-MAX DAY- NITE COLD mucinex fast-max dm max MUCINEX FAST-MAX NITE COLD-FLU MUCINEX FAST-MAX SEVERE COLD MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 00 MG MUCINEX ORAL TABLET,ER BIPHASIC HR,00 MG MUCINEX SINUS-MAX DAY- NIGHT MUCINEX SINUS-MAX PRESSUR-PAIN MUCINEX SINUS-MAX SEV CONGEST mucosa dm mucus and cough relief MUCUS RELIEF COLD & SINUS MUCUS RELIEF COLD-FLU- SORE THR MUCUS RELIEF CONGESTION-COUGH mucus relief cough oral liquid mucus relief dm mucus relief er mucus relief oral tablet mucus relief pe Name MUCUS RELIEF SEV CONGEST-COLD multi-symptom cold (pe) multi-symptom cold daytime multi-symptom cold night time multi-symptom cold-cough nasal decongestant (pe) oral tablet 0 mg nasal decongestant (pseudoeph) oral tablet nasal decongestant (pseudoeph) oral tablet extended release NASOHIST DM NATURAL HERB COUGH DROPS MUCOUS MEMBRANE LOZENGE 4.8 MG NEOTUSS PLUS NEOTUSS-D (IMPROVED FORMULA) NEXAFED night time cold & flu relief night time cold oral tablet night time cold-flu oral capsule NIGHT TIME COLD-FLU ORAL LIQUID NIGHT TIME COLD-FLU RELIEF ORAL LIQUID.5-30-,000 MG/30 ML night time cough & sore throat nighttime cold-flu nighttime cold-flu relief nighttime cough nighttime sinus nite time cold-flu formula NITE TIME COLD-FLU ORAL LIQUID NITE TIME COLD-FLU RELIEF NITE TIME COLD-FLU RELIEF (PE) nite time cough nite-time NON-DRYING SINUS ORAL TABLET NON-PSEUDO COLD RELIEF 8 ECDH_05_4

10 Name NOREL AD NOREL CS pain relief allergy sinus PAIN RELIEF COLD & COUGH PAIN RELIEF SINUS PE pain reliever pm oral tablet mg PANATUSS PED PANATUSS PED DROPS PECGEN DMX PEDIATEX TDM PHENABID DM PHENAGIL CH phenylephrine-guaifenesin oral tablet phenylhistine phenylhistine dh POLY HIST PD ORAL DROPS POLY-HIST DM (THONZYLAMINE) poly-tussin poly-tussin d POLY-VENT DM ORAL TABLET MG POLY-VENT IR ORAL TABLET MG PRES GEN PEDIATRIC PRESGEN B PRESSURE & PAIN PRIMATENE ASTHMA PRO-CHLO PRO-CLEAR AC PRO-CLEAR CAPS PRO-RED AC (W/ DEXCHLORPHENIR) promethazine vc-codeine promethazine-codeine promethazine-dm promethazine-phenyleph-codeine PSEUDOEPHED- CHLOPHEDIANOL-GG pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg Name pseudoephedrine hcl oral tablet extended release q-tapp dm refenesen oral tablet 400 mg relcof c RESCON-DM RESPA-AR RESPAIRE-30 REZIRA robafen cough ROBITUSSIN LONG- ACTING ROBITUSSIN MUCUS- CHEST CONGEST ROBITUSSIN NIGHTTIME COUGH DM robitussin pediatric rydex SAFE TUSSIN DM SCOT-TUSSIN DIABETES CF scot-tussin dm SCOT-TUSSIN SENIOR SEVERE ALLERGY-SINUS HEADACHE severe cold SEVERE COLD (DIPHEN-PE- ACETAM) severe cold multi-symptom SEVERE COLD PE SEVERE CONGESTION & COUGH MAX siltussin-dm sinus & allergy non-drowsy SINUS & COLD-D sinus congestion & pain SINUS CONGESTION & PAIN(GUAIF) sinus congestion&pain(chlorph) SINUS DAYTIME- NIGHTIME ORAL TABLETS, SEQUENTIAL sinus decongestant (pe) sinus pain relief SORBUTUSS SUDAFED HOUR SUDAFED PE PRESSURE+PAIN+COUGH 9 ECDH_05_4

11 Name sudogest sudogest pe suphedrin hour suphedrin oral tablet suphedrine suphedrine hour suphedrine pe SUPHEDRINE PE DAY- NIGHT suphedrine pe sinus headache SUPRESS A SUPRESS DM SUPRESS-PE TESSALON PERLES TG 0PEH-380GFN THERAFLU DAYTIME COLD-COUGH ORAL POWDER IN PACKET THERAFLU FLU-SORE THROAT ORAL PACKET MG THERAFLU MAX-D SEVERE COLD-FLU THERAFLU MULTI- SYMPTOM COLD THERAFLU NIGHT SEVERE COLD-CGH throat lozenges TREXBROM ORAL LIQUID MG/5 ML TRIACTIN TRIAMINIC CHEST &NASAL CONGEST TRIAMINIC COLD & COUGH (PE) ORAL LIQUID TRIAMINIC COUGH-SORE THROAT ORAL LIQUID 60-5 MG/5 ML TRISPEC DMX ORAL LIQUID 0-87 MG/5 ML TRISPEC PSE ORAL LIQUID MG/5 ML trymine cg TUSICOF tusnel c TUSNEL NEW FORMULA tusnel pediatric oral drops Name TUSNEL PEDIATRIC ORAL LIQUID TUSNEL-DM PEDIATRIC TUSSI PRES-B ORAL LIQUID MG/5 ML TUSSI-PRES ORAL LIQUID IN PACKET TUSSI-PRES PEDIATRIC TUSSICAPS tussigon tussin cf cough-cold TUSSIN CF MAX tussin cf oral liquid tussin cf oral syrup tussin chest congestion tussin cough &chest congestion tussin cough (dm only) tussin dm clear oral syrup tussin dm cough tussin dm cough & chest oral liquid tussin dm max tussin dm oral syrup 0-00 mg/5 ml tussin expectorant tussin maximum strength cough tussin oral liquid tussin pe oral liquid TUSSIONEX PENNKINETIC ER TUSSLIN ORAL LIQUID MG/ML TYLENOL COLD MULTI- SYMPT NIGHT ORAL LIQUID TYLENOL COLD MULTI- SYMPTOM DAY TYLENOL SINUS CONGESTION PAIN ORAL TABLET MG VANACOF VANACOF DM VANACOF DX VANACOF-8 VANATAB DX VICKS CHILDREN'S NYQUIL COLD&C 0 ECDH_05_4

12 Name vicks dayquil cold&flu relief vicks dayquil cough VICKS DAYQUIL MUCUS CONTROL DM VICKS DAYQUIL SEVERE COLD-FLU VICKS DAYQUIL SINEX VICKS DAYQUIL-NYQUIL VICKS DAYQUIL-NYQUIL COLD-FLU VICKS DAYQUIL-NYQUIL SEVERE VICKS NATURE FUSION VICKS NATURE FUSION COLD & FLU VICKS NATURE FUSION COUGH & CH VICKS NYQUIL COLD/FLU (CPM) vicks nyquil cold/flu liquicap VICKS NYQUIL COUGH VICKS NYQUIL NIGHTTIME RELIEF VICKS NYQUIL SEVERE COLD-FLU VICKS NYQUIL SINEX vicks vaposteam virtussin ac VITUZ Z-COF DM Z-COF I Z-TUSS AC ZEPHREX-D ZODRYL AC 5 ZODRYL AC 30 ZODRYL AC 35 ZODRYL AC 40 ZODRYL AC 50 ZODRYL AC 60 ZODRYL AC 80 ZODRYL DAC 5 ZODRYL DAC 30 ZODRYL DAC 35 ZODRYL DAC 40 ZODRYL DAC 50 ZODRYL DAC 60 ZODRYL DAC 80 Name ZODRYL DEC 5 ZODRYL DEC 30 ZODRYL DEC 35 ZODRYL DEC 40 ZODRYL DEC 50 ZODRYL DEC 60 ZODRYL DEC 80 ZONATUSS ZUTRIPRO ZYNCOF Urologicals ALPROSTADIL (BULK) CAVERJECT CAVERJECT IMPULSE CIALIS EDEX LEVITRA MUSE STAXYN STENDRA VIAGRA Vitamins, Hematinics / Electrolytes a thru z a thru z high potency oral tablet a thru z select oral tablet adults' daily formula advanced am-pm AKEDAMINS animal chews animal shapes complete oral tablet,chewable antioxidant vitamins oral tablet ANTIOXIDANT VITAMINS ORAL TABLET,000 UNIT- 00 MG-60 UNIT- MG APATATE apatate forte APETEX APETIGEN APETIGEN PLUS ORAL TABLET 3 3 ; QLL (6 per 30 days) ; QLL (6 per 30 days) ; QLL (6 per 30 days) ; QLL (6 per 30 days) ; QLL (6 per 30 days) ECDH_05_4

13 Name AQUADEKS ORAL TABLET,CHEWABLE AQUASOL A ascorbate calcium oral ASCORBATE SODIUM (BULK) POWDER ASCORBIC ACID (BULK) GRANULES ascorbic acid injection ASCORBIC ACID ORAL GRANULES ascorbic acid oral tablet,000 mg, 500 mg ascorbic acid oral tablet extended release,000 mg ascorbic acid with rose hips b complete b complex 00 injection b complex 00 oral b complex oral b complex vitamins b complex-folic acid oral tablet b complex-vitamin b b complex-vitamin c-folic acid b-50 complex oral tablet extended release b-complex with vitamin c oral tablet b00 balanced bal b-00 BALANCED B COMPLEX- VIT C balanced b-00 complex balanced b-00 oral tablet 0.4 mg, 00 mg balanced b-50 balanced b-50 beta carotene oral capsule 5,000 unit BIFERA RX biosupp biotect plus BIOTIN (BULK) POWDER 00 % biotin oral capsule 5 mg biotin oral tablet mg Name BIOTIN ORAL TABLET 0 MG biotin oral tablet 300 mcg c-000 oral tablet extended release c-000 with rose hips c-500 oral tablet c-500 oral tablet,chewable calcidol calcium carbonate-vit d3-min oral tablet,chewable 600 mg (,500 mg)-00 unit calcium citrate + d with mag calcium citrate plus (vit b6) CALCIUM PANTOTHENATE calcium-magnesium-zinc oral tablet mg CARDIOTEK-RX (BIOPERINE) centamin central vite with lutein central-vite cardio central-vite select central-vite with lycopene centratex centrum oral liquid CENTRUM ORAL TABLET,CHEWABLE CENTRUM SILVER ORAL TABLET,CHEWABLE CENTRUM ULTRA MEN'S century century adults 50+ century cardio century mature oral tablet mg-mcg-mcg CENTURY ULTIMATE MEN'S ORAL TABLET 8 MG IRON- 00 MCG-600 MCG CEREFOLIN NAC (ALGAL OIL) certa plus certavite senior-antioxidant certavite-antioxidant chelated zinc chewable multi vitamin chewable multivit-a,b,d,e,k,zn chewable-vite ECDH_05_4

14 Name child's chewable vitamins/iron child's vitamin with vitamin c children's chewable vitamin children's chewable w/minerals chromium chloride cod liver oil oral capsule cod liver oil oral oil complete 50+ COMPLETE FORMULATION MULTIVIT ORAL TABLET,CHEWABLE complete multi complete multi 50+ complete multivitamin oral tablet complete multivitamin-mineral oral tablet complete oral tablet complete senior oral tablet mg-mcg-mcg complex b-00 oral tablet extended release corvita corvita 50 CORVITE CORVITE FE CUPRIC SULFATE CYANOCOBALAMIN (VITAMIN B-) ORAL LOZENGE cyanocobalamin (vitamin b-) oral tablet 00 mcg, 50 mcg cyanocobalamin (vitamin b-) oral tablet extended release,000 mcg CYANOCOBALAMIN (VITAMIN B-) POWDER daily energy daily multi-vitamin daily multi-vitamins/iron daily multiple for men daily multiple for men 50+ DAILY MULTIPLE FOR WOMEN daily multiple for women 50+ daily multiple oral tablet, mg-mcg Name DAILY MULTIPLE ORAL TABLET MCG-MG daily multiple vitamins/iron daily multivitamin with iron daily multivitamin-minerals daily teen multi-vitamin daily vitamin daily vitamin formula daily vitamin formula-minerals daily vitamin with iron daily vites/iron daily-vite dexferrum dialyvite DIALYVITE 3000 DIALYVITE 5000 dialyvite 800 DIALYVITE 800 WITH IRON DIALYVITE 800 WITH ZINC 50 DIALYVITE SUPREME D dino-life dino-life with extra c dino-life with iron-zinc DRISDOL ORAL DROPS ear health formula oral tablet mg EFFER-K ORAL TABLET, EFFERVESCENT 0 MEQ, 0 MEQ ellis tonic ERGOCALCIFEROL (VITAMIN D) ergocalciferol (vitamin d) oral capsule essential one daily ESSENTIAL WOMAN 50+ ESTER-C WITH BIOFLAVONOIDS ORAL TABLET MG fabb fe 90 plus fe c FEOSOL BIFERA feosol oral tablet 35 mg (65 mg iron) fer-iron 3 ECDH_05_4

15 Name FERAHEME ferocon ferosul oral tablet FERRALET 90 DUAL-IRON DELIVERY FERRETTS IPS FERREX 50 ferrex 50 forte ferrex 50 forte plus FERRIC SUBSULFATE (BULK) SOLUTION ferro-time ferrocite plus ferrogels forte ferrous fumarate oral tablet 34 mg (06 mg iron) ferrous gluconate oral tablet 40 mg (7 mg iron) FERROUS SULFATE ferrous sulfate oral liquid ferrous sulfate oral solution ferrous sulfate oral syringe ferrous sulfate oral tablet 34 mg (7 mg iron) ferrous sulfate oral tablet 35 mg (65 mg iron) ferrous sulfate oral tablet,delayed release (dr/ec) 35 mg (65 mg iron) FERROUS SULFATE, DRIED (BULK) FLEXGEN FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE folbee folbee plus oral tablet mg folbic FOLGARD OS FOLGARD RX FOLIC ACID (BULK) folic acid injection folic acid oral tablet folic acid-vit b6-vit b oral tablet mg folic acid-vit b6-vit b oral tablet.5-5- mg Name folitab folivane-f folivane-plus folplex. foltabs 800 foltanx foltanx rf FOLTRATE fosfree GALZIN GERITOL COMPLETE GERITOL TONIC WITH FERREX 8 gummi bear multivitamin gummy swirls HAIR VITAMINS hair,skin & nails oral tablet healthy eyes hematinic plus vit/minerals hematinic/folic acid hematogen hematogen fa hematogen forte HEMATRON HEMATRON-AF HEMAX hemetab high potency iron honey bears honey bears with iron-zinc hydroxocobalamin intramuscular I.L.X. B- ICAPS icaps plus ICAR ORAL SUSPENSION iferex 50 forte infed INFUVITE ADULT INFUVITE PEDIATRIC INTEGRA INTEGRA F INTEGRA PLUS iron (dried) iron (ferrous sulfate) iron high potency iron oral tablet 35 mg (65 mg iron) 4 ECDH_05_4

16 Name IROSPAN 4/6 kid's vitamins + extra c kid's vitamins + iron kid's vitamins oral tablet,chewable l-methyl-b6-b l-methyl-mc l-methyl-mc nac l-methylfolate ca p-5-p me-cbl lipoflavovit LIQUI-E little animals little animals/iron lmefol ca-acetyl-meb-algal lugols oral lumitene m.v.i. adult M.V.I. PEDIATRIC M.V.I.- (WITHOUT VITAMIN K) macuvite MAGNESIUM CHLORIDE CRYSTALS manganese chloride manganese sulfate intravenous men's daily formula men's one daily oral tablet MERIBIN metafolbic metafolbic plus metafolbic plus rf METANX (ALGAL OIL) milltrium senior MTX SUPPORT multi-delyn multi-delyn with iron multi-vitamins with iron MULTICHEW multigen multigen folic multilex-t&m multiple vitamin-minerals MULTITRACE-4 MULTITRACE-4 CONCENTRATE MULTITRACE-4 NEONATAL multitrace-4 pediatric MULTITRACE-5 Name MULTITRACE-5 CONCENTRATE multivital oral tablet mg multivital platinum oral tablet multivitamin with iron multivitamin with minerals oral tablet myferon 50 forte MYKIDZ IRON mynephrocaps NASCOBAL natalvirt flt nephplex rx nephro-vite rx NEPHRON FA nephronex NEURIN-SL niacin flush free oral capsule 400 mg niacin (500 mg) NO FLUSH NIACIN NUTRIVIT OCUVITE WITH LUTEIN omnicap once daily one daily 50 plus one daily essential oral tablet, 0.4 mg one daily for men one daily for women one daily maximum one daily maximum (with ca) one daily men's 50+ oral tablet one daily oral tablet, mgmcg one daily plus iron one daily plus minerals ONE DAILY WOMEN'S METABOLISM ONE-A-DAY CHOLESTEROL PLUS one-a-day maximum formula one-a-day teen advantage ONE-A-DAY WOMENS FORMULA ORAL TABLET 8 MG IRON-400 MCG-500 MG 5 ECDH_05_4

17 Name ONE-A-DAY WOMENS FORMULA ORAL TABLET 8 MG IRON-400 MCG-500 MG CA opti-vitamins OPTISOURCE ORAL TABLET,CHEWABLE MG-MCG ORAZINC ORAL TABLET PERIDIN-C poly-iron 50 forte poly-vitamin oral drops, unit-mg-unit/ml poly-vitamins POLYSACCHARIDE IRON polyvitamin/iron POTABA ORAL CAPSULE PRO FE PROFERRIN ES PROFERRIN-FORTE prosight PROTECT IRON PROTECT PLUS purevit dualfe plus PYRIDOXINE (BULK) CRYSTALS PYRIDOXINE (BULK) POWDER pyridoxine injection pyridoxine oral tablet 00 mg, 5 mg rena-vite rena-vite rx renal caps reno caps riboflavin oral tablet 00 mg risanoid plus SCOOBY-DOO ONE A DAY se-tan plus selenium intravenous selenium oral tablet 00 mcg selenium oral tablet 00 mcg SENTRY ORAL TABLET MG-MCG sentry senior Name slow release iron oral tablet extended release 4 mg (45 mg iron), 47.5 mg iron slow release iron oral tablet extended release 60 mg (50 mg iron) soothing pureway-c SOURCECF MULTIVIT WITH ZINC ORAL TABLET,CHEWABLE spectravite advanced formula oral tablet mg-mcg-mcg spectravite men's spectravite oral tablet spectravite oral tablet,chewable spectravite senior oral tablet SPECTRAVITE SENIOR W- LYCOPENE spectravite ultra women strawberry c stress 500 stress 500 plus zinc stress b with zinc stress formula advanced stress formula with zinc strong iodine oral SUPER B-50 COMPLEX super b-50 complex plus SUPER MULTIPLE ORAL TABLET SUPER MULTIVITAMIN superplex-t SUPERVITE SUPERVITE (EC) support SUPPORT-500 tab-a-vite TANDEM DUAL ACTION TANDEM PLUS taron forte thera thera vitamin thera-m oral tablet mg thera-m oral tablet 9 mg iron-400 mcg thera-tabs 6 ECDH_05_4

18 Name THERAFLU COLD-SORE THROAT (PE) THERAFLU SINUS & COLD therapeutic formula/hematinics therapeutic-m vitamin/minerals oral tablet mg-mcg theratrum complete 50 plus therems therems-m THIAMINE HCL (BULK) thiamine hcl injection thiamine hcl oral tablet 00 mg, 50 mg tl g-fol os tl gard rx tl icon tl-hem 50 total b/c TRACE ELEMENTS 4/ PEDIATRIC TRI-VI-SOL WITH IRON tri-vitamin tricon trigels-f forte triphrocaps TROMBONEX TYR COOLER ORAL SUSPENSION UDAMIN SP ULTRA B-00 COMPLEX ORAL TABLET VASOFLEX FORTE VASOFLEX HD VASOFLEX ORAL TABLET VENOFER INTRAVENOUS SOLUTION 00 MG/5 ML IRON, 00 MG/0 ML IRON VENOFER INTRAVENOUS SOLUTION 50 MG/.5 ML IRON virt-vite virt-vite forte vision formula vision formula (with lutein) vit 3 vit a & d3 in cod liver oil vitabee/c Name vitacel (with lutein) VITAFOL ORAL TABLET VITAL-D RX vitamin a oral capsule 0,000 unit vitamin a oral capsule 8,000 unit VITAMIN A PALMITATE ORAL CAPSULE vitamin b complex oral capsule VITAMIN B COMPLEX ORAL TABLET 500 MG-400 MCG- 8 MG IRON vitamin b complex with c vitamin b- vitamin b- (mononitrate) VITAMIN B- ORAL LOZENGE 50 MCG vitamin b- oral lozenge 500 mcg vitamin b- oral tablet vitamin b- oral tablet extended release,000 mcg vitamin b- vitamin b-6 oral tablet 00 mg, 5 mg vitamin c oral syrup vitamin c oral tablet,000 mg, 50 mg, 500 mg vitamin c oral tablet 00 mg vitamin c oral tablet extended release,000 mg vitamin c oral tablet extended release 500 mg vitamin c oral tablet,chewable 500 mg vitamin c with rose hips oral tablet vitamin c with rose hips oral tablet extended release vitamin d vitamin d3 oral tablet 400 unit vitamin e oral capsule 00 unit VITAMIN E ORAL DROPS 00 UNIT/0.5 ML vitamins & minerals VITATRUM ORAL TABLET,CHEWABLE vol-care rx vp-zel 7 ECDH_05_4

19 Name wee care WOMEN'S DAILY CAPLET women's daily formula oral tablet 8 mg iron-400 mcg-500 mg ca WOMEN'S ONE DAILY ORAL TABLET 8 MG IRON- 400 MCG-500 MG CA women's one daily oral tablet mg yelets zinc zinc chloride ZINC CHLORIDE (BULK) GRANULES ZINC CHLORIDE (BULK) POWDER zinc gluconate oral tablet 30 mg zinc gluconate oral tablet 50 mg zinc lozenges oral lozenge 3 mg ZINC SULFATE (BULK) POWDER zinc sulfate intravenous solution 5 mg/ml zinc sulfate oral capsule ZINC-5 zinc-0 8 ECDH_05_4

20 Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January of each year. Limitations, copayments and restrictions may apply. The benefit information provided is a brief summary, not a complete description, of benefits. For more information, contact the plan. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.