Extra Covered Drugs. The prescription drugs in this list are covered above and beyond the drugs in your plan's Part D Formulary. ECDHLP_SHBP_v1_1901_2

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1 09 Extra Covered s The prescription drugs in this list are covered above and beyond the drugs in your plan's Part D Formulary. Y04_9_34776_I_SHBP 05/0/ MUSENMUB_GA_SHBP ECDHLP_SHBP_v_90_

2 This booklet lists the Extra Covered s included in your Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage plan. This list may change at any time. You will receive notice when necessary. For the full list of your covered Part D drugs, please refer to your Formulary booklet. Your plan includes cough/cold medications, vitamins/minerals and lifestyle drugs that are not normally covered under a Part D plan. How do "Extra Covered s" fit into your plan s prescription drug benefits? "Extra Covered s" are separate from your Part D coverage. If you fill a prescription for one of these drugs, the cost does not count toward your True Out-of-Pocket (TrOOP) expenses. These drugs do not qualify for lower Part D catastrophic copays. 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 in the chart below. You can find the cost for each drug tier by checking the benefit chart in your Evidence of Coverage. If you are receiving Medicare s "Extra Help" to pay for your prescriptions, this program will not lower your cost for these drugs. We're here to answer your questions. Please call Anthem Member Services at (TTY:7) if you have any questions about this benefit. ECDHLP_SHBP_v_90_

3 List of Extra Covered s Legend Generic drugs are shown in lowercase italics. Brand-name drugs are shown in capital letters. QLL - Quantity : Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled. This is most often set on a monthly basis. - Mail Order: Prescription drugs available through mail order. Name Antineoplastic / Immunosuppressant s IODOPEN Autonomic / Cns s, Neurology / Psych isometh-dichloralacetaminophn isomethepten-cafacetaminophen oral tablet mg PRODRIN ORAL TABLET MG Cardiovascular, Hypertension / Lipids endur-acin oral tablet extended release 50 mg endur-acin oral tablet extended release 500 mg, 750 mg MEPHYTON niacin (niacinamide) 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 oral tablet 500 mg nitro-time nitroglycerin oral PHYTONADIONE (VITAMIN K) INJECTION Name PHYTONADIONE (VITAMIN K) ORAL TABLET 00 MCG slo-niacin oral tablet extended release 500 mg SLO-NIACIN ORAL TABLET EXTENDED RELEASE 750 MG vitamin k vitamin k injection Dermatologicals/Topical Therapy acne foaming wash advanced exfoliating cleanser ALA-QUIN ALCORTIN A AVAGE benzoyl peroxide topical cleanser 0 %, 5 % blanche bp 0- bp wash topical cleanser 0 %, 5 % bpo-0 bpo-5 CORTANE-B TOPICAL foaming acne face wash HYDRO 40 hydrocortisone-pramoxine topical cream.5% - % hydroquinone hydroquinone microspheres iodoquinol-hc NSEL'S TOPICAL SOLUTION OVACE 3 ECDHLP_SHBP_v_90_

4 Name OVACE PLUS TOPICAL CLEANSER panoxyl topical cleanser PRASONE E PRASONE TOPICAL OINTMENT.5% - % QUINJA refissa RENOVA TOPICAL CREAM 0.0 % SALEX TOPICAL KIT,CLEANSER AND CREAM ER SALEX TOPICAL SHAMPOO salicylic acid er-ceramides topical kit,cleanser and cream er salicylic acid topical foam salicylic acid topical liquid 6 % salicylic acid topical shampoo salvax sulfacetamide sodium topical cleanser tretinoin (emollient) TRI-LUMA umecta topical foam ure-k urea nail stick urea topical cream 40 %, 50 % VANIQA Diagnostics / Miscellaneous Agents ADIPEX-P ORAL TABLET chromium picolinate oral capsule chromium picolinate oral tablet 00 mcg complete premium vitamin cranberry urinary comfort FERRLECIT finasteride oral tablet mg phentermine oral tablet PROPECIA sodium ferric gluconat-sucrose Ear, Nose / Throat Medications cough drops mucous membrane lozenge 0 mg Name COUGH DROPS MUCOUS MEMBRANE LOZENGE.7 MG, 5 MG, 5.4 MG, 5.8 MG, 6. MG, 7.5 MG, 7.6 MG, 9. MG FLANAX COUGH RELIEF (MENTHOL) HALLS COUGH DROPS MUCOUS MEMBRANE LOZENGE 5.8 MG HALLS COUGH DROPS MUCOUS MEMBRANE LOZENGE 7.5 MG, 7.6 MG sore throat (hexylresorcinol) mucous membrane lozenge.4 mg sore throat relief (pectin) throat drops mucous membrane lozenge.8 mg VICKS VAPODROPS Endocrine/Diabetes SSKI Erectile Dysfunction CAVERJECT CAVERJECT IMPULSE CIALIS EDEX LEVITRA MUSE sildenafil STAXYN STENDRA VIAGRA Gastroenterology ANALPRAM-HC RECTAL CREAM ANALPRAM-HC SINGLES RECTAL CREAM.5- % (4G) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) ; QLL ( EA per 30 days) 4 ECDHLP_SHBP_v_90_

5 Name anucort-hc ANUSOL-HC RECTAL SUPPOSITORY DONNATAL ORAL ELIXIR 6. MG MG/5 ML (5 ML) DONNATAL ORAL ELIXIR MG/5 ML DONNATAL ORAL TABLET hydrocortisone acetate rectal hydrocortisone-pramoxine rectal cream.5- %,.5- % (4g) phenobarb-hyoscy-atropinescop oral tablet pramcort PROCTOCORT RECTAL Obstetrics / Gynecology covaryx covaryx h.s. eemt eemt hs estrogens-methyltestosterone isoxsuprine Ophthalmology bimatoprost base of the eyelashes LATISSE Respiratory And Allergy hour decongestant abanatuss ped ABATUSS DMX actidom dmx ACTINEL ACTINEL PEDIATRIC adult cough formula dm max adult robitussin peak cold dm adult robitussin peak cold m-s adult tussin chest congestion adult tussin cough congest dm adult tussin dm adult wal-tussin adult wal-tussin dm max ADVIL ALLERGY SINUS ADVIL ALLERGY-CONGESTION RLF Name ADVIL COLD AND SINUS ORAL CAPSULE advil cold and sinus oral tablet ALAHIST CF ALAHIST DM ALEVE COLD AND SINUS ALEVE SINUS AND HEADACHE ALEVE-D SINUS AND COLD ALEVE-D SINUS AND HEADACHE ALKA-SELTZER PLUS C/C(PE, DM) ALKA-SELTZER PLUS COLD (PE) ALKA-SELTZER PLUS COLD+FLU ALKA-SELTZER PLUS COLD/ COUGHFM ALKA-SELTZER PLUS D-N (ACETAM) ALKA-SELTZER PLUS DAY ALKA-SELTZER PLUS DAY-NIGHT ALKA-SELTZER PLUS FLU alka-seltzer plus mucus-conges ALKA-SELTZER PLUS NIGHT ALKA-SELTZER PLUS NIGHT (ASA) ALKA-SELTZER PLUS SIN-ALLG- CGH ALKA-SELTZER PLUS SINUS- COUGH ALKA-SELTZER PLUS-D SINUS- COLD ALL DAY PAIN RELIEF SINUS, COLD ALL-NITE COLD-FLU allergy multi-symptom allergy plus severe sinus ha allergy relief multi-symptom ALLERGY SINUS HEADACHE (PE) allergy sinus pe allergy sinus-d allfen allfen dm antitussive dm ap-hist dm AQUANAZ 5 ECDHLP_SHBP_v_90_

6 Name ATUSS DA benzonatate BIO T PRES BIO T PRES PEDIATRIC BIO T PRES-B biobron sf biocotron BIODESP DM biogil BIOGTUSS NF BIONATUSS DXP bionel BIONEL PEDIATRIC BROMFED DM brompheniramin-phenylephrindm oral liquid -5-0 mg/5 ml brompheniramine-pseudoephdm oral syrup bronchial asthma relief BRONCOTRON PED ORAL DROPS broncotron ped oral liquid BRONKIDS brotapp dm CAPCOF CAPMIST DM CAPRON DM CAPRON DMT CARBAPHEN CH CCP CAFFEINE FREE CEPACOL SORETHROAT-COUGH cheratussin ac cherry cough drops cherry menthol chest congestion relief chest congestion relief + dm chest congestion relief pe chest congestion-cough relief chest-sinus congestion relief CHILD COLD-COUGH DAY- NIGHT child mucinex chest congestion CHILD MUCINEX CONGESTION- COUGH Name CHILD MUCINEX M-S COLD DAY-NTE CHILD MUCINEX STUFFY NOSE- COLD child mucus relief cough child mucus relief expectorant child multi-symptom cold/ cough CHILD PLUS COUGH AND RUNNYNOSE CHILD TRIAMINIC MS FEVER- COLD child wal-tussin cough relief CHILD'S MUCUS RELIEF M-S COLD children's chest congestion children's cold and cough (pe) CHILDREN'S COLD-COUGH DAYTIME CHILDREN'S COLD-COUGH- SORE children's cough CHILDREN'S COUGH AND RUNNYNOSE CHILDREN'S COUGH DM ER CHILDREN'S DELSYM COUGH children's dibromm dm coldcou children's flu relief CHILDREN'S M-S COLD DAY- NIGHT CHILDREN'S MUCINEX COLD- FEVER children's mucinex cough CHILDREN'S MUCINEX MULTI- SYMP CHILDREN'S MUCINEX NIGHT TIME children's plus flu CHILDREN'S ROBITUSSIN ER children's silfedrine CHILDREN'S STUFFY NOSE- COLD CHILDREN'S SUDAFED children's sudafed pe cough 6 ECDHLP_SHBP_v_90_

7 Name CHILDREN'S SUDAFED PE NASAL childrens plus cold childrens plus multi-symp cold CHLO HIST CHLO TUSS CHLORASEPTIC TOTAL codeine-guaifenesin CODITUSSIN AC CODITUSSIN DAC cold and cough dm cold and cough elixir COLD AND FLU RELIEF(DIPHEN- PE) COLD AND FLU SEVERE cold and sinus pain relief 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 NIGHTTIME cold relief m/s day/night COLD RELIEF ORAL TABLET, EFFERVESCENT cold relief plus cold severe congestion COLD-COUGH SINUS RELIEF PE COLD-FLU M-SYMPTOM DAY- NIGHT cold-flu relief cold-flu relief, day/night cold-sinus relief CONGESTION RELIEF (IBUPROF- PE) CONTAC COLD-FLU DAY CONTAC COLD-FLU DAY AND NIGHT Name CONTAC COLD-FLU MAX STRENGTH CONTAC COLD-FLU NIGHT CORICIDIN HBP COUGH AND COLD CORICIDIN HBP DAY-NIGHT CORICIDIN HBP ORAL CAPSULE CORICIDIN HBP ORAL TABLET cough and cold (chlorphen-dm) cough and cold mucus relief cf cough and cold oral liquid COUGH AND RUNNY NOSE COUGH AND SEVERE COLD cough control (dextromethorph) cough dm er COUGH DROPS (WITH EUCALYPTUS) MUCOUS MEMBRANE LOZENGE 3. MG cough drops (with eucalyptus) mucous membrane lozenge 6.5 mg, 7 mg, 7.6 mg, 8 mg cough formula dm cough relief oral liquid cough suppressantexpectorant cough syrup cough syrup dm cough-chest congestion dm COUGH-COLD RELIEF HBP cough-sore throat night coughtab day multi-symp flu-severe cold day-time cough day-time oral capsule mg daytime daytime and nighttime cold DAYTIME AND NITETIME SINUS DAYTIME COLD AND COUGH daytime cold-flu daytime cold-flu relief (pe) DAYTIME SINUS DAYTIME-COLD NIGHTTIME- CLD-FLU ORAL LIQUID, SEQUENTIAL 7 ECDHLP_SHBP_v_90_

8 Name DAYTIME-NIGHTTIME DAYTIME-NIGHTTIME COLD-FLU DAYTIME-NIGHTTIME COUGH DECONEX DMX ORAL TABLET MG DECONEX IR ORAL TABLET MG DECOREL FORTE PLUS DELSYM HOUR delsym cough-chest congest dm DELSYM COUGH-COLD NIGHTTIME DELTUSS DMX (DEXCHLORPHEN) DESGEN DESGEN DM (PSEUDOEPHEDRINE) desgen dm oral liquid mg/5 ml DESGEN DM ORAL LIQUID MG/5 ML despec dm-g despec eda cough-cold drops despec-dm (phenyleph-dmguaif) oral liquid mg/ 5 ml DESPEC-DM (PSEUDOEPH-DM- GUAIF) ORAL TABLET MG dextromethorphan polistirex dextromethorphan-guaifenesin oral syrup dextromethorphan-guaifenesin oral tablet diabetic siltussin das-na diabetic siltussin-dm diabetic siltussin-dm max str diabetic tussin dm diabetic tussin ex DIABETIC TUSSIN NIGHT TIME dimaphen dm dimetapp dm cold-cough (pe) DIMETAPP LONG-ACTING (CPM- DM) dm max Name dometuss-dmx DONATUSSIN dristan cold DURAFLU ORAL TABLET MG DURAVENT PE ed a-hist dm oral liquid ED A-HIST DM ORAL TABLET ed bron gp endacof - dm ENTEX T EXACTUSS TR EXAPHEN CH EXAPHEX TR expectorant cough syrup expectorant oral liquid FENESIN DM IR fenesin ir fenesin pe ir FLU AND SEVERE COLD- DAYTIME flu hbp flu relief therapy daytime flu relief therapy nighttime flu severe cold-night(diph-pe) FLU-SEVERE COLD-COUGH DAYTIME FLU-SEVERE COLD-COUGH NIGHT g tussin ac g-p-tuss dxp G-SUPRESS DX g-tron g-tron ped oral drops G-TRON PED ORAL LIQUID G-TUSICOF G-ZYNCOF GENCONTUSS geri-tussin geri-tussin dm GILPHEX TR GILTUSS COUGH-COLD GILTUSS TR glenmax peb dm GLENMAX PEB DM FORTE GLENTUSS 8 ECDHLP_SHBP_v_90_

9 Name guaiasorb dm guaiatussin ac GUAICON DMS guaifenesin ac guaifenesin dac guaifenesin oral liquid guaifenesin oral tablet 00 mg guaifenesin oral tablet 400 mg guaifenesin oral tablet extended release hr,00 mg HEAD CONGESTION DAY-NIGHT HERBIOMED ALLERGY COLD- SINUS HERBIOMED SEVERE COLD-FLU M-S HISTEX DM HISTEX-AC honey lemon hot steam liquid hydrocodonechlorpheniramine hydrocodone-cpmpseudoephed hydrocodone-homatropine oral syrup 5-.5 mg/5 ml HYDROCODONE-HOMATROPINE ORAL SYRUP 5-.5 MG/5 ML (5 ML) hydrocodone-homatropine oral tablet hydromet ibuprofen cold-sinus(with pse) kidkare cough/cold LIQUITUSS GG LITTLE REMEDIES HONEY COUGH lohist-dm LORTUSS DM lortuss ex oral syrup m-clear wc M-END DMX M-END PE m-hist dm mapap cold formula mapap sinus max strength (pe) Name MAR-COF CG MAXIFED DM maxiphen MAXIPHEN DM MEDI-PHENYL medicidin-d MEDIKOFF medikoff drops menthol drops MUCINEX COLD,FLU,SORE THROAT MUCINEX COUGH MINI-MELTS mucinex d mucinex d maximum strength mucinex dm oral tablet extended release hr mg MUCINEX DM ORAL TABLET EXTENDED RELEASE HR 60-,00 MG MUCINEX FAST-MAX COLD-FLU- THRT ORAL CAPSULE MUCINEX FAST-MAX COLD-FLU- THRT ORAL LIQUID MUCINEX FAST-MAX COLD- SINUS MUCINEX FAST-MAX CONGEST- COUGH ORAL LIQUID MUCINEX FAST-MAX CONGEST- COUGH ORAL TABLET MUCINEX FAST-MAX CONGEST- HEAD MUCINEX FAST-MAX DAY-NITE CONG ORAL LIQUID, SEQUENTIAL MUCINEX FAST-MAX DAY-NITE CONG ORAL TABLETS, SEQUENTIAL 5 MG (DY)/5 MG -5 MG-35MG(NT) MUCINEX FAST-MAX DAY- NT(DOXYL) mucinex fast-max dm max MUCINEX FAST-MAX NITE COLD-FLU ORAL LIQUID MUCINEX FAST-MAX SEVERE COLD 9 ECDHLP_SHBP_v_90_

10 Name MUCINEX FST-MX DY-NT COLD(DPH) MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 00 MG MUCINEX ORAL TABLET EXTENDED RELEASE HR, 00 MG mucinex oral tablet extended release hr 600 mg MUCINEX SINUS-MAX PRESSUR-PAIN ORAL TABLET MUCINEX SINUS-MAX SEV CONGESTN mucosa mucosa dm mucus and cough relief mucus d mucus dm max er mucus relief chest MUCUS RELIEF COLD AND SINUS mucus relief cold-flu-sore thr oral liquid MUCUS RELIEF COLD-FLU- SORE THR ORAL TABLET MUCUS RELIEF CONGESTION- COUGH mucus relief cough mucus relief d (pseudoephed) oral tablet mucus relief d (pseudoephed) oral tablet extended release hr mg mucus relief dm mucus relief dm cough mucus relief dm max MUCUS RELIEF ER ORAL TABLET EXTENDED RELEASE HR,00 MG mucus relief er oral tablet extended release hr 600 mg mucus relief oral tablet 00 mg mucus relief oral tablet 400 mg mucus relief pe Name MUCUS RELIEF SEV CONGEST- COLD mucus relief severe cold oral liquid MUCUS RELIEF SEVERE COLD ORAL TABLET mucus relief sinus MUCUS RELIEF SINUSPRESSUR-PAIN MUCUS RLF SEVERE SINUS CONGEST multi-symptom cold (pe) multi-symptom cold (pe-cpm) nasal decongestant (pe) oral tablet 0 mg NASAL DECONGESTANT (PSEUDOEPH) ORAL CAPSULE (TAMPER RESISTANT) nasal decongestant (pseudoeph) oral liquid nasal decongestant (pseudoeph) oral tablet nasal decongestant (pseudoeph) oral tablet extended release neo-tuss NEOTUSS PLUS NEOTUSS-D (IMPROVED FORMULA) NEXAFED NEXAFED SINUS PRESSURE- PAIN night time cold and flu relief night time cold-flu oral capsule night time oral capsule mg nighttime cold-flu nighttime cold-flu relief nighttime cough NINJACOF NINJACOF-A NINJACOF-XG NITE TIME COLD-FLU nite time cold-flu relief oral capsule nite time-d cold-flu relief 0 ECDHLP_SHBP_v_90_

11 Name nitetime multi-symptom NIVA-HIST DM NIVANEX DMX nohist-dm non-aspirin flu oral tablet mg NON-DRYING SINUS ORAL TABLET NON-PSEUDO COLD RELIEF NOREL AD OBREDON pain relief allergy sinus PAIN RELIEF COLD AND COUGH PAIN RELIEF SINUS PE PANATUSS PED PANATUSS PED DROPS PECGEN DMX PECGEN PSE pedia relief cough-cold pedia relief infant nasal pediacare multi-symptom cold pediatric cough and cold oral liquid -5-5 mg/5 ml PHENAGIL CH POLY HIST PD POLY-HIST DM (THONZYLAMINE) POLY-TUSSIN AC ORAL LIQUID MG/5 ML POLY-VENT DM ORAL TABLET MG POLY-VENT IR ORAL TABLET MG pres gen PRES GEN PEDIATRIC PRESGEN B PRESSURE-PAIN PE PLUS COLD PRESSURE-PAIN PE PLUS MUCUS PRIMATENE ASTHMA PRO-RED AC (W/ DEXCHLORPHENIR) promethazine vc-codeine promethazine-codeine promethazine-dm Name promethazine-phenylephcodeine pseudoephedrine hcl oral liquid pseudoephedrine hcl oral tablet 30 mg pseudoephedrine hcl oral tablet 60 mg pseudoephedrine hcl oral tablet extended release pseudoephedrine-guaifenesin refenesen dm refenesen oral tablet 400 mg refenesen pe RELCOF IR RELHIST DMX RESCON-DM rescon-gg RESPA-AR RESPAIRE-30 ri-tussin ri-tussin dm robafen robafen ac robafen cf (phenylephrine) robafen cough robafen dm robafen dm cough robafen dm cough-chest congest robitussin cough and cold cf robitussin cough-chest cong dm oral capsule robitussin cough-chest cong dm oral liquid 5-00 mg/5 ml ROBITUSSIN COUGHGEL ROBITUSSIN LONG-ACTING ROBITUSSIN NIGHTTIME COUGH DM robitussin pediatric RYCONTUSS rydex rynex dm SAFE TUSSIN DM SAFETUSSIN PM SCOT-TUSSIN DIABETES CF ECDHLP_SHBP_v_90_

12 Name scot-tussin dm scot-tussin expectorant SCOT-TUSSIN SENIOR SEVERE ALLERGY-SINUS HEADACHE severe cold SEVERE COLD AND FLU (PE) SEVERE COLD AND FLU NIGHTTIME SEVERE COLD AND FLU(DAY/ NIGHT) SEVERE COLD COUGH-FLU severe cold multi-symptom SEVERE COLD PE SEVERE CONGESTION RELIEF SEVERE SINUS siltussin dm das siltussin sa siltussin-dm sinus hour SINUS AND COLD-D sinus congest-pain day-night sinus congestion and pain sinus congestion-pain(chlorph) sinus congestion-pain(guaif) SINUS DAYTIME-NIGHTIME sinus decongestant (pe) sinus headache pe sinus pain relief SINUS PAIN-PRESSURE (PE) ORAL TABLET 5-35 MG sinus pain-pressure (pe) oral tablet mg sinus pe decongestant SINUS PE PRESSURE-PAIN- COLD sinus relief (non-drowsy) SINUS RELIEF MAX STR DAY- NIGHT ORAL TABLETS, SEQUENTIAL MG(D)/ 5-5MG-35MG(N) SINUS RELIEF PRESSURE AND PAIN SINUS RELIEF SEVERE CONGESTION sorbugen nr Name SORBUTUSS SUDAFED SUDAFED HOUR SUDAFED 4 HOUR SUDAFED PE SUDAFED PE PRESSURE+PAIN+COUGH sudogest sudogest -hour sudogest pe suphedrin suphedrin hour suphedrine suphedrine hour suphedrine pe suphedrine pe sinus headache SUPRESS A SUPRESS DM supress dx SUPRESS-PE tab tussin dm TESSALON PERLES TG 0PEH-380GFN tg 0peh-380gfn-5dm THERAFLU EXPRESSMAX COLD DAY THERAFLU EXPRESSMAX COLD NIGHT ORAL TABLET THERAFLU FLU-SORE THROAT THERAFLU NIGHT SEVERE COLD-CGH throat lozenges TRIAMINIC COLD AND COUGH (PE) TRISPEC DMX ORAL LIQUID 0-87 MG/5 ML TRISPEC PSE ORAL LIQUID MG/5 ML TUSICOF tusnel c tusnel diabetic TUSNEL NEW FORMULA tusnel pediatric oral drops TUSNEL PEDIATRIC ORAL LIQUID TUSNEL-DM PEDIATRIC ECDHLP_SHBP_v_90_

13 Name tussi pres-b oral liquid mg/5 ml TUSSI PRES-B ORAL LIQUID MG/5 ML tussi-pres oral liquid TUSSI-PRES ORAL LIQUID IN PACKET TUSSI-PRES PEDIATRIC TUSSICAPS tussigon tussin tussin cf (pe-dm-guaif) tussin cf cough-cold tussin cf max tussin chest congestion tussin cough (dm only) tussin cough-chest congestion tussin dm clear tussin dm cough tussin dm cough and chest oral syrup tussin dm max oral liquid 0-00 mg/5 ml tussin dm oral liquid tussin dm oral syrup 0-00 mg/5 ml tussin dm oral tablet tussin expectorant tussin honey tussin long-acting tussin maximum strength cough tussin mucus-chest congestion TUSSIN NIGHTTIME COUGH DM TUSSIONEX PENNKINETIC ER TUSSLIN TUZISTRA XR TYLENOL COLD HEAD CONGEST SEVR VANACOF VANACOF AC VANACOF DM VANATAB AC VANATAB DM vaporizing steam Name VICKS CHILDREN'S NYQUIL COLD-C vicks dayquil cold-flu relief vicks dayquil cough VICKS DAYQUIL MUCUS CONTROL DM VICKS DAYQUIL SEVERE COLD- FLU VICKS DAYQUIL-NYQUIL VICKS DAYQUIL-NYQUIL COLD- FLU VICKS DAYQUIL-NYQUIL SEVERE VICKS DAYQUIL-NYQUIL SINEX VICKS NYQUIL COLD/FLU (CPM) vicks nyquil cold/flu liquicap VICKS NYQUIL COUGH VICKS NYQUIL NIGHTTIME RELIEF VICKS NYQUIL SEVERE COLD- FLU VICKS SINEX DAYTIME VICKS SINEX NIGHTTIME VICKS VAPOINHALER vicks vaposteam virtussin ac virtussin dac wal-dryl severe allergy-sinus WAL-FLU DAY-NIGHT COLD- COUGH wal-flu night severe cold WAL-FLU NIGHT TIME WAL-FLU SEVERE COLD AND COUGH WAL-FLU SEVERE COLD-COUGH wal-phed hour wal-phed d wal-phed oral tablet 30 mg wal-phed pe WAL-PHED PE COLD-COUGH WAL-PHED PE DAY-NIGHT wal-phed pe nighttime cold WAL-PHED PE PRESSURE+PAIN+COLD WAL-PHED PE SEVERE COLD WAL-PHED PE SINUS HEADACHE 3 ECDHLP_SHBP_v_90_

14 Name WAL-PHED PE TRIPLE RELIEF wal-profen cold-sinus wal-profen d cold and sinus wal-tap dm wal-tussin cough wal-tussin cough and cold cf wal-tussin dm wal-tussin max strength cough 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 ZODRYL DEC 5 ZODRYL DEC 30 ZODRYL DEC 35 ZODRYL DEC 40 ZODRYL DEC 50 ZODRYL DEC 60 ZODRYL DEC 80 ZYNCOF ORAL LIQUID zyncof oral tablet Vitamins, Hematinics / Electrolytes a thru z a thru z advanced formula a thru z high potency A THRU Z MEN'S ULTIMATE a thru z select 50+ formula a thru z select oral tablet, mcg A THRU Z SELECT ORAL TABLET MCG a thru z select women's ABANEU-SL abc plus Name acerola c-500 adults 50 plus animal chews animal shape vitamins animal shapes complete oral tablet,chewable antioxidant vitamins oral tablet,000 unit-00 mg-60 unit- mg APATATE apatate forte APETEX APETIGEN apetigen plus oral liquid APETIGEN PLUS ORAL TABLET AQUADEKS ORAL TABLET, CHEWABLE AQUASOL A aquasol e (d-alpha tocopherol) ascorbate calcium ascorbic acid (vitamin c) injection ascorbic acid (vitamin c) oral capsule, extended release ASCORBIC ACID (VITAMIN C) ORAL GRANULES ascorbic acid (vitamin c) oral tablet ascorbic acid (vitamin c) oral tablet extended release 500 mg ascorbic acid (vitamin c) oral tablet,chewable 500 mg ascorbic acid with rose hips ASCORBIC ACID-ASCORBATE SODIUM ORAL WAFER b complex b complex 00 injection b complex 00 oral b complex-vitamin b b complex-vitamin c-folic acid b-00 complex oral tablet extended release b- dots b-complex oral tablet 4 ECDHLP_SHBP_v_90_

15 Name b-complex with vitamin c oral capsule b-complex with vitamin c oral tablet b-complex with vitamin c oral tablet extended release balance b-00 balance b-50 balanced b-00 complex oral tablet extended release 00 mg balanced b-00 oral tablet 0.4 mg, 00 mg balanced b-50 complex balanced b-50 oral tablet bee-zee beta carotene oral capsule 0, 000 unit beta carotene oral capsule 5, 000 unit BIFERA RX bioflex biosupp biotect plus biotin oral capsule 5 mg biotin oral tablet mg, 300 mcg BIOTIN ORAL TABLET 0 MG biovol c complex c-000 oral tablet c-000 oral tablet extended release c-000 with rose hips c-500 calcidol calcium carbonate-vit d3-min oral tablet,chewable 600 mg (,500 mg)-00 unit calcium citrate plus (vit b6) calcium-magnesium-copperzinc calcium-magnesium-zinc oral tablet mg CARDIOTEK-RX (BIOPERINE) centamin Name CENTRAM-CARE centratex centravites centravites 50 plus CENTRUM MEN CENTRUM ORAL LIQUID CENTRUM ORAL TABLET, CHEWABLE CENTRUM SILVER CENTRUM SILVER MEN CENTRUM ULTRA MEN'S centrum women century adults 50 plus century cardio century mature oral tablet mg-mcg-mcg century oral tablet mgmcg CENTURY ULTIMATE MEN'S century ultimate women's oral tablet mg-mcg CEREFOLIN NAC (ALGAL OIL) cerovite advanced formula cerovite jr oral tablet,chewable cerovite senior certa plus certavite senior-antioxidant certavite-antioxidant chelated zinc chewable-vite chewable-vite with iron child's chewable vitamins/iron oral tablet,chewable child's vitamin with iron children's chewable vitamin children's iron childs chew vite childs/iron cholecalciferol (vitamin d3) oral tablet 400 unit chromium chloride cod liver oil oral capsule cod liver oil oral capsule,50-35 unit cod liver oil oral oil compete 5 ECDHLP_SHBP_v_90_

16 Name complete 50+ complete multi complete multi 50+ complete multivitamin oral tablet complete multivitamin-mineral oral tablet complete oral tablet mg-mcg-mcg-mcg complete senior oral tablet complete senior oral tablet mg-mcg-mcg complete women complex b-00 oral tablet extended release corvita corvita 50 CORVITE CORVITE FE ORAL TABLET 50 MG IRON- MG CYANOCOBALAMIN (VITAMIN B- ) ORAL LOZENGE 50 MCG CYANOCOBALAMIN (VITAMIN B- ) ORAL LOZENGE 500 MCG cyanocobalamin (vitamin b-) oral tablet,000 mcg, 00 mcg cyanocobalamin (vitamin b-) oral tablet 500 mcg cyanocobalamin (vitamin b-) oral tablet extended release, 000 mcg cyanocobalamin (vitamin b-) sublingual tablet,000 mcg cyanocobalamin (vitamin b-) sublingual tablet,500 mcg daily multi-vitamin daily multi-vitamins/iron daily multiple for men DAILY MULTIPLE FOR WOMEN daily multiple for women 50+ daily multiple oral tablet, mg-mcg daily multiple vitamins/iron daily multivitamin with iron daily multivitamin-minerals daily value Name daily vitamin formula daily vitamin formula-iron daily vitamin formula-minerals daily vitamin with iron daily vitamin with iron and ca daily vites/iron daily-vite delta d3 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 duofer ear care ear health formula oral tablet ear health formula oral tablet mg eldertonic endur-c with rose hips ergocalciferol (vitamin d) oral capsule ergocalciferol (vitamin d) oral drops essentia essential daily ESSENTIAL MAN ESSENTIAL MAN 50+ ESSENTIAL WOMAN 50+ ESTER-C WITH BIOFLAVONOIDS EXTRA-VIRT PLUS DHA eye health plus lutein ezfe 00 FA-8 fabb fe c FEOSOL BIFERA feosol oral tablet 35 mg (65 mg iron) FERAHEME 6 ECDHLP_SHBP_v_90_

17 Name ferate oral tablet 40 mg (7 mg iron) ferocon ferosul oral elixir ferosul oral tablet FERRALET 90 DUAL-IRON DELIVERY ferretts FERRETTS IPS ferrex 50 ferrex 50 forte ferrex 50 forte plus ferrex 50 plus ferric x-50 ferro-time ferrocite ferrocite plus ferrous fumarate oral tablet 34 mg (06 mg iron) ferrous gluconate oral tablet 40 mg (7 mg iron), 34 mg (38 mg iron) ferrous sulfate oral drops ferrous sulfate oral elixir ferrous sulfate oral liquid ferrous sulfate oral solution ferrous sulfate oral tablet 35 mg (65 mg iron) ferrous sulfate oral tablet, delayed release (dr/ec) 35 mg (65 mg iron) ferrousul FLEXGEN FLINTSTONES COMPLETE (IRON) ORAL TABLET, CHEWABLE folbee folbee plus oral tablet mg folbic FOLGARD OS FOLGARD RX folic acid injection FOLIC ACID ORAL CAPSULE 0.8 MG folic acid oral tablet Name folic acid-vit b6-vit b oral tablet mg folitab folivane-f folivane-plus folplex. foltabs 800 foltanx foltanx rf FOLTRATE fosfree fruit c-500 full spectrum b-vitamin c GALZIN geriaton GERITOL COMPLETE GERITOL TONIC WITH FERREX 8 gummi bear multivitamin hair vitamins hair,skin and nails oral tablet HAIR,SKIN AND NAILS(FA- BIOTIN) healthy eyes hematinic plus vit/minerals hematinic/folic acid hematogen hematogen fa hematogen forte HEMATRON-AF hemetab high potency iron oral tablet 34 mg (7 mg iron) honey bears honey bears with iron-zinc hydroxocobalamin i-vite i-vite protect I.L.X. B- ICAPS ICAR ORAL SUSPENSION iferex 50 iferex 50 forte infed INFUVITE ADULT INFUVITE PEDIATRIC 7 ECDHLP_SHBP_v_90_

18 Name INTEGRA INTEGRA F INTEGRA PLUS iron (dried) iron (ferrous sulfate) iron chews iron high potency iron oral tablet 35 mg (65 mg iron) iron, carbonyl iron,carbonyl-vitamin c IROSPAN 4/6 kobee l-methyl-b6-b l-methyl-mc l-methyl-mc nac little animals little animals-iron oral tablet, chewable lmefol ca-acetyl-meb-algal lugols oral lumitene lysiplex plus oral liquid m.v.i. adult M.V.I. PEDIATRIC mag 64 mag-delay MAGNESIUM CHLORIDE ORAL TABLET,DELAYED RELEASE (DR/EC) 64 MG manganese chloride manganese sulfate mega multiple/chelated mineral men's daily multivit-mineral men's multi-vitamin men's one daily oral tablet MERIBIN metafolbic metafolbic plus metafolbic plus rf METANX (ALGAL OIL) milltrium senior MTX SUPPORT multi complete with iron multi-day with iron Name multi-delyn with iron multigen multigen folic multilex multilex-t and m multiple vitamin-minerals multiple vitamins MULTITRACE-4 MULTITRACE-4 CONCENTRATE MULTITRACE-4 NEONATAL multitrace-4 pediatric MULTITRACE-5 MULTITRACE-5 CONCENTRATE multivitamin 50 plus multivitamin oral tablet multivitamin with iron multivitamin with minerals oral liquid multivitamin with minerals oral tablet MVW COMPLETE FORMUL MULTIVIT ORAL TABLET, CHEWABLE MVW COMPLETE FORMULATION D3000 ORAL TABLET, CHEWABLE myferon 50 myferon 50 forte mynephrocaps mynephron NASCOBAL natural b-00 complex nephplex rx nephro-vite rx NEPHRON FA nephronex NEURIN-SL niacin (inositol niacinate) oral capsule 400 mg niacin (500 mg) niacin flush free oral capsule 400 mg niacin (500 mg) NIACIN NO FLUSH norwegian cod liver oil NUTRIVIT ocutabs 8 ECDHLP_SHBP_v_90_

19 Name OCUVITE WITH LUTEIN omnicap once daily one daily calcium/iron one daily complete one daily energy oral tablet one daily essential oral tablet, 0.4 mg one daily for men one daily for men 50+ advanced one daily for women one daily maximum one daily men's 50 plus memory one daily multi-vit w-mineral one daily multivit-iron(folic) one daily multivitamin oral tablet one daily oral tablet, mg-mcg one daily plus iron oral tablet mg-mcg one daily plus minerals one daily with iron one daily women's one daily women's health one daily womens 50 plus ONE-A-DAY CHOLESTEROL PLUS one-a-day essential one-a-day maximum formula one-a-day teen advantage ONE-A-DAY WOMENS FORMULA ORAL TABLET 8 MG IRON-400 MCG-500 MG CA opti-vitamins ORAZINC ORAL TABLET PERFECT IRON PERIDIN-C phlexy-vits pnv-ferrous fumarate-docu-fa poly-iron poly-iron 50 forte poly-vitamins polyvitamin with iron Name POTABA ORAL CAPSULE prenatabs fa PRO FE PROFERRIN ES PROFERRIN-FORTE PROTECT IRON purevit dualfe plus pyridoxine (vitamin b6) injection pyridoxine (vitamin b6) oral tablet 00 mg, 5 mg quintabs-m iron free rena-vite rena-vite rx renal caps reno caps riboflavin (vitamin b) oral tablet 00 mg, 50 mg SCOOBY-DOO ONE A DAY se-tan plus selenium intravenous selenium oral tablet 00 mcg selenium oral tablet 00 mcg selenomax senior tabs sentry sentry (with lutein) sentry senior SLOW FE slow release iron oral tablet extended release 4 mg (45 mg iron), 60 mg (50 mg iron), 50 mg (50 mg iron) soothing pureway-c spectravite adult 50+ oral tablet spectravite advanced formula oral tablet mg-mcg spectravite men's spectravite senior SPECTRAVITE ULTRA MEN 50+ SPECTRAVITE ULTRA MEN'S SR spectravite ultra women strawberry c stress b plus zinc stress b with zinc 9 ECDHLP_SHBP_v_90_

20 Name stress formula stress formula 600 c stress formula plus iron stress formula with iron stress formula with iron(sulf) stress formula with zinc strong iodine oral super b complex-vitamin c super b maxi complex super b-50 complex super b-50 complex plus super b/c super multiple oral tablet super multivitamin super quints super quints b-50 super thera vite m superplex-t SUPERVITE support SUPPORT-500 tab-a-vite tab-a-vite-minerals tab-a-vite/iron TANDEM DUAL ACTION TANDEM PLUS taron forte thera m plus (ferrous fumarat) thera oral tablet thera oral tablet 400 mcg thera-m oral tablet, mg thera-m oral tablet 9 mg iron- 400 mcg thera-tabs thera-tabs m theralogix companion therapeutic liquid therapeutic-m oral tablet 9 mg iron-400 mcg therapeutic-m vitamin/ minerals theratrum complete 50 plus/ lut theratrum complete with lutein therems therems-m Name thiamine hcl (vitamin b) injection thiamine hcl (vitamin b) oral tablet 00 mg, 50 mg, 50 mg thiamine mononitrate (vit b) tl g-fol os tl gard rx tl icon total b/c TRACE ELEMENTS 4/PEDIATRIC tricon trigels-f forte triphrocaps TROMBONEX tyr cooler oral liquid UDAMIN SP ULTIMATE MEN'S COMPLETE 50+ ultra b-00 complex oral tablet unicomplex-m VASOFLEX FORTE VASOFLEX HD VASOFLEX ORAL TABLET VENOFER INTRAVENOUS SOLUTION 00 MG IRON/5 ML, 00 MG IRON/0 ML VENOFER INTRAVENOUS SOLUTION 50 MG IRON/.5 ML virt-gard virt-vite vision formula (with lutein) vit 3 vit a and d3 in cod liver oil vit b complex-folic acid oral tablet VITA-BEE WITH C vitacel (with lutein) VITAFOL VITAL-D RX vitalee vitalets oral tablet,chewable vitamin a oral capsule 0,000 unit vitamin a oral capsule 8,000 unit 0 ECDHLP_SHBP_v_90_

21 Name vitamin a palmitate oral capsule vitamin b complex oral capsule vitamin b complex oral tablet 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- sublingual tablet,500 mcg vitamin b- vitamin b-6 oral tablet 00 mg, 5 mg vitamin c oral capsule, extended release vitamin c oral tablet,000 mg, 50 mg, 500 mg vitamin c oral tablet 00 mg vitamin c oral tablet extended release vitamin c oral tablet,chewable 500 mg vitamin c with rose hips oral tablet vitamin c with rose hips oral tablet extended release VITAMIN C WITH ROSE HIPS ORAL TABLET,CHEWABLE vitamin d vitamin d3 oral tablet 400 unit vitamin e (dl, acetate) oral capsule 00 unit vitamin e oral capsule 00 unit, 600 unit VITAMIN E ORAL DROPS 00 UNIT/0.5 ML vitamin e oral drops 50 unit/ ml vitamins and minerals Name vitamins b complex oral capsule vitamins b complex oral tablet VITAMINS B COMPLEX ORAL TABLET 500 MG-400 MCG- 8 MG IRON vitatrum vitrum senior oral tablet vol-care rx vp-vite rx vp-zel WAL-FLU COLD AND SORE THROAT wee care WOMEN'S DAILY CAPLET women's daily formula oral tablet 8 mg iron-400 mcg-500 mg ca, mg WOMEN'S ONE DAILY yelets zinc zinc chloride zinc gluconate oral tablet 00 mg zinc gluconate oral tablet 30 mg, 50 mg zinc sulfate intravenous solution 5 mg/ml zinc sulfate oral capsule zinc sulfate oral tablet ZINC-5 zinc-0 zoo chews ECDHLP_SHBP_v_90_

22 It s important we treat you fairly That s why we follow Federal civil rights laws in our health programs and activities. We don t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn t English, we offer free language assistance services through interpreters. Interested in these services? Call Member Services for help (TTY: 7). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, 436 Irwin Simpson Rd, Mailstop: OH005-A537; Mason, Ohio Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 00 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 00 or by calling (TTY: ) or online at Complaint forms are available at Get help in your language Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the Member Services number on the back of your ID card. English: You have the right to get this information and help in your language for free. Call the Member Services number on your ID card for help. (TTY: 7) ECDHLP_SHBP_v_90_

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28 Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. and Anthem Insurance Companies, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ECDHLP_SHBP_v_90_