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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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