2021 Extra Covered Drugs - Shawhankinsbenefits
2021Extra Covered DrugsThe prescription drugs in this list are covered above and beyond the drugs in yourplan's Part D Formulary.Y0114 21 121337 I C 203 07/09/2020507735MUSENMUB 203 ABS HLPECDHLP v2 2101 1
This booklet lists the “Extra Covered Drugs” included in your plan.“Extra Covered Drugs” 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 forlower Part D catastrophic copays.This list may change at any time. You will receive notice when necessary. For the full list of your coveredPart D drugs, please refer to your Formulary booklet online at www.anthem.com, or call the PharmacyMember Services number listed on your membership card.Your plan includes cough and cold medications, vitamins and minerals, and Erectile Dysfunction (ED)drugs that are not normally covered under a Part D plan.How do "Extra Covered Drugs" fit into your plan's prescription drug benefits?Like your covered Part D drugs, the cost you pay for “Extra Covered Drugs” is based on the assigned tier foreach drug. You can find the tier number next to the drug name in the chart below. You can find the cost foreach drug tier by checking the benefit chart in your Evidence of Coverage online at www.anthem.com, orcall the Pharmacy Member Services number listed on your membership card.If you are receiving Medicare's “Extra Help” to pay for your prescriptions, this program will not lower yourcost for these drugs.Below you will find an example of how to read the list of “Extra Covered Drugs.”2ECDHLP v2 2101 1
We're here to answer your questions.Please call Pharmacy Member Services at the number listed on your membership card if you have anyquestions about this benefit.3ECDHLP v2 2101 1
List of Extra Covered DrugsLegendGeneric drugs are shown in lowercase italics.Brand-name drugs are shown in capital letters.QLL - Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtainbenefits each time you get a prescription filled. This is most often set on a monthly basis.MO - Mail Order: Prescription drugs available through mail order.Drug NameDrugTierRequirements/LimitsAnalgesicsaspirin chew tab 81 mgaspirin tab 81 mgaspirin tab delayed release 81mghydrocod polst-cpm polst er oralsuspension extended 11MOMO11Blood Products/ Modifiers/ VolumeExpandersMONSELS FERRICSUBSULFATE EXTERNAL2Cardiovascular Agentseql niacin flush freeisoxsuprine hcl oral tablet10 mgisoxsuprine hcl oral tablet20 mgniacin flush free oral capsule500mgnitro-timenitroglycerin er1111MOMO11MOMOMOCentral Nervous System AgentsADIPEX-P ORAL TABLETphentermine hcl oral tabletDrugTierRequirements/LimitsDental And Oral AgentsAntineoplasticsteo-tustotalday multipleDrug Name21MOMOCEPACOL SORE THROAT& COUGHCEPACOL SORE THROATMOUTH/THROATLOZENGE 5.4 MGcepastat mouth/throatlozenge5-6-10 mgcherry cough drops mouth/throatlozenge6.1 mgchloraseptic totalcough drops mentholCOUGH DROPSMOUTH/THROATLOZENGE 2.7 MGcough drops mouth/throatlozenge10 mg, 3.1 mg, 5 mg,5.4 mg, 5.8 mg, 6.5 mg, 7 mg,7.5 mg, 7.6 mg, 8 mg, 8.4 mgcvs cherry menthol dropscvs cough drops sugar freecvs honey lemon dropscvs menthol dropsCVS SORE THROATRELIEF POPSDENTIVADIABETIC TUSSINCOUGH DROPSeq cough sugar free2211112111112221You can find information on what the abbreviations on this table mean by going to the beginning of this table.4ECDHLP v2 2101 1
Drug Nameeql cough dropseql sore throat & coughgnp cough drops mouth/throatlozenge6.5 mg, 7 mggnp herbalgnp natural herbgnp throat drops mouth/throatlozenge2.8 mglarynexLUDENS THROAT DROPSMOUTH/THROATLOZENGE 2.8 MGmedikoff drops mouth/throatlozenge7.6 mgmenthol cough dropsmouth/throat lozenge5 mgnatural herb cough dropsmouth/throat lozenge3 mgnycoffqc sore throatra cough drops mouth/throatlozenge10 mg, 5 mg, 5.8 mg,6.5 mg, 7 mg, 9.1 mgricola mountain herbricola natural herbSALESEsm cough drops mouth/throatlozenge10 mg, 3.1 mg, 5 mg,5.8 mg, 6.5 mg, 7 mg, 8 mgsm natural herb cough dropssore throat & cough lozengesSUCRETS SORE THROATtgt cough drops mouth/throatlozenge7 mgtgt throat dropsthroat discsVICKS VAPODROPSZINC 11211122Dermatological Agentsacne foaming washALA-QUIN12MOMODrug NameALCORTIN ABENZAC AC WASHEXTERNAL LIQUIDbenzoyl peroxide wash externalliquidbimatoprost externalblanchebp 10-1bp wash external liquid10 %, 5%CORTANE-B EXTERNALcvs acne foaming face washcvs advanced 3-in-1 cleansercvs foaming acne face washdermazeneEPIQUIN MICROfinasteride oral tablet1 mggordons urea external creamHYDRO 40hydrocortisone ace-pramoxineexternal cream2.5-1 %hydrocortisone-iodoquinolexternal cream1-1 %hydroquinone external creamhydroquinone time releaseiodine strong (lugol's)iodoquinol-hc-aloe polysacchkp benzoyl peroxide washexternal liquid5 %LATISSEmelpaque hpOVACE PLUS WASHEXTERNAL LIQUIDOVACE WASHpanoxyl foaming washPRAMOSONE EXTERNALCREAMPRAMOSONE EXTERNALOINTMENTPROPECIADrug RequirementsTier /Limits2 MOMOMO212MOMOMO212MOMOMO2MO2MOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.5ECDHLP v2 2101 1
Drug NameQUINJArefissaremergent hqRENOVARENOVA PUMPsalicylic acid external foamsalicylic acid-cleanser externalkit6 % (cream)SALVAXsodium sulfacetamide washsulfacetamide sodium externalliquidsulfamez washtl hydroquinonetretinoin (emollient)TRI-LUMAumecta mousseurea external cream40 lytes/Minerals/Metals/Vitamins50 adult eye healtha&da thru z advanceda thru z advanced adulta thru z advantagea thru z high potencya thru z select 50 advanceda thru z select 50 mensa thru z select advanceda thru z select oral tableta thru z select oral tabletchewablea thru z select ultimate womena thru z ultimate 112MOMOMOMOMOMOMOMODrug RequirementsTier /Limitsabatron af1 MOABC COMPLETE SENIOR2 MOWOMENS 50 abc plus1 MOabc plus senior1 MOabc plus senior adults 50 1 MOACEROLA C 5002actical1 MOACTIFLOVIT EAR2HEALTHACTITROM2ACTITROM-D2activite1 MOACTIVNUTRIENTS2 MOADRENAL C FORMULA2ADRENAL STRESS CALM2 MOADRENOID2adult gummy1ADULT ONE DAILY2 MOGUMMIESADVANCED C PLUS2ADVANCED2 MOCALCIUM/D/MAGNESIUMADVANCED COLLAGEN2 MOADVANCED DIABETIC2 MOMULTIVITAMINadvanced eye health oral capsule1 MOadvanced multi ea1advanced stress formula/zinc1 MOairavite1 MOairborne gummies1airborne oral tablet chewable1ALIVE ENERGY 50 2 MOalive gummies for children1ALIVE MENS ENERGY2 MOALIVE ONCE DAILY2 MOWOMENSALIVE ONCE DAILY2 MOWOMENS 50 Drug NameYou can find information on what the abbreviations on this table mean by going to the beginning of this table.6ECDHLP v2 2101 1
Drug NameALIVE WOMENS 50 ORAL TABLETALIVE WOMENS ENERGYALIVE WOMENS GUMMYallbee/cALLERWELL ALLERGYFORMULAamoryn mood boosteranimal chews oral tabletchewableanimal shapesANIMAL SHAPES/IRONanti-allergyanti-oxidantanti-oxidant formulaantioxidant a/c/e/seleniumantioxidant formula oral tabletantioxidant formula/mineralsantioxidant oral capsuleantioxidant protection formulaantioxidant vitaminsantioxin 4000APETEXAPETIGENAPETIGEN-PLUSAQUADEKS ORALTABLET CHEWABLEaqueous vitamin ORascorbic acid injectionASCORBIC ACID ORALPOWDERascorbic acid oral tabletb completeb complexDrug RequirementsTier /Limits2 MO111MOMOMOMOMOMOMOMOMOMOMOMOMOMODrug Nameb complex 100 trb complex formula 1b complex plusb complex vitamins oralb complex-b12b complex-biotin-fab complex-c oral capsuleb complex-c oral tabletBCOMPLEX-C-BIOTIN-E-FAb complex-c-folic acidb complex-vitamin cb-1 high potencyb-1 oral tablet100 mgb-1 oral tablet250 mgb-100b-100 b-complexb-100 complex crb-100 complex oral tabletb-100 crb-100 trB-12 DOTSb-12 microlozengeB-12 ORAL TABLET 2000MCGb-12 oral tablet extendedrelease1000 mcgb-12 oral tablet100 mcg, 1000mcg, 250 mcg, 500 mcgb-12 oral tablet50 mcgb-12 sublingual tabletsublingual1000 mcg, 2500 mcgb-12 sublingual tabletsublingual500 mcgb-12 tr oral tablet extendedrelease1000 mcgb-12 tr oral tablet extendedrelease2000 mcgb-12-slb-2 oral tablet100 11111111111212MO1MO1MO11MOMOMOMOMOMO11MO111MOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.7ECDHLP v2 2101 1
Drug Nameb-2 oral tablet50 mgb-50b-50 complex oral tabletextended releaseb-6 oral tablet100 mgb-caro-tb-compleet-100b-compleet-50b-complex balancedB-COMPLEX INJECTIONb-complex oral tabletb-complex-c oral tabletb-complex/b-12 oralb-complex/vitamin cb-plexb-plex plusb-redi/red hearts/red roostersb-stressb2b50 complex trb6 naturalBACMINbalance b-100balance b-50balanced b complexbalanced b complex crbalanced b-100 complex crbalanced b-100 oral tabletbalanced b-100 oral tabletextended releasebalanced b-50 complex oralcapsulebalanced b-50 complex oraltabletbalanced b-50 oral tabletBARIATRIC FUSIONBARIATRICMULTIVITAMINS/IRONBASIC AMDrug RequirementsTier /Limits11 MOMOMOMOMOMOMO11MO122MOMOMO2MODrug NameBASIC PMbec/zincbenfotiamine multi-bBETA CAROTENE ORALCAPSULE 10000 UNITbeta carotene oral capsule25000unitbeta carotene provitamin abetter b complexBIFERAbig 100BILBERRY PLUSBIO-35 GLUTEN-FREEBIO-35 IRON FREEBIOCALbiocelbioflexbiotin 5000biotin maximum strength oralcapsulebiotin maximum strength oraltabletbiotin oral capsule5 mg, 5000mcgbiotin oral tablet10 mg, 10000mcgbiotin oral tablet1000 mcg, 300mcgBIOTIN PLUS KERATINbiotin plus/calcium/vit ONE DENSITY BUILDERbounty bears/cBP VIT 3bprotected multi-vitebprotected pedia ironbprotected pedia poly-vitebprotected pedia poly-vite/feDrug RequirementsTier /Limits2 MO1 112121111MOMOMOMOMOMOMOMOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.8ECDHLP v2 2101 1
Drug Namebprotected vitamin cBRAIN MIGHT/DHA &CO Q10BURIED TREASUREACTIVE 55 PLUSc&ec 1000C1000-BIOFLAVONOIDSROSE HIPSc 250 oral tabletc 500c 500/rose hipsc complexc-1000 oral tabletc-1000 oral tablet extendedreleasec-1000 src-1000/rose hipsc-1000/rose hips src-250 oral tabletc-500 non-acidc-500 oral tabletc-500 oral tablet chewablec-500 oral tablet extendedreleasec-500 sr oral capsule extendedreleasec-500 sr oral tablet extendedreleasec-500/rose hipsC-BUFFc-chewable oral tabletchewable500 mgC-PLEXc-timec1000 tr/rose hip/bioflavonoidc1500 tr/rose hip/bioflavonoidoral tablet extendedrelease1500-50-50 mgDrug RequirementsTier /Limits12 111MOMOMODrug Namec1500/rose hips/bioflavonoidCAL MAG ZINC D3cal-citrate plus vitamin dCAL-CO3YCAL-DAY 1000CAL-MAG-ZINC-DCALCET CREAMY BITESCALCITRATE ORALTABLET 315-250MG-UNITcalcitrate plus dcalcium d oral tablet315-200mg-unitcalcium d3 oraltablet600-200 mg-unitcalcium d3 oraltablet600-800 mg-unitcalcium 1000 dcalcium 1200calcium 500 d3 oral tabletcalcium 500 dcalcium 500 d high potencycalcium 500 d3calcium 500/dcalcium 500/vitamin dcalcium 600 dcalcium 600 mineralscalcium 600 d high potencycalcium 600 d oraltablet600-200 mg-unit,600-400 mg-unitcalcium 600 d oraltablet600-800 mg-unitcalcium 600 d plus mineralscalcium 600 d3 oraltablet600-200 mg-unit,600-400 mg-unitcalcium 600 d3 oraltablet600-800 mg-unitcalcium 600 d3 plus OMO2MO11MOMO2MO2MOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.9ECDHLP v2 2101 1
DrugTiercalcium 600-d1calcium 600/vitamin d1calcium 600/vitamin d32calcium ascorbate oral1calcium carb-cholecalciferol oral1tablet chewablecalcium carbonate-vitamin d1oral capsulecalcium carbonate-vitamin d1oral tablet500-400 mg-unit,600-400 mg-unitcalcium carbonate-vitamin d31calcium citrate d oral1tablet250-200 mg-unit,315-200 mg-unit, 315-250mg-unitcalcium citrate d31calcium citrate d3 maximum1calcium citrate oral tablet1calcium citrate oral1tablet315-200 mg-unitcalcium citrate d1calcium citrate chewy bite1calcium citrate plus1calcium citrate plus/magnesium1calcium citrate d31calcium citrate d3 petites1calcium citrate-mag-minerals1calcium citrate-vitamin d oral2tablet200-125 mg-unit, 250-50mg-unitcalcium citrate-vitamin d oral1tablet315-200 mg-unit,315-250 mg-unitcalcium citrate-vitamin d3 oral1tabletcalcium creamies1calcium extra d31calcium gummies1calcium high potency/vitamin d1Drug OMOMOMOMOMOMOMOMODrug Namecalcium oral tabletchewable500-100 mg-unitcalcium oral tabletchewable600-400 mg-unitcalcium oral tablet500-125mg-unitcalcium oral tablet600-200mg-unitcalcium plus d3 absorbablecalcium plus vitamin d oralcapsulecalcium plus vitamin d oraltabletcalcium plus vitamin d3 oralcapsulecalcium plus vitamin d3 oraltabletcalcium d3 oral tablet500-10mg-mcg, 500-15 mg-mcgcalcium d3 oral tablet600-20mg-mcg, 600-800 mg-unitcalcium-magnesium-zinc oraltablet , 333-133-5 mg,333.33-133.33-5 in dcalcium-vitamin d oraltablet500-125 mg-unit,600-200 mg-unitcalcium-vitamin d oraltablet500-200 mg-unit,500-400 mg-unit, 600-125mg-unit, 600-400 mg-unitcalcium-vitamin d-mineralsoral tablet chewable600-400mg-unitcalcium-vitamin d3 oralcapsule600-400 mg-unitcalcium-vitamin d3 oralcapsule600-500 mg-unitDrug RequirementsTier /Limits1 O1MOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.10ECDHLP v2 2101 1
Drug Namecalcium-vitamin d3 oraltablet250-125 mg-unit,500-400 mg-unit, 600-125mg-unit, 600-400 mg-unitcalcium/d3 adult gummiescalcium/vitamin dcalcium/vitamin d3/adultgummyCALTRATE 600 D PLUSMINERALSCALTRATE 600 D3CALTRATE 600 D3 SOFTCALTRATE MINIS PLUSMINERALSCARDIO TONECARDIOPRESScaroguardcarraviteCELEBRATE CALCIUMCITRATECELEBRATE CALCIUMPLUS 500CELEBRATEMULTI-COMPLETE 18CELEBRATEMULTI-COMPLETE 36CELEBRATEMULTI-COMPLETE 45CELEBRATEMULTI-COMPLETE 60CELLULAR SECURITYcentamincentavitecentavite a-z complete-mineralCENTRATEXcentravitesCENTRAVITES ADULTSCENTRUM ADULTSCENTRUM CARDIOCENTRUM FLAVORBURSTDrug RequirementsTier /Limits1 12222MOMOMOMOMOMOMOMOMOMODrug NameCENTRUM FLAVORBURST ADULTCENTRUM FLAVORBURST KIDSCENTRUM MENCENTRUM ORAL LIQUIDCENTRUM ORAL TABLETCHEWABLECENTRUMPERFORMANCECENTRUM SILVERCENTRUM SILVER50 MENCENTRUM SILVER50 WOMENCENTRUM SILVERADULT 50 CENTRUM SILVERULTRA WOMENSCENTRUM SPECIALISTENERGYCENTRUM SPECIALISTHEARTCENTRUM SPECIALISTIMMUNECENTRUM SPECIALISTVISIONCENTRUM ULTRAWOMENSCENTRUM VITAMINTSCENTRUM WOMENcenturycentury matureCEREFOLINCEREFOLIN NAC ORALTABLET 6-90.314-2-600MGcerovite advanced formula oraltabletcerovite seniorcerta pluscertagen oral tabletDrug RequirementsTier /Limits2 122MOMOMOMOMOMO1MO111MOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.11ECDHLP v2 2101 1
Drug nts oral tabletchelated zinc oralchew-cchewable vite childrenschild chewable vitamins/ironchildrens chewable multi vitschildrens chewable vitaminschildrens gummieschildrens multivitamin oraltablet chewablechildrens multivitamin/ironchildrens vitamins/ironCHOICEFULMULTIVITAMINCHOLASE CONTROLchromagen oral capsulechromic chloride intravenouschromium gtfchromium oral tablet200 mcgCHROMIUMPICOLINATE ORALCAPSULE 200 MCGchromium picolinate oraltablet200 mcgCITRACAL D3CITRACAL CALCIUMGUMMIESCITRACAL MAXIMUMCITRACALPETITES/VITAMIN DCITRACAL PLUScitrus calcium/vitamin d oraltablet200-250 mg-unitclassic prenatalCLINICAL NUTRIENTS45-PLUS WMNCLINICAL NUTRIENTS50-PLUS MENDrug RequirementsTier /Limits2 OMO22MOMO21MOMO22MOMO2MODrug NameCLINICAL NUTRIENTSANTIOXIDANTCLINICAL NUTRIENTSFEMALE TEENCLINICAL NUTRIENTSFOR MENCLINICAL NUTRIENTSFOR WOMENCLINICAL NUTRIENTSMALE TEENCO-NATAL FACOD LIVER OIL FORKIDScod liver oil oral capsule , 10minim, 1000 mg, 1250-130unit, 1250-133 unit,1250-133.33 unit, 1250-135unit, 4000-200 unitCOD LIVER OIL ORALOILcod liver oil w/vit a & dcod liver oil/low vitamin acod liver oil/vitamins a & dCOLAMINECOLLAGEN ULTRAcompanioncompetecompletecomplete daily/luteincomplete energycomplete multi-vitamincomplete multivitamin/mineralcomplete pms support complexcomplete seniorcomplete womenscomplex b-100complex b-50 prolonged releasecoral calcium plus oral capsulecorvitacorvita 150Drug RequirementsTier /Limits2 MOMOMOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.12ECDHLP v2 2101 1
Drug NameCORVITE 150 ORALTABLETCORVITE 150 ORALTABLET 150-1.25 MGCORVITE FEcranberry urinary comfortCVS AIRSHIELDIMMUNITY SUPPORTcvs b complex plus ccvs b-1cvs b-12 oral tabletcvs b6cvs balanced b50cvs beta carotene oral capsule15mgcvs biotin high potencycvs biotin oral capsule5000 mcgcvs calcium 600 & vitamin d3cvs calcium 600 d/mineralsoral tablet600-800 mg-unitcvs calcium 600 d oraltablet600-800 mg-unitcvs calcium citrate d3cvs calcium citrate d3 petitescvs calcium-magnesium-zinccvs daily gummiescvs daily multiple for mencvs daily multiple women 50 cvs eye health & luteincvs folic acid oral tablet800 mcgcvs gummy dinoscvs gummy multivitamin kidscvs inner ear pluscvs iron oral tablet240 (27 fe)mg, 325 (65 fe) mgcvs menopause supportcvs mens daily gummiescvs niacin flush freecvs one daily essentialDrug RequirementsTier /Limits2 11111MOMO1111MOMOMOMOMOMOMODrug NameCVS ONE DAILY MENS50 ADVcvs one daily womens formulacvs oyster shell calcium-vit d oraltablet500-125 mg-unitcvs prenatal oral tablet27-0.8mgcvs selenium oral tablet200 mcgCVS SPECTRAVITEADULT 50 cvs spectravite advanced oraltabletcvs spectravite seniorCVS SPECTRAVITEULTRA MEN 50 CVS SPECTRAVITEULTRA WOMENcvs spectravite womens seniorcvs stress formula/zinccvs super b complex/ccvs vitamin b-12 oral tabletextended releasecvs vitamin b-12 oraltablet1000 mcgcvs vitamin b-2cvs vitamin b12cvs vitamin c oral tabletcvs vitamin c-rose hipscvs womens active dailycvs womens daily gummiescvs zinc oralcyanocobalamin sublinguald 400 oral capsuled 400 oral tabletd-400d-natural-5d3 high potency oral tabletdaily beticdaily combo multi vitaminsDrug RequirementsTier /Limits2 11111MOMOMOMOMOMOMOMOMOMOMOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.13ECDHLP v2 2101 1
Drug NameDAILY ENERGYENFUSIONdaily mens health formuladaily multidaily multi 50 daily multiple vitaminsdaily multiple vitamins/irondaily multiple vitamins/mindaily multivitamindaily value multivitamindaily vitamin formula irondaily vitamin formula mineralsdaily vitamin oral tabletdaily vitamin plusdaily vitamins oral tabletdaily vitedaily vite multivitamin/irondaily vitesdaily womens health formuladaily-vitamindaily-vitamin ITEDEKAS BARIATRICDEKAS PLUS ORALCAPSULEDEKAS PLUS ORALTABLET CHEWABLEdelta d3DERMAVITEdiabetes health formuladialyviteDIALYVITE 3000DIALYVITE 5000dialyvite 800 oral tabletDIALYVITE 800-ZINC 15ORAL TABLET 0.8 MO2MO12112212MOMOMOMOMOMOMOMODrug NameDIALYVITE 800/IRONORAL TABLET 29-0.8 MGdialyvite 800/ultra dDIALYVITE 800/ZINCDIALYVITE SUPREME DDIALYVITE/ZINCdino-lifedino-life w/extra cDINO-LIFE W/IRON-ZINCdisney cars gummiesdisney princess gummiesdoctors choice menDRISDOL ORAL CAPSULEdry eye formulae-oil orale600ear health formulaear health pluseasy-cecee pluseldertonic oral liquidELON MATRIX 5000ELON MATRIX 5000COMPLETEELON MATRIXCOMPLETEELON MATRIX PLUSELON R3EMERGEN-C IMMUNEPLUS/VIT DEMERGEN-C VITAMIN CORAL R-VM WITH IRONeq calcium 500 OMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.14ECDHLP v2 2101 1
Drug Nameeq calcium 600 d oraltablet600-800 mg-uniteq calcium 600 d mineralseq calcium citrate deq calcium citrate d3eq calcium citrate d3 petiteseq complete multivit adult 50 EQ COMPLETEMULTIVITAMIN-ADULTeq multivitamin gummiesEQ MULTIVITAMINSADULT GUMMYeq multivitamins gummy childEQ ONE DAILY MENS 50 EQ ONE DAILY MENSHEALTHEQ ONE DAILY WOMENS50 eq one daily womens pro-activeeq slow-release ironeq vision formula 50 eql b complex 50 oral tableteql b-100 complexeql b-12 oral tableteql b-6eql biotineql calcium citrate/vitamin deql calcium citrate/vitamin d3eql calcium/vitamin d oralcapsuleeql calcium/vitamin d oraltableteql calcium/vitamin d3eql carbonyl ironeql centuryeql century matureEQL CENTURY MATUREADULTS 50 eql century mature men 50 eql century mature women 50 Drug RequirementsTier /Limits2 OMO1MO21112MO11MOMOMOMOMOMOMOMOMOMOMODrug RequirementsTier /LimitsEQL CENTURY MENS2 MOEQL CENTURY WOMENS2 MOeql gummies childrens oral1tablet chewableeql iron supplement therapy oral1 MOtablet325 mgeql natural zinc1 MOEQL ONE DAILY ADULT2 MOGUMMIESEQL ONE DAILY MENS2 MOeql one daily mens 50 advance1 MOeql one daily mens health1 MOeql one daily womens1eql one daily womens 50 adv1 MOeql prenatal formula2 MOeql slow release iron1eql stress b-complex c/zinc1 MOeql super b complex/vitamin c1 MOeql vision formula1 MOeql vitamin b-121 MOeql vitamin b-12 tr1 MOeql vitamin c oral tablet1 MOeql vitamin c/rose hips1 MOergocalciferol oral capsule1 MOessentia1 MOessential balance1 MOessential one daily multivit1ester-c oral tablet , 500-550 mg1ester-c oral tablet extended1releaseESTROFACTORS2 MOextress1 MOextress-super1 MOEYE HEALTH2 MOeye vitamins oral capsule1 MOeye-vites1 MOeyeprotect1 MOEZFE 2002 MOfa-8 oral capsule1Drug NameYou can find information on what the abbreviations on this table mean by going to the beginning of this table.15ECDHLP v2 2101 1
Drug Namefa-8 oral tabletfa-vitamin b-6-vitamin b-12fabbfe c tabfe tabsFEM-CAL CITRATEFEOSOL BIFERAFEOSOL NATURALRELEASEFEOSOL ORAL TABLET200 (65 FE) MGFER-IN-SOLFERAHEMEferate oral tablet240 (27 fe) mgfergonferoconferosul oral tabletferotrinsicFERRALET 90FERRETTSFERRETTS IPSferrex 150FERREX 150 FORTE ORALCAPSULE 150-1-25MG-MG-MCGFERREX 150 FORTE PLUSFERREX 150 PLUSferric x-150FERRLECITferrociteferrocite plus oral tabletferrotabsferrous fumarate oral tablet324(106 fe) mgFERROUS GLUCONATEORAL TABLET 324 (38 FE)MGferrous gluconate oral tablet240(27 fe) mgferrous sulfate MOMOMOMOMO2MO1MO1MOMODrug RequirementsTier /Limitsferrous sulfate oral elixir1 MOFERROUS SULFATE ORAL2LIQUIDferrous sulfate oral solution751 MO(15 fe) mg/mlFERROUS SULFATE ORAL2SYRUPferrous sulfate oral tablet1delayed release325 (65 fe) mgferrous sulfate oral tablet27 mg1ferrous sulfate oral tablet3251 MO(65 fe) mgferrousul1 MOFITNESS TABS FOR MEN2 MOAM/PMFITNESS TABS FOR2 MOWOMEN AM/PMflexgen1FLINTSTONES GUMMIES2FLINTSTONES GUMMIES2COMPLETEflintstones gummies omega-31 MOdhaFLINTSTONES GUMMIES2PLUSflintstones plus calcium1 MOFLINTSTONES SOUR2GUMMIESflintstones/extra c1flintstones/my first1 MOFLORIVA PLUS2 MOfluoritab oral tablet chewable1 MOfolbee1 MOfolbee plus cz1 MOfolbic1 MOFOLGARD OS2 MOFOLGARD RX2 MOFOLIC B122 MOfolic acid injection1 MOfolic acid oral capsule0.8 mg1Drug NameYou can find information on what the abbreviations on this table mean by going to the beginning of this table.16ECDHLP v2 2101 1
Drug Namefolic acid oral tablet1 mg, 400mcg, 800 mcgFOLITAB 500FOLIVANE-FFOLIVANE-PLUSfolplex 2.2foltabs 800FOLTANXFOLTANX RFFOLTRATEfoltrinFORTAVITFOSFREEFREEDAVITEFRUIT C 200fruit c 500fruity chewsfruity chews/ironFULL SPECTRUMB/VITAMIN CGALZINgenicin vita-sGERI-FREEDA SENIORFORMULAgeriatonGERITOL COMPLETEGERITOL TONICgerivite completeGLUCO CORglucotenGLYCO-TECHGLYCOTROLGLYCOTROL COMPLETEgnp animal shapesgnp animal shapes plus extra cgnp animal shapes plus irongnp b-100 complexgnp b-12gnp b-50 balancedDrug RequirementsTier /Limits1 MO122121222111111MOMOMOMOMOMOMOMOMOMOMOMODrug Namegnp b-50 complexgnp b-complex plus vitamin cgnp biotingnp cal mag zinc d3gnp calcium 1200gnp calcium 500 d3gnp calcium 500/dgnp calcium 600 d/mineralsoral tabletgnp calcium 600 d3gnp calcium 600 d3/mineralsgnp calcium 600 plus d/mineralgnp calcium 600/dgnp calcium citrate d3gnp calcium citrate dmaximumgnp calcium plus 600 dgnp calcium-magnesium-zincgnp calcium/vitamin d/mineralsgnp centurygnp century adult formulagnp century adults 50 seniorgnp century cardio healthGNP CENTURY ENERGYMETABOLISMgnp century maturegnp century mature women's50 gnp century ultimate mensgnp century ultimate womensgnp childrens chewables/ex cgnp childrens chewables/irongnp cod liver oilgnp daily prenatalgnp diabetic support formulagnp essential one dailygnp folic acidgnp hair/skin/nailsgnp healthy MOMOMOMOMOMOMOMOMOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.17ECDHLP v2 2101 1
Drug Namegnp healthy eyes supervisiongnp healthy eyes supervision 2gnp iron oral tablet extendedreleasegnp iron oral tablet200 (65 fe)mggnp iron oral tablet325 (65 fe)mggnp little ones childrensgnp maximum one dailygnp mega multi for mengnp mega multi for womengnp niacingnp niacin flush freegnp niacin trgnp norwegian cod liver oilgnp one daily maximumgnp one daily mens50 advancedgnp one daily mens health 50 gnp one daily mens/lycopenegnp one daily plus irongnp one daily womensgnp one daily womens 50 gnp one daily womens healthgnp opti-vitaminsgnp prenatalgnp slow release irongnp therapeutic-mgnp vitamin b-1gnp vitamin b-12gnp vitamin b-12 trgnp vitamin b-6 oral tablet100mggnp vitamin b1gnp vitamin c crgnp vitamin c oral tabletgnp vitamin c oral tabletchewableDrug RequirementsTier /Limits1 MO1 MO1 MOMOMOMOMOMOMOMOMOMOMOMOMOMODrug Namegnp vitamin c oral tabletextended releasegnp vitamin c w/rose hipsgnp vitamin c/rose hipsgnp vitamin c/rose hips trgnp vitamin d-400 oraltablet10 mcg (400 unit)gnp womens one dailygnp zincgnp zinc chelatedgnp zoochews gummiesgoodsense irongoodsense prenatal vitaminsGRAPE SEED ORALCAPSULE 250-50 MGGREEN SOURCEgtf chromiumgummi bear multivitamin/minHAIR FAREhair formula extra strengthHAIR NOURISHINGSUPPLEMENTHAIR SKIN & NAILSADVANCEDhair skin and nails formulahair skin nailshair vitaminshair/skin/nails oral tablethair/skin/nails/biotinhealthy eyeshealthy eyes/luteinhealthy hair/skin/nailsHEALTHY HEARTCOMPLEXhealthy kids overall healthHEART SAVIORhematinic plus vit/mineralshematinic/folic 12111MOMOMOMOMOMOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.18ECDHLP v2 2101 1
DrugTierHEMATOGEN FA2hematogen forte1HEMATRON-AF2hemax oral tablet1HEMOCYTE2HEMOCYTE PLUS2hemocyte-f oral tablet1hemocyte-plus oral tablet106-11mghi c-5001hi-kovite 2-part formula1hi-potency multi-vitamin1hm antioxidant vitamins1hm b complex/c1hm biotin oral capsule1hm calcium 600 & vitamin d32hm calcium 600 d plus2mineralshm calcium citrate d3 petite1hm calcium citrate vitamin d1hm calcium magnesium & zinc1hm calcium-vitamin d oral1tablet500-200 mg-unit,600-400 mg-unithm calcium-vitamin d oral2tablet600-800 mg-unithm calcium-vitamin d-minerals1hm complete 50 1HM COMPLETE 50 2MENS ULTIMATEHM COMPLETE 50 2WOMEN ULTIMATEHM COMPLETE MEN2hm complete women1hm folic acid1HM HAIR/SKIN/NAILS2hm iron1hm iron slow release1hm mens 50 advanced one1dailyDrug OMOMOMOMOMOMOMOMOMOMOMOMOMOMODrugTierhm multivitamin adult gummy1hm niacin1hm niacin tr1HM ONE DAILY MENS2hm one daily prenatal2HM ONE DAILY2WOMENShm one daily/iron1hm prenatal2hm selenium1hm slow release iron1hm super vitamin b complex/c1hm vita-mini multi complete1hm vitamin b complex/vitamin1chm vitamin b-121hm vitamin b-12 tr1hm vitamin b11hm vitamin b100 complex1hm vitamin b121hm vitamin b50 complex1hm vitamin b61hm vitamin c1hm vitamin c tr1hm vitamin c/rose hips1hm vitamin d oral tablet10 mcg1(400 unit)hm womens 50 advanced daily 1hm zinc1HONEY BEARS2HONEY BEARS2W/IRON-ZINChydroxocobalamin acetate1hylavite1i-vite1i-vite protect1icaps1ICAPS AREDS FORMULA2icaps lutein & omega-31Drug OMOMOMOMOMOMOMOMOMOMOMOMOMOYou can find information on what the abbreviations on this table mean by going to the beginning of this table.19ECDHLP v2 2101 1
DrugTiericaps mv1ICAR ORAL SUSPENSION2ICAR-C2iferex 150 forte1IMMUNE SUPPORT2immunicare1INFED2INFUVITE ADULT2INFUVITE PEDIATRIC2INTRAVENOUSSOLUTIONINTEGRA2INTEGRA F2INTEGRA PLUS2INULOSE BLOOD SUGAR2SUPPORTiodine strong oral1iron (ferrous sulfate)1iron 100/c1iron 271IRON CHEWS PEDIATRIC2iron complex1iron high-potency1iron oral tablet240 (27 fe) mg,1325 (65 fe) mgiron supplement childrens1iron supplement oral elixir1IROSPAN 24/62IS 24/62k 1001K-PAX DOUBLE2STRENGTHK-PAX IMMUNE2PROFESSIONAL STK-PAX SINGLE
8 ECDHLP_v2_2101_1 b-2 oral tablet50 mg 1 b-50 1 MO b-50 complex oral tablet extended release 1 b-6 oral tablet100 mg 1 MO b-caro-t 1 b-compleet-100 1 MO b-compleet-50 1 MO b-complex balanced 1 MO B-COMPLEX INJECTION 2 b-complex oral tablet 1 MO b-complex-c oral tablet 1 MO b-complex/b-12 oral 1 MO b-complex/vitamin c 1 MO
2019 . Extra Covered Drugs . The prescription drugs in this list are covered above and beyond the drugs in your plan's . Part D Formulary. Y0114_19_34776_I_103 05/01/2018 70952MUSENMUB_103_ABC_HLP
Drugs Affecting Autonomic Nervous System, 2. Drugs Affecting Central Nervous System, 3. Drugs Affecting Cardiovascular System, 4. Drugs Affecting Haemostasis and Thrombosis, 5. Drugs Affecting Renal Function, 6. Drugs Affecting Endocrine System, 7. Drugs Affecting Respiratory System, 8. Drugs Affecting Gastr
Drugs in this tier are non-preferred brand drugs, covered drugs not on the drug list and covered brand drugs that are approved as medically necessary by Health Net. 4 Drugs indicated as "tier 4" are self-injectable drugs and coverage may differ based on your benefits. Please refer to your plan documents for specific
NDC labeler code 47335 (Sun Pharmaceutical Industries, Inc.) only. drugs cdl p1a 3 Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D) Page u
These include drugs affecting the autonomic nervous system; anesthetics and analgesics; drugs to treat the heart and diseases of the cardiovascular system; drugs affecting the pulmonary system; antibiotics; drugs used to treat psychiatric disorders; drugs of abuse and drugs use to treat addiction; drugs that affect the immune
b. Drugs acting on Central Nervous system: Analgesics, Nonsteroidal anti inflammatory drugs, Sedatives and Hypnotic, Anti convulsants and Antipsychotic drugs. Drugs used in parkinsonism. c. Drugs acting on Autonomic Nervous system: Drugs which influence the working of autonomic nervous system, Adrencrgic drugs
What are generic drugs? Premera Blue Cross Medicare Advantage Plans cover both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage?
Artificial Intelligence and the Modern Productivity Paradox: A Clash of Expectations and Statistics Erik Brynjolfsson, Daniel Rock, and Chad Syverson NBER Working Paper No. 24001 November 2017 JEL No. D2,O3,O4 ABSTRACT We live in an age of paradox. Systems using artificial intelligence match or surpass human level performance in more and more domains, leveraging rapid advances in other .
