Special Benefit for Care1st Health Plan Members Get Over-the-Counter Products Each Year at No Cost to You! 2013 OVER-THE-COUNTER (OTC) BENEFIT CATALOG As a member of our Care1st TotalDual Plan (HMO SNP) you have a quarterly Overthe-Counter (OTC) benefit in the amount of $50.00, which allows you to purchase OTC products you may need such as bandages, cold and allergy medicines, pain relievers, non-prescription medications, and some vitamins. We hope that you take advantage of this valuable benefit each quarter. Categories The Over-the-Counter (OTC) items listed below have been assigned to one of the following categories: Eligible Over-the-Counter Items, Dual-Purpose OTC Medications and Products. A detailed description of both categories can be found below. Eligible OTC Items – includes medicines or products that alleviate or treat injuries or illness. You do not need to provide a statement from a medical provider or indicate a diagnosis. Dual Purpose OTC Medications & Products – do not require a letter of medical necessity from a physician, however, Care1st Health Plan encourages members to have appropriate conversations with their personal provider and have their personal provider orally recommend the OTC item for a specific diagnosable condition prior to purchase. Information on how to place your OTC order can be found on the last page. H5928_13_228_OTC Approved *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. Eligible Over-the-Counter Items Ibuprofen 100 tabs1004 $8.70 Ibuprofen Children's1421 $8.20 Naproxen *D 1097 $14.40 Acne Gel 10% Benzoyl Peroxide1076 $7.20 Pain Reliever 8 Hour1311 $19.40 Acne Treatment Allergy Prevention and Treatment Pain Relieving Rub All Day Allergy Tablets1090 $7.90 Chlorpheniramine 1008 $6.00 Clearatadine Children's 1424 $11.90 Cromolyn Sodium Diphenhist 1356 $21.40 1308 $7.90 Loratadine-D 24 Hr 10 tabs1083 $14.90 Loratadine-D 24 Hr 15 tabs1351 $20.10 Nasal Decongestant Spray 12 Hr 1091 $9.50 1102 $7.80 Antacids and Acid Reducers Alka-Seltzer1313 $15.20 Chewable Antacid1346 $7.00 Effervescent Pain1314 $8.90 Famotidine *D 1108 $7.30 Gas-X1312 $8.60 Milk of Magnesia Mintox Mag 1011 $8.40 1006 $9.50 $39.80 Nasal Saline Spray 1052 $9.50 Omeprazole *D 28 caps1110 Nasal Strips Small/Med1265 $10.00 Anti-Arthritic $13.30 Nasal Strips Med/Lg1267 $10.00 Glucosamine Joint/Muscle1114 $16.50 Sudogest PE1352 $6.00 Glucosamine/Chondroitin1003 Analgesics/Antipyretics 2. Anticandial (Yeast) Acetaminophen1001 $8.60 Clotrimazole Vaginal Cream w/applicator *D1115 $12.80 Acetaminophen Children's1423$6.20 Micanozole 3 Day Treatment 1117 $16.90 Aleve1104 $14.20 Tioconazole 1 Day Treatment 1119 $29.10 Aspirin 1095 $4.90 Antidiarrheal and Laxatives Aspirin Enteric Coated 1096 $7.10 Beano1316 $9.40 Aspir-Low1002 $7.10 Bisacodyl 1128 $6.50 Extra Strength Pain Reliever 1105 $6.00 Bismatrol Chewable 1045 $7.90 *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. Docusate Sodium 1126 $18.10 Herpecin-L Lip Balm Ex-Lax 1124 $8.20 Releev Cold Sore Treatment Glycerin Suppository 1125 $6.80 Cold, Flu, Decongestant and Loperamide HCL *D1133 $5.90 Acetaminophen Children's Cough Methylcellulose 1354 $19.90 Cold Head Congestion Pepto-Bismol1317 $15.40 Cough & Cold for Pink Bismuth1318 $8.40 High Blood Pressure 1153 $9.10 1359 $40.10 Sinus 1425 $10.20 1357 $8.40 1166 $7.30 Senna Plus1130 $8.70 Mentholatum 1164 $8.40 Antifungal Sudogest Cold & Allergy 1156 $7.10 Clotrim Antifungal Cream1047 $13.00 Miconazole 2% Cream1135 $13.60 Terbinefine HCL Tube 1046 $16.70 Tolnafate Cream 1064 $5.90 Contact Lens Supplies Cleaning & Soaking Solution1468 $8.40 Cough Suppressants or Expectorant All-Nite Cold/Flu1361 $8.30 Antihistamines Cough Drop Cherry 1056 $10.10 Tavist Allergy-D PSE/Cetirizine 1138 $14.30 Diabetic Tussin DM1323 $9.60 1355 $21.30 Guaifenesin 1180 $11.00 Dimaphen Children's 1426 $6.10 Q-DRYL 1428 $6.60 Guaifenesin Syrup1054 $5.00 Mucus Relief DM1178 $8.00 Anti-Itch Lotions and Creams Sore Throat Lozenges Cherry1176 Bactine Solution Caldyphen Clear 1142 $12.60 1144 $10.80 Sore Throat Lozenges1360 $9.60 Sugar Free Cough Drop Menthol 1182 $6.40 Diphenhydramine HCL/ Zinc Acetate1140 $5.80 Dental Hydrocortisone Cream1074 $5.80 Dental Floss Abreva 1455 $5.90 Fixodent 1187 Orajel Oral Pain Reliever Gel 1454 $9.10 Cold Sore and Fever Blister 1152 $20.60 $7.10 $9.30 3. Rechargeable Toothbrush1450 $38.20 Tooth Brush • Colgate1413 $5.20 Tooth Brush • Tek Pro1412 $4.80 Bacitracin Ointment1020 $5.80 Bandages 1344 $8.00 Tooth Paste • Pepsodent1414 $5.90 Conforming Gauze Sterile *B 1223 $15.00 Denture Digital Ear Thermometer 1285 $16.70 1063 Denture Cleaning Tablets Denture Holder 1032 $7.90 1461 $11.70 Polident Denture Cream1324 $11.20 Ear Ear Drops Ear Wax Removal System 1190 $6.30 1363 $9.90 Cold Pack Digital Oral Thermometer $4.80 Elastic Bandage *B • 4” X 5 yd 1211 $5.20 Elastic Bandage *B • 6” X 5 yd 1213 $6.10 Eye Wash Solution1196 $7.00 Lantiseptic Skin Protectant Ointment PuraLube Ointment1194 $11.40 First Aid and Medical Supplies Alcohol Pads *D Ankle Support Antiseptic Towelettes 4. 1200 $7.10 1225 $11.50 1201 $7.60 $9.60 Elastic Bandage *B • 3” X 5 yd 1209 Eye Drops1061 $6.10 Knee Support Fiber Tabs 1012 $13.70 Natural Vegetable Laxative1340 $16.00 $8.50 Elastic Bandage *B • 2” X 5 yd 1207 $4.50 Elbow Support Eye Care First Aid Kit Artificial Tears1192 $6.10 Hydrogen Peroxide Clear Eyes Eye Drops 1199 $8.20 Isopropyl Alcohol Fiber Supplements 1062 1224 $14.60 1215 $10.60 1228 $5.10 1229 $7.40 1226 $11.70 1202 $10.60 Leader Knee Stabilizer 1465 $27.10 Neosporin Plus1326 $14.70 Night Wrist Sleep Support1463 $35.40 Non-skid Bath Mat Non-skid Shower Mat 1459 $18.50 1460 $28.50 Povidone Iodine1203 $5.30 Rib Belt - Male Universal 1456 $25.20 Rib Belt - Female Universal 1457 $25.20 Automatic Blood Pressure Monitor1253 $44.40 *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. Tape, Paper Surgical *B Incontinence Supplies 1” X 10 yd 1217 $4.70 A&D Ointment 1300 $6.60 Tape, Paper Surgical *B 2” X 10 yd 1218 $5.90 Adult Briefs Med 32" - 44” waist 1303 $12.60 Tape, Silk Surgical *B 1” X 10 yd 1219 $5.40 Adult Briefs LG 44” - 58” waist 1304 $15.60 Tape, Silk Surgical *B 2” X 10 yd 1220 $7.20 Adult Briefs XL 59” - 64” waist 1305 $15.60 Tape, Transparent Surgical *B 1” X 10 yd 1221 $5.30 Barrier Cream 1302 $10.50 Tape, Transparent Surgical *B Underpad 23" x 36" 1299 $16.00 2” X 10 yd 1222 $7.00 Washcloth w/Lanolin1348 $9.60 Triple Antibiotic Ointment 30 gm1014 $9.90 Lactose Intolerance Wrist Splint Wrist Support Foot Care Callus Remover Pad 1230 $23.90 1227 $13.50 1238 $9.80 Corn Remover Pad 1236 $9.80 Medicated Foot Powder1240 $7.40 Hand Sanitizer Hand Sanitizer 1065 Hemorrhoidal Anu-Med Suppository Hemorrhoidal Ointment Hemorrhoidal Suppository Preparation H Cream $7.20 1245 $8.50 1066 $9.00 1247 $6.60 1248 $18.50 Pre-Moist Hemorrhoid Pads1364$12.10 Lactase Medicated Lip Products 1067 $12.30 Blistex Lip Ointment 1256$5.90 Carmex 1255 $5.40 Menstrual Cycle Menstrual Relief Migraine Relief Migraine Relief 100 tabs Wellpatch Migraine 1257 $6.90 1365 $9.90 1261 $11.10 Motion Sickness Banophen Diphenhydramine 1009 $8.30 Dramamine Orange 1264 $10.70 Driminate Meclizine Tronolane Cream1244 $15.70 1263 $6.00 1366 $12.00 5. Pediculicide Lice Treatment Shampoo1271 $14.00 Permethrin Cream Rinse1269 $17.70 Skin Care Ammonium Lactate 1368 $14.30 Women's Compression Knee Hi Nude Small 4-51406 $16.60 Women's Compression Knee Hi Nude Med 51/2 - 71/21407 $16.60 Women's Compression Knee Hi Nude Large 8 - 101/2 1408 $16.60 Women's Compression Knee Hi Black Small 4-51409 $16.60 Capsaicin 1367 $11.40 Gold Bond Ultimate1319 $21.80 Women's Compression Knee Hi Black Med 51/2 - 71/2 1410 $16.60 Sleep Aids Pain Reliever PM Extra Strength Restfully Sleep Smoking Cessation Nicotine Gum Nicotine Patch Step 1 Nicotine Patch Step 2 Nicotine Patch Step 3 1332 $11.60 1276 $7.10 1372 $27.00 1369 $40.30 1370 $40.30 1371 $40.30 Sunscreen/Burn Aloe Vera Cream Sunscreen Lotion SPF 15 Sunscreen Lotion SPF 30 6. Teething/Toothaches Oral Pain Relief 1286 $8.70 Wart Remover Dr. Scholl’s Wart Removal System 1288 $19.70 Wart Remover 1075 Wartners Wart Removal System 1289 $27.90 $9.00 1070 $10.70 Dual Purpose Over-the-Counter Items 1283 $11.10 Home Diagnostics 1284 $12.80 Colon Cancer Test Home Cholesterol Test 1416 $18.60 Calcium 600 1291 $8.30 1373 $6.50 Support Items Women's Compression Knee Hi Black Large 8 - 101/21411 $16.60 Men's Compression Knee Hi Black Large 101/2-12 1399 $27.40 Vitamins/Minerals Men's Compression Knee Hi White Med 8-101400 $27.40 Calcium-Vitamin D Centrum Silver Men's Compression Knee Hi 1/2 White Large 10 -121401 $27.40 1251 $38.10 1420 $33.50 *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. Century Senior Vitamin 1392 $13.10 Daily Multiple w/Minerals Ferrous Gluconate 1385 $7.10 1375 $7.60 Ferrous Sulfate 1376 $7.60 Iron 1417 $10.00 LDR Once Daily Vitamin 1393 $8.10 Magnesium Magnesium Oxide 1418 $8.40 1377 $9.30 Multi Vitamin Children's 1422 $10.00 Niacin 100 tabs, 500 mg Niacin 100 tabs, 100 mg 1394 $9.60 1378 $7.00 Zinc Chelated 1419 $7.40 Prenatal Vitamins1274 $10.00 Rena-Vite 1395 $21.40 Vitamin A 1379 $6.30 Vitamin B-Complex 1382 $8.20 Vitamin B-1 Vitamin B-6 100 tabs, 50 mg Vitamin B-6 100 tabs, 100 mg 1016 $7.50 1380 $6.60 1388 $7.10 Vitamin B-12 100 tabs, 500 mcg 1389 $8.20 Vitamin B-12 100 tabs, 1000 mcg 1381 $11.20 Vitamin C 1017 $6.50 Vitamin D 100 tabs, 1000 iu Vitamin D 100 tabs, 400 iu 1390 $8.10 1383 $8.00 Vitamin E 100 tabs, 100 iu Vitamin E 100 tabs, 400 iu 1391 $7.40 1384 14.40 7. Helpful Information • If you have questions or would like to place an order over the phone, OTC Specialists are available Monday – Friday from 8:00am to 5:00pm PST at 1-800-355-7913 (TTY: 1-800-355-8224). • When mailing an order form, the quarter we receive your form is the quarter the amount you spent will be applied to. For example, if you mail your order form on June 29th, but we receive it on July 1st, the amount of your order will be applied to your July (or third quarter) benefit, not your June (or second quarter) benefit.   If you’re getting close to the end of the quarter and you do not think your order form will be received in time, you can call in your order. • Your quarterly benefit amount is $50.00. We encourage you to use your full quarterly benefit amount in one order. This benefit amount does not accumulate from quarter to quarter. • The total quarterly order may not exceed the quarterly benefit allowance permitted under your benefit. Cash, checks or money orders are not accepted under this Over-the-Counter (OTC) benefit. • Orders may only be placed by the member, an authorized representative verbally approved by the member at time of the order, and/or the member’s power of attorney representative on file. • OTC products are intended for member use only. • Once your order is received, please allow 7 - 10 days for delivery. • Products may not be purchased at a local retail pharmacy or through any other source other than the Care1st Health Plan Over-the-Counter (OTC) Benefit Catalog. • If you disenroll from Care1st Health Plan, your Over-the-Counter (OTC) benefit will automatically terminate. • Returns are not accepted. • There are some items listed in this catalog that may also be covered under your Medicare Part B (medical) benefit or Part D (pharmacy) benefit. These items have a *B or a *D after their name. For example, alcohol pads are covered under Part D if they are used for the purpose of administering insulin. For all other purposes, this item is covered under your OTC benefit. • Items in the 2013 OTC Benefit Catalog may change throughout the year. A copy of this catalog is also available on the Care1st Health Plan website at www.care1st.com/ca/medicare. For up-to-date information, please call our OTC Specialists from Monday - Friday from 8:00am to 5:00pm PST at 1-800-355-7913 (TTY: 1-800-355-8224). Care1st Health Plan is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program. The benefit information provided herein is a brief summary, not a complete description of benefits. For more information contact the plan. Member Services: 1-800-544-0088 (TTY 1-800-735-2929), 8am – 8pm, 7 days a week. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. This information is available for free in other languages. Please contact Member Services: 1-800-544-0088 (TTY 1-800-735-2929), 8am – 8pm, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY 1-800-735-2929), de 8:00 a.m. a 8:00 p.m., los 7 días de la semana.