IMPORTANT NOTICE. Our file shows that you may have filled a prescription for one of these medications.

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1 1145 Broadway Tacoma Financial Center Suite 300 Tacoma, WA IMPORTANT NOTICE November 25, 2015 Dear Member, Your health is important to us. On 01/01/2016, Coordinated Care will no longer cover some Over the Counter (OTC) products. The attached list shows OTC products that are not on the Washington State Health Care Authority s (HCA) list of covered drugs. Per the HCA, these drugs should not have been covered. They are being removed from our Preferred Drug List (PDL). Our file shows that you may have filled a prescription for one of these medications. Please call your doctor to find out if there s an alternate medication for you to take. Please do not stop taking your medication before speaking with your doctor. This should not interfere with your doctor s advice. Only your doctor can decide what drugs are right for you. If you have any questions, please contact our Pharmacy Department at (877) Ext Thank you, Coordinated Care Pharmacy Department Enclosed: List of Non-Covered OTC

2 OTC Products That Are Not Covered by HCA Acetaminophen w/ DM Liq MG/5ML Alum & Mag Hydroxide-Simethicone Susp MG/5ML Aluminum Hydroxide Gel Susp 320 MG/5ML Aluminum Hydroxide Gel Susp 600 MG/5ML Ascorbic Acid Tab 1000 MG Ascorbic Acid Tab 250 MG Ascorbic Acid Tab 500 MG Aspirin Chew Tab 75 MG Aspirin Suppos 120 MG Aspirin Suppos 200 MG Aspirin Suppos 300 MG Aspirin Suppos 60 MG Aspirin Suppos 600 MG Aspirin Tab Delayed Release 500 MG Attapulgite Susp 750 MG/15ML Bacitracin-Polymyxin B Powder B-Complex Vitamin Cap B-Complex Vitamin Tab B-Complex w/ C Cap Benzoyl Peroxide Gel 10% Benzoyl Peroxide Gel 2.5% Benzoyl Peroxide Gel 5%

3 Benzoyl Peroxide Liq 10% Benzoyl Peroxide Liq 5% Benzoyl Peroxide Lotion 10% Benzoyl Peroxide Lotion 5% Brompheniramine & Phenylephrine Elixir MG/5ML Brompheniramine & Phenylephrine Liqd 2-5 MG/ML Brompheniramine & Pseudoephedrine Elixir 1-15 MG/5ML Calcium Carbonate-Vitamin D Tab 250MG-125IU Calcium Carbonate-Vitamin D Tab 500MG-125IU Calcium Polycarbophil Tab 625 MG Camphor & Menthol Lotion % Capsaicin Cream 0.025% Capsaicin Cream 0.035% Capsaicin Cream 0.075% Capsaicin Cream 0.1% Capsaicin Gel 0.025% Capsaicin Gel 0.05% Capsaicin Gel 0.075% Capsaicin Lotion 0.035% Carbonyl Iron Chew Tab 15 MG (Elemental Iron) Cetirizine-Pseudoephedrine Tab SR 12HR MG Chlorpheniramine & Phenylephrine Liquid MG/ML Chlorpheniramine-DM Liquid 2-15 MG/5ML Chlorpheniramine-DM Syrup MG/5ML Chlorphen-Pseudoephedrine w/ APAP Cap MG Cholecalciferol Cap 2000 Unit

4 Cholecalciferol Cap 5000 IU Cholecalciferol Cap Unit Clemastine Fumarate Tab 1.34 MG Coal Tar Shampoo 0.5% Cromolyn Sodium Nasal Aerosol Soln 5.2 MG/ACT (4%) Dexchlorpheniramine Maleate Syrup 2 MG/5ML Dexchlorpheniramine Maleate Tab CR 4 MG Dextromethorphan HBr Liquid 7.5 MG/5ML Dextromethorphan Polistirex Liquid CR 30 MG/5ML Dextromethorphan-APAP-Chlorpheniramine Cap MG Dextromethorphan-Doxylamine-APAP Liquid MG/30ML Dextromethorphan-Guaifenesin Liquid MG/5ML Dextromethorphan-Guaifenesin Liquid MG/5ML Dextromethorphan-Guaifenesin Liquid MG/5ML Dextromethorphan-Guaifenesin Liquid MG/5ML Dextromethorphan-Guaifenesin Liquid MG/5ML Dextromethorphan-Guaifenesin Tab SR 12HR MG Dextromethorphan-Phenylephrine-APAP Cap MG Dibucaine Oint 1% Diphenhydramine & Pseudoephedrine Cap CR MG Diphenhydramine & Pseudoephedrine Tab MG Diphenhydramine HCl Cream 2% Docusate Sodium Cap 50 MG Epinephrine HCl Nasal Soln 0.1% Ergocalciferol Cap IU Ferrous Fumarate Tab 325 MG (106 MG Elemental Fe)

5 Ferrous Gluconate Tab 225 MG (27 MG Fe Equivalent) Ferrous Gluconate Tab 240 MG Ferrous Gluconate Tab 246 MG (28 MG Elemental Fe) Ferrous Sulfate Dried Tab CR 160 MG (50 MG Fe Equivalent) Ferrous Sulfate Tab 28 MG (Elemental Fe) Folic Acid Tab 400 MCG Folic Acid Tab 800 MCG Ginger (Zingiber officinalis) Cap 250 MG Glucose Polymers Liqd Glucose Polymers Powder 94% Guaifenesin Tab SR 12HR 1200 MG Guaifenesin Tab SR 12HR 600 MG Guaifenesin-Codeine Liquid MG/5ML Guaifenesin-Codeine Soln MG/5ML Hydrocortisone-Aloe Vera Cream 1% Ketoconazole Shampoo 1% Lanolin Cream Lanolin Lidocaine HCl Gel 2% Magnesium Oxide Cap 400 MG (Elemental Mg) (Mg Supplement) Magnesium Oxide Tab 400 MG Magnesium Oxide Tab 400 MG (240 MG Elemental Mg) Melatonin Tab 3 MG Melatonin Tab 5 MG Miconazole Nitrate Vaginal Supp 200 MG & 2% Cream 9 GM Kit Miconazole Nitrate Vaginal Suppos 100 MG

6 Miconazole Nitrate Vaginal Suppos 200 MG Multiple Vitamin Tab Multiple Vitamins w/ Iron Tab Multiple Vitamins w/ Minerals Tab Neomycin-Bacitracin-Polymyxin Oint***Neomycin-Polymyxin w/ Pramoxine Cream 1% Nit Remover - Shampoo Niacin Cap CR 250 MG Niacin Tab CR 250 MG Omega-3 Fatty Acids Cap 1000 MG Omega-3 Fatty Acids Cap 1200 MG Pediatric Multiple Vitamin w/ C & FA Chew Tab Pediatric Multiple Vitamin w/ C Soln 35 MG/ML Permethrin Aerosol 0.4% Permethrin Aerosol 0.5% Permethrin Liq Spray 0.25% Permethrin Spray & Pyrethins-Piperonyl Butoxide Shamp Kit Phenir-PE w/ Sod Salicyl & Caff Cit Liq MG/5ML Phenolphthalein-DSS Tab MG Phenylephrine HCl Soln 2.5 MG/5ML Phenylephrine HCl Tab 10 MG Phenylephrine-APAP-Caffeine Tab MG Phenylephrine-DM Soln MG/5ML Phenylephrine-Guaifenesin Liqd MG/5ML Phenylephrine-Pyrilamine-DM Syrup MG/5ML Phenylephrine-Shark Liver Oil-MO-Pet Oint % Phenyleph-Shark Liver Oil-Cocoa Butter Suppos %

7 Polyethylene Glycol-Polyvinyl Alcohol Ophth Soln 1-1% Polysaccharide Iron Complex Cap 150 MG Pramoxine HCl Rectal Foam 1% Pseudoeph-Doxylamine-DM w/ APAP Cap MG Pseudoeph-Doxylamine-DM w/ APAP Liq MG/30ML Pseudoeph-Doxylamine-DM w/apap Liquid MG/30ML Pseudoephed-Bromphen-DM Elixir MG/5ML Pseudoephed-Bromphen-DM Syrup MG/5ML Pseudoephed-Chlorphen-DM Liq MG/5ML Pseudoephed-Chlorphen-DM Liq MG/5ML Pseudoephedrine HCl Liq 15 MG/5ML Pseudoephedrine HCl Liq 30 MG/5ML Pseudoephedrine HCl Syrup 30 MG/5ML Pseudoephedrine HCl Tab SR 12HR 120 MG Pseudoephedrine w/ Acetaminophen Liquid MG/5ML Pseudoephedrine w/ APAP-DM Cap MG Pseudoephedrine w/ COD-GG Soln MG/5ML Pseudoephedrine w/ DM-GG Liquid MG/5ML Pseudoephedrine-DM Elixir MG/5ML Pseudoephedrine-DM Liqd MG/5ML Pseudoephedrine-DM Soln MG/0.8ML Pseudoephedrine-Guaifenesin Syrup MG/5ML Pseudoephedrine-Guaifenesin Tab SR 12HR MG Pseudoephedrine-Ibuprofen Susp MG/5ML Pseudoephedrine-Ibuprofen Tab MG Psyllium Cap 0.52 GM

8 Pyreth-Piper But Spray & Pyreth-Piper But Shamp Kit Pyreth-Piperonyl Butox Sham-Permeth Aero-Nit Remover Gel Kit Pyrethrins-Piperonyl Butoxide Liq % Pyrethrins-Piperonyl Butoxide Liq 0.2-2% Pyrethrins-Piperonyl Butoxide Shampoo Kit Pyridoxine HCl Tab 100 MG Pyridoxine HCl Tab 25 MG Riboflavin Tab 100 MG Riboflavin Tab 25 MG Riboflavin Tab 50 MG Salicylic Acid Gel 6% Selenium Sulfide Lotion 1% Senna Powder Senna Tab 187 MG Sennosides-Docusate Sodium Tab MG Sodium Bicarbonate Tab 325 MG Sodium Bicarbonate Tab 650 MG Terbinafine HCl Cream 1% Thiamine HCl Tab 250 MG Thiamine HCl Tab 50 MG Thiamine HCl Tab 500 MG Tioconazole Vaginal Oint 6.5% Vitamin E Cap 100 IU Vitamin E Cap 200 IU Vitamin E Cap 400 IU Vitamin E Chew Tab 400 IU

9 Vitamins w/ Lipotropics Cap Xanthan Gum Oral Thickening Gel Zinc Lozenge 15 MG Zinc Oxide Oint 20% Zinc Sulfate Cap 220 MG (50 MG Elemental Zn)