Your 2015 Over-the-Counter (OTC) Items Benefit

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1 Your 2015 Over-the-Counter (OTC) Items Benefit

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3 Your health, as well as your family s, is important to us here at WellCare. One way you can help to be your healthiest is by using your OTC benefit. With this benefit, you can choose from hundreds of health and wellness items. Things like: Medicines to help with allergies, fever and heartburn Cough and cold medicine Toothbrushes, toothpaste and floss First aid items Sunblock Vitamins On top of a long list of items, we make it easy for you to get them. Look over the list of supplies on the next few pages. When you ve made your choices, we have a couple of ways for you to place your order: 1. Call us toll-free. Customer Service: TTY: We re here to help Monday Friday, 8 a.m. to 7 p.m. You can talk with someone on our team. Follow the phone instructions and have your item number(s) handy. Remember to use your OTC benefit every month. If you don t use it one month, it doesn t roll over to the next. wellcareplans.com 1 NY5OTCCAT62731E

4 2. If you have a computer or smart phone, log on to our website. Go to wellcareplans.com. (If you already have a username and password, use them to log in. If you don t, it s easy to sign up. Just follow the instructions.) After you ve logged in, click on the Over-the-Counter (OTC) Items link to get started. You ll be able to order items until they add up to your monthly $20 allowance. Once your order is placed, we ll ship it right to your home. It s that easy! To get the most out of your OTC benefit: Make sure to order your items each month. If you don t, you ll lose your $20 allowance for that month. It will not carry over to the next month. Use your monthly order to stock up on different items. Important reminders: Your OTC allowance is for each family member who s on our plan. Items, quantities, sizes and values may change depending on availability. The brand names of the OTC items listed are trademarks of their respective owners. wellcareplans.com 2

5 Items You Can Order From Us or Buy at a Retail Store Do you prefer lower-cost generics or familiar brand-name products? Your OTC benefit lets you make the choice! Look over the list of eligible items on the next few pages. You can order online or by calling us and telling us the ID numbers of the items you want. We ll send them to your home and deduct the amount from your monthly benefit. Don t see your items? You can buy these and other items at a store near you and get reimbursed by sending us your itemized receipt and the enclosed OTC claim form. OUR CATALOG ITEMS ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT 1 2 Allergy Relief (Cetirizine) 10mg Tablets Allergy Relief (Loratadine) 10mg Tablets ALLERGY PREVENTION AND TREATMENT 30 $8 501 Zyrtec 14 $15 30 $7 502 Claritin 10 $10 ANALGESICS / ANTIPYRETICS 3 Acetaminophen 325mg Tylenol 325mg Regular 100 $3 503 Tablets Strength Tablets 100 $10 4 Acetaminophen 500mg Tylenol 500mg Extra 100 $4 504 Tablets Strength Tablets 100 $16 5 Aspirin 325mg Tablets 100 $3 505 Bayer Aspirin 325mg 100 $8 6 Aspirin 81mg Chewable 36 $3 No Brand Available 7 Aspirin Enteric Coated Bayer EC Aspirin 81mg 120 $ mg Tablets (Adult Regimen) 32 $4 8 Aspirin Enteric Coated 325mg Tablets 100 $4 508 Ecotrin Tablets 100 $6 ANTACIDS AND ACID REDUCERS 9 Acid Reducer (Famotidine) 10mg Tablets 30 $6 509 Pepcid AC Tab 30 $11 10 Acid Reducer (Omeprazole) 20mg 14 $ Prilosec 14 $12 11 Acid Reducer (Ranitidine) 75mg Tablets 30 $7 511 Zantac Tablets 30 $15 12 Antacid Tablets 150 $4 512 Tums Tablets 150 $6 * = Quantities and brands may vary depending upon availability. = Dual-purpose items ** = Covered under either Part B or Part D wellcareplans.com 3

6 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT ANTACIDS AND ACID REDUCERS 13 Effervescent Tablets 36 $4 513 Alka-Seltzer 24 $7 14 Gas Relief Tablets Extra-Strength 30 $4 514 Gas-X Extra Strength 18 $6 ANTICANDIAL (YEAST) Miconazole Vaginal Monistat Vaginal Cream 15 1 $ Cream 3 day 3 day ANTIDIARRHEAL AND LAXATIVES Adult Glycerin Fleet Adult $3 516 Suppositories Suppositories 17 Anti-Diarrheal Caplets 12 $4 No Brand Available 1 $24 50 $5 18 Anti-Nausea Liquid 4 $6 518 Emetrol 4 $9 19 Bisacodyl 5mg Tablets 25 $4 519 Dulcolax Tablets 25 $7 20 Laxative (Bisacodyl) 10mg Suppositories 12 $5 520 Dulcolax Suppositories 8 $13 21 Stomach Relief Flavored Tablets 30 $3 521 Pepto Bismol Tablets 30 $5 22 Stool Softener Capsules 100 $4 522 Colace Softgels 30 $13 ANTI-INFLAMMATORY 23 Ibuprofen 200mg Liquid Gel Caps 20 $5 523 Advil Liquid Gel Caps 20 $6 24 Ibuprofen 200mg Tablets 50 $5 524 Advil Tablets 50 $10 25 Naproxen Sodium 220mg Caplets 50 $8 525 Aleve Caplets 24 $7 ARTHRITIS MEDICINE 26 Arthritis Pain Relief Tablets 24 $5 No Brand Available 27 Hot/Cold Patches 5 $5 527 Icy Hot Patches 5 $ Adult Protective Briefs Small/Medium Adult Protective Briefs Large BLADDER CONTROL ITEMS 20 $18 No Brand Available 20 $18 No Brand Available wellcareplans.com 4

7 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT Adult Protective Briefs XL Adult Bladder Control Pads Disposable Bed Underpads BLADDER CONTROL ITEMS 20 $20 No Brand Available 28 $9 No Brand Available 5 $6 No Brand Available CHILDREN S PRODUCTS 198 A&D ointment 1 $3 No Brand Available 28 Acetaminophen 80mg Chew Tabs 30 $5 No Brand Available 29 Acetaminophen Infants Drops 1.0 $6 No Brand Available Acetaminophen Jr. 30 Strength Chew Tabs 24 $5 No Brand Available 160mg 32 Children s Chewable Multi-Vitamins 100 $7 No Brand Available 33 Children s Ibuprofen Suspension 100mg 4 $10 No Brand Available 34 Children's Acetaminophen Liquid 4 $5 No Brand Available 35 Children's Cold and Allergy Liquid 4 $5 No Brand Available 31 Children's Glycerin Suppositories 12 $4 No Brand Available 36 Children's Toothbrush 1 $2 No Brand Available 195 Children's Toothpaste 2 $3 No Brand Available 37 Diaper Rash Ointment 1 $3 No Brand Available 38 Diphenhydramine Liquid 4 $4 No Brand Available 39 Duofilm 1 $7 No Brand Available 40 Gas Relief Drops 1 $10 No Brand Available 41 Ibuprofen Infants Drops 0.5 $8 No Brand Available wellcareplans.com 5

8 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT CHILDREN S PRODUCTS 42 Jr. Strength Ibuprofen Chew Tabs 100mg 24 $7 No Brand Available 43 Orajel Baby 0.33 $6 No Brand Available 44 Poly Vitamin Drops 1 $7 No Brand Available 47 Premium (16-28 lbs) Diapers (MEDIUM) 20 $10 No Brand Available 48 Premium (22-37 lbs) Diapers (LARGE) 18 $10 No Brand Available 49 Premium (27+ lbs) Baby Diapers (XLARGE) 16 $10 No Brand Available 50 Premium (35+ lbs) Baby Diapers (XXL) 14 $10 No Brand Available 46 Premium (8-16 lbs) Diapers (SMALL) 24 $10 No Brand Available 45 Premium (Preemie to 6 lbs) Diapers 20 $9 No Brand Available 51 Premium Baby Wipes 80 $4 No Brand Available 52 Tooth and Gum Cleanser 1 $6 No Brand Available COLD/COUGH/FLU REMEDIES 53 APAP Sinus Congestion 24 $4 553 Tylenol Sinus Congestion 24 $8 54 Cough/Throat Drops 30 $3 554 Halls Cough Drops 25 $3 55 Daytime Cold/Flu Relief Caplets 16 $5 555 DayQuil Caplets 16 $8 56 Daytime Cold/Flu Relief Liquid 4 $5 556 DayQuil Liquid 8 $8 174 Daytime/Nite-time Cold/Flu Caplets 16 $5 674 DayQuil/NyQuil caplets 32 $16 57 Mucus Relief DM Tablets 30 $9 557 Mucinex-DM 20 $15 58 Mucus Relief Tablets 30 $8 558 Mucinex 20 $15 59 Nasal Decongestion Spray 1 $4 559 Afrin Nasal Spray 1 $10 6 wellcareplans.com

9 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT COLD/COUGH/FLU REMEDIES 60 Nasal Decongestion PE Tablets 36 $4 No Brand Available 61 Nite-Time Cold/Flu Relief Caplets 16 $5 561 NyQuil Caplets 16 $8 62 Nite-Time Cold/Flu Relief Liquid 4 $5 562 NyQuil Liquid 8 $8 63 Saline Nasal Spray 1.5 $3 563 Ocean Nasal Spray 1.5 $6 64 Sore Throat Spray 6 $4 No Brand Available 65 Tussin DM Syrup SF 4 $4 565 Robitussin DM Syrup 4 $7 66 Tussin Syrup 4 $4 No Brand Available 67 Vapor Rub 3.53 $5 No Brand Available DENTAL AND DENTURE CARE 68 Dental Travel Kit 1 $5 No Brand Available 69 Denture Adhesive Cream 2.4 $4 569 Fixodent 2.4 $5 70 Denture Cleaner 40 $4 570 Efferdent 16 $5 71 Fluoride Toothpaste 6 $2 571 Colgate 4.6 $4 72 Premium Adult Toothbrush 1 $2 572 Aim Toothbrush 1 $3 73 Premium Dental Floss 1 $2 573 Aim Dental Floss 1 $3 74 Premium Mouthwash 1 $3 No Brand Available 75 Sensitive Teeth Toothpaste 4 $3 No Brand Available 76 Toothache Relief $4 576 Anbesol Liquid/Gel Liquid/Gel EAR CARE 77 Ear Syringe 1 $3 No Brand Available 78 Ear Wax Drops 0.5 $6 578 Debrox Ear Wax Drops 0.5 $8 $9 wellcareplans.com 7

10 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT EYE CARE 79 Artificial Tears 0.5 $4 579 Visine Tears 0.5 $7 80 Eyeglass Repair Kit 1 $5 No Brand Available Red Eye Relief Drops 0.5 $3 593 Visine Drops 0.5 $6 FIBER SUPPLEMENTS Vitafusion Fiber Well 94 Fiber Gummies 60 $ $18 Gummies 95 Fibertab Tablets 90 $9 595 FiberCon Tablets 90 $16 FIRST AID AND MEDICAL SUPPLIES 96 Adhesive First-Aid Tape** 1 $2 No Brand Available 189 Aid Ankle Support 1 $8 No Brand Available 8 wellcareplans.com

11 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT FIRST AID AND MEDICAL SUPPLIES 191 Aid Elbow Support 1 $8 No Brand Available 192 Aid Hand Support 1 $8 No Brand Available 166 Aid Knee Support 1 $8 No Brand Available 190 Aid Wrist Support 1 $8 No Brand Available 97 Alcohol Pads** 100 $3 No Brand Available 162 Anti-Embolism Stockings Extra Large 1 $13 No Brand Available 163 Anti-Embolism Stockings Large 1 $13 No Brand Available 164 Anti-Embolism Stockings Medium 1 $13 No Brand Available 165 Anti-Embolism Stockings Small 1 $13 No Brand Available 98 Athletic Bandage** 1 $2 No Brand Available 99 Bandages Assorted 100 $3 599 Band-Aids 100 $7 100 Butterfly Closures** 10 $2 No Brand Available 101 Corn and Callus Remover 0.5 $4 No Brand Available 102 Cotton Balls 100 $2 No Brand Available 103 Cotton Swabs 150 $3 603 Q-Tips Cotton Swabs 170 $4 104 First Aid Kit 1 $8 No Brand Available 105 Flexible Tip Thermometer 1 $10 No Brand Available 106 Ice Bag 1 $4 No Brand Available 187 Kitchen Scale Dial 1 $10 No Brand Available 107 Liquid Wart Remover 0.5 $6 607 Compound W Wart Remover 108 Oral Digital Thermometer 60 Second 1 $5 No Brand Available 188 Peak Flow Meter 1 $14 No Brand Available 194 Pedometer 1 $10 No Brand Available wellcareplans.com 9 1 $8

12 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT FIRST AID AND MEDICAL SUPPLIES 202 Spacer 1 $14 No Brand Available 109 Stretch Gauze Bandage** 1 $2 No Brand Available 124 Thermometer Probe Covers 30 $3 No Brand Available HEADACHE RELIEF 110 Headache Relief Tablets 24 $4 610 Excedrin Migraine 24 $6 HEMORRHOIDAL PREPARATIONS 111 Hemorrhoid Ointment 2 $7 611 Preparation H Ointment 2 $ Hemorrhoid Pads 100 $8 612 Tucks Medicated Pads 100 $ Hemorrhoid Relief Suppositories Preparation H 12 $5 613 Suppositories LACTOSE INTOLERANCE 12 $7 114 Lactase Enzyme 60 $ Lactaid Tablets 32 $10 MOTION SICKNESS MEDICATION Dramamine Motion 115 Motion Sickness Tablets 12 $3 615 Sickness OTHER ITEMS 199 Antibacterial Bar Soap 1 $3 No Brand Available 117 Antibacterial Liquid Hand Soap Pump 1 $5 No Brand Available 118 Antibacterial Wet Wipes 24 $4 No Brand Available 119 Calamine Lotion 6 $4 No Brand Available 120 Disposable Douche Twin Pack 1 $5 No Brand Available 121 Dry Skin Therapy Moisturizing Cream 1 $8 No Brand Available 122 Feminine Hygiene Wipes 40 $5 No Brand Available 123 Fever Strip Thermometer 1 $3 No Brand Available 12 $6 wellcareplans.com 10

13 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT OTHER ITEMS 125 Hand Sanitizer Spray Pen Twin Pack 1 $3 No Brand Available 126 Lip Balm 1 $1 No Brand Available 127 Male Condoms 3 $2 No Brand Available 201 Maxi-Pads 12 $3 No Brand Available 135 Medicine Dropper 1 $2 No Brand Available 128 Medicine Spoon 1 $1 No Brand Available 130 Pill Box 1 $2 No Brand Available 131 Pill Splitter 1 $3 No Brand Available 132 Pocket Facial Tissue 1 $2 No Brand Available 133 Pregnancy Test 1 $8 No Brand Available 134 Premium Tampons 8 $2 No Brand Available PEDICULICIDES (HEAD LICE TREATMENTS) 136 Lice Comb 1 $3 No Brand Available 137 Lice Treatment Shampoo 4 $ Rid Lice Shampoo 4 $ SLEEPING AIDS Night Time Sleep Tablets (Diphenhydramine) 24 $4 638 Sominex Tablets 16 $7 Sleep Aid Tablets (Doxylamine) 16 $5 639 Unisom Tablets 16 $7 SMOKING CESSATION PRODUCTS 196 Nicotine Gum 2mg 20 $10 No Brand Available 197 Nicotine Gum 4mg 20 $10 No Brand Available TOPICAL OINTMENTS AND CREAMS 140 Anti-Itch Cream 1 $3 640 Benadryl Cream 1 $ Clotrimazole 1% Cream 1 $5 641 Lotrimin AF $10 wellcareplans.com 11

14 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT TOPICAL OINTMENTS AND CREAMS 142 Cold Sore Treatment 1 $8 No Brand Available 143 Hydrocortisone 1% Cream 1 $3 No Brand Available 144 Muscle Rub Cream 1.25 $3 644 Bengay 2 $6 145 Petroleum Jelly 4 $3 645 Vaseline Jelly 171 SPF 50 Sunblock 4 $6 No Brand Available 146 Tolnaftate 1% Cream 147 Triple Antibiotic Ointment 1.25 wellcareplans.com $5 646 Tinactin Cream 0.5 $10 1 $4 647 Neosporin Ointment 0.5 $6 VITAMINS AND MINERALS 148 Adult Multi-Vitamins 100 $8 No Brand Available 149 Calcium Vitamin D 60 $6 649 Caltrate D Tablets 60 $ Calcium Tablets 60 $5 No Brand Available 151 Ferrous Sulfate (Iron) 325mg Tablets 100 $6 No Brand Available 152 Folic Acid 400mcg Tablets 100 $4 No Brand Available 153 Magnesium 250mg Tablets 100 $4 No Brand Available 155 Vitamin A 10,000 IU Caplets 100 $4 No Brand Available 156 Vitamin B $5 No Brand Available 157 Vitamin B-Complex 100 $5 No Brand Available 158 Vitamin B-Complex Gummy 70 $8 No Brand Available 159 Vitamin C 500mg Tablets 100 $4 No Brand Available 193 Vitamin C Gummy 60 $8 No Brand Available 160 Vitamin E 100 IU Caplets 100 $7 No Brand Available 161 Zinc 50mg Tablets 100 $5 No Brand Available $5

15 ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT ADAPTIVE AIDS 172 Adult Bib Clothing Protector 1 $12 No Brand Available 186 Button and Zipper Puller 1 $5 No Brand Available 173 Door Knob Gripper 1 $6 No Brand Available 175 Jar Opener/Faucet Gripper 1 $6 No Brand Available 176 Key Turner 1 $3 No Brand Available 177 Lamp Switch Turner 1 $3 No Brand Available 178 Letter Opener 1 $2 No Brand Available 179 Long Handle Bath Sponge 1 $7 No Brand Available 180 Pill Bottle Opener Aid 1 $4 No Brand Available 181 Pill Crusher 1 $8 No Brand Available 182 Reaching Aid Device 1 $15 No Brand Available 183 Shopping Bag Carrier 1 $4 No Brand Available 184 Soap Gripper 1 $8 No Brand Available 185 Toothpaste Squeezer 1 $3 No Brand Available wellcareplans.com 13

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17 $ $ $ Grand Total: $ NY027668_HIX_FRM_ENG Internal Approved WellCare 2014 NY ~ NY50TCFRM62751E " Over-the-Counter (OTC) Items Claim Form FAX form and receipt to OR MAIL form and receipt to WellCare OTC DMR Center P.O. Box Tampa, FL Use this claim form to be reimbursed for eligible OTC items. Please submit one form per member. Member Name: Subscriber ID: 0 Check here if new address Address: City: State: Telephone:_{ Receipts must be submitted within 90 days of receipt date and are processed within 30 days of receipt. Do not send original receipts. Purchase Date Merchant Name Merchant ZIP Code Item Name/Description Package Size Total Item Cost ~ist URL if an online purchase) {if multiple count of same item, use a line for each count) ZIP Code: {i.e., 6, 36 capsules/tablets) {include any applicable tax in the totaq By signing this form, I confirm that the request for reimbursement is for eligible over-the-counter items and is not covered by any other plan or program. (If you have questions regarding eligible items, please refer to your OTC benefit information or call Customer Service at the number listed on the back of your member ID card.) Member's Signature: Date: ~WellCare Health Plans

18 Sample Receipt*: Remember: Green Pharmacy 123 West Road Tampa, FL # /13/13 Aspirin 325 mg. $10.00 Daytime Cold Relief $10.00 Candy $6.00 SUBTOTAL $26.00 TAX (7%) $1.82 TOTAL $27.82 r Complete the claim form on the other side of this page. r Include a copy of the receipt for the item(s) purchased. r Your receipt must include the date of purchase and item(s) purchased. All fields must be completed for reimbursement. Handwritten receipts will not be accepted. r You may fax or mail your claim form and receipt, but faxing provides faster customer service. r FAX your form and receipt to: WellCare OTC DMR Center at OR r MAIL your form and receipt to: WellCare OTC DMR Center P.O. Box Tampa, FL et more informa tion or le earn how t o g et more claim f orms, ple eas ase act Cust omer Service e at one of the tol l-free number s listed in y our T c O o g ont TC benefit inf orma tion. Sample Claim Form: Purchase Date Merchant Name Merchant ZIP Code Item Name/Description Package Size Total Item Cost (list URL if an online purchase) (if multiple count of same item, use a line for each count) (i.e., 6, 36 capsules/tablets) 8/13/2013 Green Pharmacy Aspirin 325mg 100 tablets $10.70* (include any applicable tax in the total) 8/13/2013 Green Pharmacy Daytime Cold Relief 16 $10.70* Grand Total: $21.40 * To calculate total item cost, multiply cost of item by 7% tax ($10.00 X.07 = $0.70) and add together ($ $.70 = $10.70).

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20 Customer Service: TTY/TDD: We re here to help Monday Friday, 8 a.m. to 7 p.m. This document is available in alternate languages. Please call Customer Service at the number listed above for alternate languages available in your area. Este documento se encuentra disponible en idiomas alternativos. Para obtener información sobre los idiomas alternativos disponibles en su área, por favor llame a Servicio al Cliente al número indicado más arriba. 本文件備有可選語言版本 請致電上列電話號碼, 聯絡客戶服務部, 索取您所在地區提供的可選語言版本 NY027662_HIX_OTC_ENG Internal Approved WellCare 2014 NY_09_14 NA5OTCCAT62731E 62731

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