2016 Over-the-Counter (OTC) Benefit Catalog

2016 Over-the-Counter (OTC) Benefit Catalog As a member of Care1st Health Plan, you have an Over-the-Counter (OTC) benefit every quarter. This benefit allows you to get OTC products you may need such as bandages, cold and allergy medicines, pain relievers, and vitamins at no cost to you. Benefit amounts do not roll over, so be sure to use them before the end of every quarter. Simply call the toll-free number OR fill out and mail the order form provided. Your order will be shipped directly to your door. Special Benefit for Care1st Health Plan Members Get Over-the-Counter Products Every Quarter at No Cost to You! Information on how to place your OTC order can be found on the last page. *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. H5928_16_013_PD_OTC Accepted

2. You can get the following items without having to talk with your doctor, but we always recommend that you talk with your doctor before starting a new product regimen. Acne Treatment Acne Gel 10% Benzoyl Peroxide 1.5 oz 1076 $7.20 Allergy, Cold, Flu, Decongestant and Sinus All Day Allergy Tablets 14 tabs 1090 $7.90 All-Nite Cold/Flu 500-15-6.25 mg 1361 $8.30 Children's Dimaphen 4 oz 1426 $6.10 Children's Diphenhydramine HCL 1428 $6.60 Chlorpheniramine Maleate 100 tabs, 4 mg 1008 $6.00 Cromolyn Sodium (Allergy Nasal Spray) 1356 $21.40 Cough & Cold for High Blood Pressure 16 tabs 1166 $9.30 Diphenhist (Antihistamine) 100 tabs 1308 $7.90 Diphenhydramine HCL 24 capsules, 25 mg 1009 $8.30 Multi Symptom Cold Formula 24 tabs 1357 $8.40 Nasal Decongestant Spray 12 Hr, 1oz 1091 $9.50 Nasal Spray (Saline) 1.5 oz 1052 $9.50 Sudogest PE 36 tabs, 10 mg (Nasal and Sinus Decongestant) 1352 $6.00 Vapor Rub 1 oz 1164 $8.40 Pain Relievers and Fever Reducers Acetaminophen 100 tabs, 325 mg 1001 $8.60 Acetaminophen 50 tabs, 500 mg 1105 $6.00 Aleve 100 tabs, 220 mg 1104 $14.20 Aspirin 100 tabs, 325 mg 1095 $4.90 Aspirin Enteric Coated 100 tabs, 325 mg 1096 $7.10 Aspirin Low Dose 1002 120 tabs, 81 mg $7.10 Children's Acetaminophen 30 chewables, 80 mg 1423 $6.20 Children's Ibuprofen 100 mg/ 5 ml 1421 $8.20 Ibuprofen 100 tabs, 200 mg 1004 $8.70 Menstrual Relief 24 tabs 1257 $6.90 Naproxen *D 100 tabs, 220 mg 1097 $14.40 Pain Reliever PM Extra Strength 100 tabs 1332 $11.60 Antacids and Acid Reducers Alka-Seltzer 36 tabs 1313 $15.20 Chewable Antacid 150 tabs, 500mg 1346 $7.00 Effervescent Pain Reliever 36 tabs 1314 $8.90 Famotidine *D 30 tabs 1108 $7.30 Gas-X 36 chewables, 80 mg 1312 $8.60 Antacid/Anti-Gas Liquid 1006 $9.50 Omeprazole *D 28 caps 1110 $39.80 Anti-Arthritic Arthritis Pain Reliver 100 tabs 1311 $19.40 Capsaicin 1367 $11.40 Glucosamine Joint/Muscle 1114 60 capsules $13.30 Glucosamine/Chondroitin 60 capsules 1003 $16.50

Anticandial (Yeast) Clotrimazole Vaginal Cream w/applicator *D 1115 $12.80 Micanozole 3 Day Treatment 1117 $16.90 Tioconazole 1 Day Treatment with applicator 1119 $29.10 Antidiarrheal Bismatrol (Bismuth Subsalicylate) 30 tabs 1045 $7.90 Loperamide HCL *D 12 tabs 1133 $5.90 Pepto-Bismol 1317 $15.40 Pink Bismuth 1318 $8.40 Antifungal Clotrim Antifungal Cream 1047 $13.00 Miconazole 2% Cream 1135 $13.60 Terbinafine HCL Tube 1046 $16.70 Tolnaftate Cream 1064 $5.90 Anti-Itch Lotions and Creams Bactine Solution 1142 $12.60 Pramoxine Topical Analgesic 1144 $10.80 Diphenhydramine HCL/ Zinc Acetate 1140 $5.80 Hydrocortisone 1% Cream 1074 $5.80 Contact Lens Supplies Multi Purpose Contact Lens Solution 1468 $8.40 Cough Suppressants and Expectorants Cherry Cough Drop 30 lozenges 1056 $10.10 Diabetic Tussin DM 1323 $9.60 Guaifenesin Cough Expectorant 60 tabs 1180 $11.00 Cough Syrup, Expectorant 1054 $5.00 Mucus Relief DM (Guaifenesin Expectorant and Dextromethorphan Cough Suppressant) 30 tabs, 400-20 mg 1178 $8.00 Sore Throat Lozenges Cherry 18 lozenges 1176 $7.10 Sugar Free Cough Drop Cherry 25 lozenges 1182 $6.40 Dental/Denture Care Dental Floss 55 yards 1455 $5.90 Denture Cleaning Tablets 40 tabs 1032 $7.90 Fixodent 1187 $9.10 Oral Pain Relief 1286 $8.70 Orajel Pain Relief 1454 $9.30 Cold Sore, Fever Blister and Other Medicated Lip Products Abreva 1152 $20.60 Blistex Lip Ointment 1256 $5.90 Carmex 1255 $5.40 Herpecin-L Lip Balm 1153 $9.10 Releev Cold Sore Treatment 1359 $40.10 Rechargeable Toothbrush 1450 $38.20 Tooth Brush Colgate Clean Adult Soft 1413 $5.20 Tooth Brush Tek Pro Straight Soft 1412 $4.80 Tooth Paste Pepsodent 1414 $5.90 Polident Denture Cream 1324 $11.20 *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. 3.

4. Digestive Health Beano 30 tabs 1316 $9.40 Enema 4.5 oz 1733 $8.00 Lactase Capsules 60 capsules 1067 $12.30 Ear Care Ear Drops 1190 $6.30 Ear Wax Removal System with Rubber Bulb 1363 $9.90 Eye Care Artificial Tears Drops 1192 $6.10 Clear Eyes Eye Drops 1199 $8.20 Eye Drops (Redness Relief) 1061 $6.10 Eye Wash Solution 1196 $7.00 Artificial Tears Ointment 1194 $11.40 First Aid and Medical Supplies Adhesive Bandages 60 bandages 1344 $8.00 Alcohol Pads *D 100 pads 1200 $7.10 Ankle Support 1225 $11.50 Antiseptic Towelettes 100 pack 1201 $7.60 Automatic Blood Pressure Monitor Desktop 1253 $44.40 Bath Bench WITH Back 1728 $71.00 WITHOUT Back 1727 $55.00 Bath Mat (non-skid) 1459 $18.50 Bath Tub Safety Rail 1730 $38.00 Conforming Gauze Sterile *B 12 pads, 3 X 4 yd 1223 $15.00 Cushion FOAM RING 1732 $22.00 LUMBAR 1731 $27.00 Elastic Bandage *B 2 X 5 yd 1207 $4.50 3 X 5 yd 1209 $4.80 4 X 5 yd 1211 $5.20 6 X 5 yd 1213 $6.10 First Aid Kit 48-piece 1215 $10.60 Folding Cane with Ergonomic Handle 1726 $22.00 Hot/Cold Pack for Injury 1062 $8.50 Hydrogen Peroxide 1228 $5.10 Lantiseptic Skin Protectant Ointment 1202 $10.60 Knee Stabilizer 1465 $27.10 Neosporin Plus 1326 $14.70 Night Wrist Support Smart Glove 1463 $35.40 Povidone Iodine 1203 $5.30 Raised Toilet Seat 1729 $36.00 Rib Belt One size fits most MALE 1456 $25.20 FEMALE 1457 $25.20 Shower Mat (non-skid) 1460 $28.50 Tape, Paper Surgical *B 1 X 10 yd 1217 $4.70 2 X 10 yd 1218 $5.90 Tape, Silk Surgical *B 1 X 10 yd 1219 $5.40 2 X 10 yd 1220 $7.20 Tape, Transparent Surgical *B 1 X 10 yd 1221 $5.30 2 X 10 yd 1222 $7.00 Thermometer DIGITAL 1063 $9.60 DIGITAL - EAR 1285 $16.70

Wintergreen Isopropyl Alcohol 1229 $7.40 Wrist Splint 1230 $23.90 Wrist Support 1227 $13.50 Foot Care Callus Remover Pads 6 pads 1238 $9.80 Corn Remover Pads 9 pads 1236 $9.80 Medicated Foot Powder 1240 $7.40 Hemorrhoidal Preparations Hemorrhoidal Ointment 1066 $9.00 Hemorrhoidal Suppository box of 12 1247 $6.60 Preparation H Cream 1248 $18.50 Pre-Moist Hemorrhoid Pads 100 pads Home Diagnostics 1364 $12.10 Colon Cancer Test 1416 $18.60 Home Access Cholesterol Test 1251 $38.10 Incontinence Supplies A&D Ointment 1300 $6.60 Adult Briefs Med 32" - 44 waist, 12 pk LG 45-58 waist, 18 pk XL 59-64 waist, 15 pk 1303 1304 1305 $12.60 $15.60 $15.60 Barrier Cream 1302 $10.50 Underpad 23" x 36" 1299 $16.00 Washcloth w/lanolin 1348 $9.60 Laxatives Bisacodyl 100 tabs 1128 $6.50 Docusate Sodium 100 capsules 1126 $18.10 Ex-Lax 8 tabs 1124 $8.20 Glycerin Suppository 1125 25 tabs, 2 gm $6.80 Methylcellulose 1354 $19.90 Milk of Magnesia 12 oz 1011 $8.40 Natural Vegetable Laxative 1340 $16.00 Polycarbophil Fiber Tablets 1012 90 tabs $13.70 Senna Plus 60 tabs, 8.6-50 mg 1130 $8.70 Migraine Relief Migraine Relief 100 tabs 1365 $9.90 Wellpatch Migraine box of 4 1261 $11.10 Minerals Calcium Carbonate Tabs 1291 60 tabs $8.30 Calcium-Vitamin D 60 tabs 1373 $6.50 Ferrous Sulfate 100 tabs, 325 mg 1376 $7.60 Niacin 100 tabs, 100 mg 1378 $7.00 Niacin 100 tabs, 500 mg 1394 $9.60 Magnesium 110 tabs, 250 mg 1418 $8.40 Magnesium Oxide 100 tabs, 250 mg 1377 $9.30 Rena-Vite 100 tabs 1395 $21.40 Zinc Chelated 100 tabs, 50 mg 1419 $7.40 *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. 5.

Motion Sickness Dramamine Orange 8 chews 1264 $10.70 Driminate 12 tabs 1263 $6.00 Meclizine 100 tabs 1366 $12.00 Pediculicide Lice Treatment Shampoo 1271 $14.00 Permethrin Cream Rinse 1269 $17.70 Personal Care Ammonium Lactate 1368 $14.30 Aloe Vera Cream 1070 $10.70 Hand Sanitizer 1065 $7.20 Sunscreen Lotion SPF 30 1284 $12.80 Sleep Aids Nasal Strips box of 30 SMALL/MEDIUM 1724 $14.00 MEDIUM/LARGE 1725 $14.00 Sleep Tabs 24 tabs 1276 $7.10 Smoking Cessation Nicorelief Gum 1372 $27.00 Nicotine Patches box of 14 STEP 1 21 mg/24 hr 1369 $40.30 STEP 2 14 mg/24 hr 1370 $40.30 STEP 3 7 mg/24 hr 1371 $40.30 Support Items Men's Compression Knee Hi Socks BLACK - LG Shoe size 10 1/2-12 (15-20 mmhg) 1399 $27.40 WHITE - MED Shoe Size 8-10 (15-20 mmhg) 1400 $27.40 WHITE - LG Shoe Size 10 1/2-12 (15-20 mmhg) 1401 $27.40 Women's Compression Knee Hi Socks NUDE - SM Shoe Size 4-5 (8-15 mmhg) 1406 $16.60 NUDE - MED Shoe Size 5 1/2-7 1/2 (8-15 mmhg) 1407 $16.60 NUDE - LG Shoe Size 8-10 1/2 (8-15 mmhg) 1408 $16.60 BLACK - SM Shoe Size 4-5 (8-15 mmhg) 1409 $16.60 BLACK - MED Shoe Size 5 1/2-7 1/2 2 (8-15 mmhg) 1410 $16.60 BLACK -LG Shoe Size 8-10 1/2 (8-15 mmhg) 1411 $16.60 Topical Antibiotics Bacitracin Ointment 1020 $5.80 Triple Antibiotic Ointment 1014 $9.90 Wart Remover Dr. Scholl s Wart Removal System 1288 $19.70 Wart Remover 1075 $9.00 Wartners Wart Removal System Kit 1289 $27.90 6. *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D.

Before ordering any of the items below, you should talk with your doctor. Vitamins Centrum Silver 60 tabs 1420 $33.50 Daily Multiple Vitamin Tabs 100 tabs 1385 $7.10 Ferrous Gluconate (Iron Supplement) 100 tabs 1375 $7.60 Iron 110 tabs, 27 mg 1417 $10.00 Multi Vitamin Children's 100 chewables 1422 $10.00 Prenatal Vitamins 100 tabs 1274 $10.00 Vitamin A 100 tabs, 10 mu 1379 $6.30 Vitamin B-Complex 100 tabs 1382 $8.20 Vitamin B-1 100 tabs, 100 mg 1016 $7.50 Vitamin B-6 100 tabs, 50 mg 1380 $6.60 Vitamin B-6 100 tabs, 100 mg 1388 $7.10 Vitamin B-12 100 tabs, 500 mg 1389 $8.20 Vitamin B-12 100 tabs, 1000 mcg 1381 $11.20 Vitamin C 500 mg, 100 tabs 1017 $6.50 Vitamin Century Senior 90 tabs 1392 $13.10 Vitamin D 100 tabs, 1000 iu 1390 $8.10 Vitamin D 100 tabs, 400 iu 1383 $8.00 Vitamin E 100 tabs, 100 iu 1391 $7.40 Vitamin E 100 tabs, 400 iu 1384 14.40 Vitamin One A Day 100 tabs 1393 $8.10 Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. 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: 711), 8am - 8pm PST, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los Miembros: 1-800-544-0088 (TTY: 711), de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. 這 項 免 費 資 訊 T 以 其 它 語 言 提 供 懇 請 聯 絡 會 員 服 務 Ł 處 : 免 費 熱 線 1-800-544-0088 ( 聽 障 及 語 障 人 士 h 專 線 711) 每 週 七 天 辦 公, 早 上 8:00 點 I 至 晚 上 8:00 點 7.

Helpful Information If you have questions or would like to place an order over the phone, OTC Advocates are available Monday Friday from 8:00am to 5:00pm PST at 1-800-355-7913 (TTY 711). If you place your order using an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29th, but we receive it on July 1st, your order total 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. We encourage you to use your full quarterly benefit amount in one order. This benefit amount does not roll over from quarter to quarter. Your order total may not exceed the quarterly benefit amount shown in the letter you received with this catalog. Cash, checks or money orders are not accepted under this 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. To use your benefit, you must select products from this catalog that will help you with a health or medical need. Your order total may not exceed your benefit amount. OTC products are intended for members use only. Care1st Health Plan prohibits the use of this benefit to order OTC items for family members and friends. OTC items are available through mail-order only. Once your order is received, please allow 7-10 business days for delivery. Products may not be purchased at a local retail pharmacy or through any other source other than the Care1st Health Plan OTC Benefit Catalog. If you disenroll from Care1st Health Plan, your OTC benefit will automatically terminate. Returns are not accepted. Some items listed in this catalog 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 administering insulin. For all other purposes, this item is covered under your OTC benefit. Items in the 2016 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 Advocates from Monday - Friday from 8:00am to 5:00pm PST at 1-800-355-7913 (TTY 711).