Section d – appendices

2014 OVER-THE-COUNTER (OTC) LIST
Eligible Over-the-Counter (OTC) Expenses include medicines or products that help treat injuries or illness for you. You do not need to provide a statement from a medical provider or indicate a diagnosis in order to receive reimbursement. The products listed here are examples, and this list does not include every OTC item. OTC items may only be purchased by you and are for your use only. By regulation, you are cannot buy OTC items for family members or friends. If it is discovered that you bought OTC items for family or friends, you could be required to pay back for the items you purchased, and you could face additional penalties, such as loss of your Fidelis Medicare Advantage or Dual Advantage coverage and/or criminal prosecution. Dual purpose items listed below may be purchased, but (1) the enrollee must speak with his or her primary care provider, and (2) the provider recommends the OTC item for a specific condition. Members enrolled in Fidelis Dual Advantage and Fidelis Dual Advantage Flex receive the OTC benefit through a debit card that is redeemable at most chain pharmacies (e.g., CVS, RiteAid, Duane Reade, Walgreens, etc.) The 2014 OTC benefit amount is: Fidelis Medicare Advantage without Prescription Drugs Medicaid Advantage Plus Not Available Fidelis Long Term Care Advantage
*Additional OTC purchases can be made up to the amount of your Flex Benefit limit.
We have supplied a list of covered and non-covered items below. If you are unsure as to whether
an OTC item is covered, before you buy the item, please call Member Services 1-800-247-1447.
From October1 to February14th our office hours are 8:00 a.m. to 8:00 p.m. seven days a week and
from February 15th through September 30th, our office hours are Monday through Friday, 8:00 a.m.
to 8:00 p.m. TTY users should call 1-800-695-8544.558-1125
Please note that in 2014, you must submit receipt(s) for Flex benefit reimbursement within 90
days from the date you received the item or service.
EXAMPLES OF COVERED ITEMS
Acetaminophen (TYLENOL) Acne Medication ALIGN Allergy Relief Medicine (Antihistamines, SUDAFED, BENADRYL, CLARITIN) Analgesic Ointment (Deep-Heat Rub, Pain Patches) Antacids (GAS-X, MYLANTA, PRILOSEC OTC) Antibiotics - Topical (NEOSPORIN, BACITRACIN) Aspirin Bandages Blood pressure monitor/cuff Bowel prep kit Chap Stick - Medicated Cold Sore/Blister Medications (ABREVA) Colon Cleanse Compression Stockings Cough/Cold/Flu Medicine/Cough Drops (TYLENOL COLD & FLU, ADVIL COLD & SINUS) Dental Care (Toothbrushes, Toothpaste, Mouthwash, POLYGRIP, ORAJEL) Diabetic Supplies (Test Strips, Insulin) Epsom Salt (Anti-Itch, Muscle Soothing Salt) Eye Drops (Allergy, Lubricants) Eye Lid Wipes Foot Care (Callous Removers, Bunion, Blister, and Corn Treatments) Hemorrhoid Medications (PREPARATION H) Ibuprofen (MOTRIN, ADVIL) Incontinence Supplies - Adult Diapers (DEPENDS, POISE) Lactose Intolerant Medications (LACTAID, LACTRASE) Laxatives (DIOCTO, DULCOLAX, COLACE) OYSTER CALCIUM Rash Ointments (A&D ointment, DESITIN, BALMEX) Rubbing Alcohol (Peroxide, Witch Hazel) Smoking Cessation Aids (NICORETTE Gum) Sunscreen Vitamins (A, B, B5, C, D, E, BIOTIN, Niacin) EXAMPLES OF NON-COVERED ITEMS
HERBAL REMEDIES
NUTRACEUTICALS
Proline- Non-essential synthetic compound SC4: Secretagogue HGH human growth hormone EXAMPLES OF NON-COVERED ITEMS
OTHER/MISC
PROBIOTICS
Eligibility Type
Category
Sub-categories
Exceptions
Eligibility Type
Category
Sub-categories
Exceptions
Eligibility Type
Category
Sub-categories
Exceptions
Notes: 1. Each item in the following alphabetized list is either a medicine, ointment or spray, or a condition which is addressed by a medicine, ointment or spray, which has active medical ingredients: acne, allergy, analgesics (which reduce pain, inflammation), anti-acid, anti-arthritics, antibiotics, antiradicals, anti-diarrheas, anti-fungals, anti-gas, anti-histamines, anti-inflammatory, anti-insect, anti-itch, anti-parasitic, antiseptics, antipyretics (fever reducing), arthritis, asthma, blood clotting, bruises, burns, calluses, corns, colds, cold sores, cough, diabetes, flu, decongestants, dermatitis, eczema, digestive aids, ear drops, expectorants (mucus), eye drops, gastro-intestinal, hay fever, headaches, hemorrhoidal, incontinence, influenza, laxatives, (medicated) lactose intolerance products, lice, (medicated) lip products, menopausal, menstrual, sinus, motion sickness, nasal, osteoporosis, pain, psoriasis, pediculicide, rash, respitory, scars, sleep, smoking, snoring, sore throat, stomach problems, travel sickness, steroids, sunscreen, thrush, wart, worms, wounds. 2. The following are not eligible: Baby medicines are non-eligible. Dehydration drinks are non-eligible. Dry skin lotions (e.g. Eucerin, Aquaphor) are non-eligible. For Food supplements see below. Contraceptives are non-eligible. Dairy Care is non-eligible (it is non-medicated). Lactaid milk is a food (not a medicine) and non-eligible. Certain smoking cessation aides may be covered under Part B. Certain diabetic supplies may be covered under either Part B or Part D. Shampoos to fight dandruff are non-eligible. Hair-loss products are non-eligible. 3. Lip balm, deodorants, facial cleansers, feminine products, grooming devices, hair conditioners, hair removal, hair bleaches, moisturizers, perfumes, anti-perspirants, shampoos, shaving and men’s grooming, and soaps.

Source: http://www.fideliscareny.com/Portals/0/DocumentLibrary/Products/Medicare/2014%20Products/OTCList.pdf