2019 Over-the-Counter Drugs and Vitamins - Puerto Rico*

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1 209 Over-the-Counter Drugs and Vitamins - Puerto Rico* Federal Employees Health Benefits Program Effective January, 209 OVER-THE COUNTER COVERAGE FOR PUERTO RICO CATEGORY PRODUCT LIMIT Allegra-D 2 Hour Allergy Allegra-D 24 Hour Allergy cetirizine/pseudoephedrine fexofenadine/pseudoephedrine loratadine/pseudoephedrine Antihistamines - 2nd Generation Allegra Allergy Antihistamines - 2nd Generation cetirizine hcl Antihistamines - 2nd Generation Children S Allegra Allergy Antihistamines - 2nd Generation Children S Zyrtec Antihistamines - 2nd Generation Children S Zyrtec Allergy Antihistamines - 2nd Generation Claritin Antihistamines - 2nd Generation Claritin Reditabs Antihistamines - 2nd Generation fexofenadine hcl Antihistamines - 2nd Generation levocetirizine dihydrochloride Antihistamines - 2nd Generation loratadine Eye Antihistamines ketotifen fumarate Proton-pump Inhibitors esomeprazole Proton-pump Inhibitors lansoprazole Proton-pump Inhibitors Nexium 24HR Proton-pump Inhibitors omeprazole Proton-pump Inhibitors Prilosec * NOTE: Select over-the-counter () drugs will be covered at a $0 copayment when prescribed by a physician. PAGE of 4

2 ascorbic acid (vitamin C) ASCORBIC ACID 500 MG/ML VIAL calcitriol CALCITRIOL 0.5 MCG CAPSULE calcitriol CALCITRIOL MCG/ML AMPUL calcitriol CALCITRIOL MCG/ML SOLUTION calcitriol CALCITRIOL 0.25 MCG CAPSULE Corvita Corvita.25 mg-2.5 mg-7 mg Corvite Corvite.25 mg-2.5 mg-7 mg cyanocobalamin (vitamin B-2) CYANOCOBALAMIN 0,000 MCG/0 cyanocobalamin (vitamin B-2) CYANOCOBALAMIN,000 MCG/ML cyanocobalamin (vitamin B-2) CYANOCOBALAMIN 0,000 MCG/0 Ferrex 50 Forte Plus Ferrex 50 Forte Plus 50 mg-60 mg-25 mcg- mg capsule Folbee Folbee 2.5 mg-25 mg- mg Folbee Plus Folbee Plus 5 mg Folbee Plus Folbee Plus 5 mg-.5 mg-25 mg Folgard OS Folgard OS 500 mg-. mg folic acid FOLIC ACID 5 MG/ML VIAL hydroxocobalamin HYDROXOCOBALAMIN,000 MCG/ML Infed Infed 00 mg/2 ml (50 mg/ml) injection solution Infuvite Adult Infuvite Adult 00 unit-50 mcg/0 ml intravenous solution Infuvite Pediatric Infuvite Pediatric 80 mg-400 unit-200 mcg/5 ml intravenous solution Klor-Con 0 Klor-Con 0 meq,extended release Klor-Con M5 Klor-Con M5 meq,extended release leucovorin calcium LEUCOVORIN CALCIUM 25 MG TAB leucovorin calcium LEUCOVORIN CALCIUM 0 MG TAB leucovorin calcium LEUCOVORIN CALCIUM 5 MG TAB leucovorin calcium LEUCOVORIN CALCIUM 5 MG TAB Mephyton Mephyton 5 mg * NOTE: Select over-the-counter () drugs will be covered at a $0 copayment when prescribed by a physician. PAGE 2 of 4

3 Nephplex Rx Nephplex Rx mg-60 mg-00 mcg-2.5 mg Nephro-Vite Rx Nephro-Vite Rx mg-60 mg-00 mcg Neurin-SL Neurin-SL 600 mcg-600 mcg sublingual Poly-Vi-Flor Poly-Vi-Flor 0.25 mg/ml fluoride biphasic oral drops Poly-Vi-Flor with Iron Poly-Vi-Flor with Iron 0.25 mg fluoride-7 mg iron/ml bphase oral drops potassium chloride POTASSIUM CL ER 0 MEQ TABLET potassium chloride POTASSIUM CL ER 20 MEQ TABLET POTASSIUM CHLORIDE CR Potassium Cl Er 0 Meq Tablet POTASSIUM CHLORIDE CR Potassium Cl Er 20 Meq Tablet Proferrin-Forte Proferrin-Forte 2 mg- mg Se-Tan Plus Se-Tan Plus 62 mg-5.2 mg (06 mg)- mg capsule sodium fluoride SODIUM FLUORIDE MG (2.2 MG) sodium fluoride FLUORIDE 0.25 MG TABLET CHEW sodium fluoride SODIUM FLUORIDE 0.5 MG/ML DROP sodium fluoride SODIUM FLUORIDE 0.5 MG(. MG) sodium fluoride FLUORIDE 0.5 MG TABLET CHEW sodium fluoride FLUORIDE MG TABLET CHEWABLE Strovite One Strovite One mg-,000 unit-5 mg-5 mg Supervite Supervite,000 mg-75 mg- mg/5 ml oral liquid Tandem Plus Tandem Plus 62 mg-5.2 mg (06 mg)- mg capsule TL Icon TL Icon 0 mg-0.5 mg capsule Tri-Vi-Flor Tri-Vi-Flor 0.25 mg/ml fluoride biphasic oral drops * NOTE: Select over-the-counter () drugs will be covered at a $0 copayment when prescribed by a physician. PAGE of 4

4 Tri-Vi-Flor Tri-Vi-Flor 0.5 mg/ml fluoride biphasic oral drops Tri-Vi-Floro TRI-VI-FLORO 0.25 MG/ML DROP Tri-Vi-Floro TRI-VI-FLORO 0.5 MG/ML DROP Tri-Vitamin With Fluoride Tri-Vitamin With Fluoride 0.5 mg fluoride (. mg)/ml oral drops Tri-Vitamin With Fluoride Tri-Vitamin With Fluoride 0.25 mg fluoride (0.55 mg)/ml oral drops Virt-Vite Virt-Vite 2.5 mg-25 mg- mg Vitamin B-Complex 00 B-complex 00 Injection vitamin K vitamin K mg/0.5 ml injection solution Vitamin K Vitamin K 0 mg/ml injection solution zinc sulfate ZINC SULFATE 220 MG CAPSULE zinc sulfate Zinc 50 Mg Capsule * NOTE: Select over-the-counter () drugs will be covered at a $0 copayment when prescribed by a physician. Offered by Humana Health Plans of Puerto Rico, Inc. License # PAGE 4 of 4

5 Discrimination is against the law Humana Inc. and its subsidiaries comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries provide: ()free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate; and, (2) free language services to people whose primary language is not English when those services are necessary to provide meaningful access, such as translated documents or oral interpretation. If you need these services, call or if you use a TTY, call 7. If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Discrimination Grievances, P.O. Box 468, Lexington, KY If you need help filing a grievance, call or if you use a TTY, call 7. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 2020, , (TDD). Complaint forms are available at Multi-Language Interpreter Services ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (TTY: 7)... ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7)... 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 7)... CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 7)... 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 7) 번으로전화해주십시오... PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 7)... Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7)... ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 7)... ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 7)... UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 7)... ATENÇÃO: Se fala português, encontramse disponíveis serviços linguísticos, grátis. Ligue para (TTY: 7)... ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 7)... ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 7)... 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 7) まで お電話にてご連絡ください... توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با (7 (TTY: تماس بگیرید. D77 baa ak0 n7n7zin: D77 saad bee yn7[ti go Diné Bizaad, saad bee k n7da wo d66, t jiik eh, 47 n h0l=, koj8 h0d77lnih (TTY: 7)... ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: 7(. GCHJV5REN 07

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