Health Partners Medicare Special (HMO SNP) Approved Over-the-Counter (OTC) Medication List
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1 Health Partners Medicare Special (HMO SNP) Approved Over-the-Counter (OTC) Medication List The following OTC items are approved for the Health Partners Medicare Special plan. Members enrolled in Health Partners Medicare Special (a dual-eligible Special Needs Plan) are eligible for coverage of up to $50 per month toward the items below, at participating pharmacies. Another $50 will be available each month, but unused amounts do not roll over into the next month. Please note that a prescription is required from your doctor or other prescriber for OTC items to be covered through this benefit. Abreva 10% cream Advil, Motrin (ibuprofen suspension) 100mg/5mL Advil, Motrin (ibuprofen) 200mg Aleve (naproxen) 220mg Alka Seltzer 324mg, 500mg Allegra 60mg Amlactin (ammonium lactate 12%) Artificial tears (dextran) Aspirin 81mg chewable tablet Aspirin 325mg Aspirin enteric coated 81mg Aspirin enteric coated 325mg Aveeno bath packet (colloidal oatmeal) Aveeno moisturizing cream, lotion (colloidal oatmeal) Azo cranberry (cranberry extract) 250mg-60mg capsule Azo standard (phenazopyridine) 95mg tablet Bacitracin ointment Benadryl (diphenhydramine) topical cream 2% Benadryl (diphenhydramine) 12.5mg rapid dissolve tablet Benadryl (diphenhydramine) 12.5mg/5mL solution Benadryl (diphenhydramine) 25mg capsule Benzoyl peroxide cream 10% Benzoyl peroxide gel 5% Biotene dry mouth mouthwash (saliva stimulant) Biotene moisturizing mouth spray (saliva stimulant) Bufferin (aspirin with buffers) 81mg, 325mg Burow s solution (aluminum acetate) Calamine lotion Calcium carbonate 600mg tablet Calcium carbonate with Vitamin D 600mg-200 unit Calcium gluconate 45 (500mg) tablet Calcium gluconate 50mg tablet Calcium gluconate 60 (648mg) tablet Calcium gluconate 60 (650mg) tablet Calcium gluconate 61 (648mg) tablet
2 Calcium lactate 65mg tablet Calcium lactate 8 (648mg) tablet Calcium lactate 85 (650mg) tablet Calmol-4 (zinc oxide suppositories) Centrum Silver Cetaphil cleansing bar Chloraseptic (sore throat lozenge) Chloraseptic (sore throat spray) Chlor-Trimeton (chlorpheniramine maleate) 4mg tablet Citracal (calcium citrate) Citracal + Vitamin D (calcium citrate) 250mg-200mg tablet Citroma (magnesium citrate) Claritin (loratadine) 10mg tablet Coenzyme Q10 30mg capsule Coenzyme Q10 30mg/5mL liquid Coenzyme Q10 50mg capsule Coenzyme Q10 200mg capsule Coenzyme Q10 100mg capsule Colace (docusate sodium) 50mg, 100mg capsule Colace (docusate sodium) 60mg/15mL syrup Commit (nicotine lozenges) Compound W wart remover adhesive patch 40% Compound W wart remover gel 17% Compound W wart remover liquid 17% Cool Gel (mineral ice) Coricidin HBP (dextromethorphan/ chlorpheniramine/acetaminophen) mg Cyclivert (cyclizine) 25mg tablet Debrox (carbamide peroxide) Desenex (clotrimazole) cream 1% Domeboro (aluminum sulfate/ calcium acetate) powder pack Dramamine (dimenhydrinate) 25mg chewable tablet Dramamine (dimenhydrinate) 50mg tablet Dulcolax (bisacodyl) 10mg suppository Dulcolax (bisacodyl) 5mg tablet Emetrol (dextrose/phosphoric acid) solution Epsom salt crystals Epsom salt granules Ester-C Eucerin Excedrin (aspirin/acetaminophen/caffeine) Ferrous fumarate 324 (106mg) tablet Ferrous fumarate 89 (29mg) tablet Ferrous gluconate 325mg Ferrous sulfate 300mg/5mL liquid Ferrous sulfate 325 (65mg) tablet Fibercon (fiber) 625mg tablet Fish Oil 1,200mg Fish Oil with Vitamin D 360mg/1,000 unit Fish Oil/Omega 3 300mg/1,000mg Fish Oil/Omega 3 1,200mg/300mg Fleet enema 133mL Flonase Folic acid 1mg tablet mg capsule mg tablet mg tablet with Vitamin C Glucose tablets 4gm Glycerin suppositories Gold Bond powder 2
3 Guaifenesin syrup (Robitussin) 100mg/5mL Gyne-Lotrimin (clotrimazole) cream/applicator 1% Gyne-Lotrimin (clotrimazole) 2% Hibiclens (chlorhexidine) 4% Hydrocortisone 0.5%, 1% cream Hydrocortisone 0.5%, 1% lotion Hydrocortisone 0.5%, 1% ointment Hydrogen peroxide 3% solution ICaps Areds Icy Hot adhesive patch Imodium A-D (loperamide) liquid, tablet, and capsules Iodine 2% tincture Isopto Tears (hydroxypropyl methylcellulose) 0.5% Kaolin Pectin (kaolin/pectin) Lactaid chewable tablet Lamisil AT (terbinafine) 1% cream Listerine Maalox Advanced Magnesium oxide 250mg Magnesium oxide 400mg Melatonin 3mg Metamucil (psyllium) powder, packet Metamucil, Citrucel Milk of magnesia (magnesium hydroxide) 400mg/5mL oral suspension Mineral oil Monistat 7 (miconazole) 2% Mucinex (guaifenesin) 200mg, 400mg tablet Mucinex DM 600mg/30mg Multivitamins Multivitamins with minerals Mylanta, Maalox Plus (magnesium hydroxide/aluminum hydroxide/simethicone) Mylicon, Gas-X (simethicone) 125mg capsule, chewable tablet Mylicon, Gas-X (simethicone) 180mg capsule Nasacort OTC Nasalcrom (cromolyn sodium) 5.2mg spray Natalins Neosporin (neomycin/polymyxin/bacitracin) Neosporin Plus (neomycin/polymyxin/bacitracin/ pramoxine) Niacin 50mg tablet Niacin 100mg tablet Niacin 500mg tablet Niacinamide 100mg tablet Niacinamide 500mg tablet Nicoderm CQ (nicotine patch) Nicorette gum (nicotine gum) Nix (permethrin) 1% Ocean Mist (sodium chloride) 0.65% spray Ocuvite capsule Ocuvite 1, tablet Oscal + D 500mg-200mg Oscal + D 500mg-600mg Pedialyte (electrolyte rehydration solution) Pepto Bismol (bismuth subsalicylate) oral suspension 262mg/15mL & tablets Peri-Colace, Senna-S (senna/docusate sodium) 8.6mg-50mg tablet Phos-Nak Plan B Polysporin (bacitracin/polymyxin) 3
4 liver/ccb) suppositories % liver/ccb) cream 1% liver/ccb) medicated pad 50% liver/ccb) ointment Preservision Areds Preservision Areds 2 Preservision Lutein Probiotic (acidophilus) Refresh Plus (sodium carboxymethylcelullose) 0.5% Rid kit (piperonyl butoxide/pyrethrins) Rid shampoo (piperonyl butoxide/pyrethrins) Robitussin CF (guaifenesin/dextromethorphan/ phenylephrine) mg/5mL Rubbing alcohol (ethanol) 70% Rubbing alcohol (isopropyl) 70% Senna (senokot) 8.6mg tablet Sudafed (pseudoephedrine) 30mg IR tablet Sudafed PE (phenylephrine) 10mg tablet Swim Ear/Auro-Dri 95%-5% drops Tears Naturale PM ointment Thera-Plus Tinactin (tolnaftate) cream, spray, powder 1% Tucks (pramoxine/zinc oxide/mineral oil) ointment 1%-12.5% Tucks pads 50% Tucks suppositories 51% Tums (calcium carbonate with vitamin D) Tums (calcium carbonate) 200mg(500) Tums (calcium carbonate) 300mg(750) Tums Ultra (calcium carbonate) 1,000mg Tussin CF (guaifenesin/dextromethorphan/ pseudoephedrine 100mg-10mg-30mg) Tussin DM mg/5mL (guaifenesin/dextromethorphan) Tussin PE (guaifenesin/pseudoephedrine) mg-5mL Tylenol (acetaminophen) 325mg tablet Tylenol (acetaminophen) 500mg Tylenol (acetaminophen) elixir 160/5mL Tylenol Arthritis (acetaminophen) ER 650mg tablet Tylenol PM (acetaminophen/diphenhydramine) 500mg-25mg tablet Tylenol Sinus (acetaminophen/phenylephrine) Urea 20% cream Vicks Vaporub (medicated chest rub) Visine A Visine redness remover Vision Plus Lutein Vitamin A 10,000 unit capsule Vitamin A 25,000 unit capsule Vitamin B complex tablet Vitamin B-1 50mg tablet, 100mg Vitamin B-6 100mg Vitamin B-12 1,000mcg tablet Vitamin C 500mg chewable tablet Vitamin C 500mg tablet Vitamin C 1,000mg tablet Vitamin D 400 unit tablet Vitamin D 1,000 unit tablet and capsule Vitamin D 2,000 unit softgel Vitamin D 5,000 unit tablet Vitamin D 50,000 unit tablet Vitamin E 100 unit capsule Vitamin E 400 unit capsule 4
5 White petroleum jelly Zaditor eye drops (ketotifen) Zantac (ranitidine) 75mg and 150mg tablet Zinc sulfate 220mg capsule Zinc sulfate 220mg tablet Zostrix (capsaicin cream) 0.025%, 0.075%, 0.1% Zyrtec (cetirizine) 5mg Zyrtec (cetirizine) 10mg Zyrtec D If you have any questions, please call Health Partners Medicare Member Relations at anytime, 24 hours a day, seven days a week. (TTY users please call 711.) Health Partners Plans is an HMO with a Medicare contract. Enrollment in Health Partners Medicare depends on contract renewal. Health Partners Medicare Special is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits may change on January 1 of each year. H9207_HPM-519b-16 Accepted 6/2016 5
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