Eligible OTC Expenses include me by fjzhxb


									2009 Over-the Counter Benefit Information
Eligible Over-the-Counter (OTC) Expenses include medicines or products that alleviate or 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 do NOT constitute an endorsement or an exhaustive listing of reimbursable OTC products. Type/Class of Drug or Product Acne Treatment Examples Acne Free, Acnomel, Ambi Even & Clear, Bye Bye Blemish, Clean & Clear, Clearasil, Murad Acne Complex Kit, Nature’s Cure Acne Treatment, Neutrogena Acne Treatment, OXY , Proactiv Solution, StriDex, ZAPZYT Acne Treatment, Zeno Acne Clearing Device Note: Generic and store brand equivalents of name brand acne treatments are also eligible. Actifed, Allerest, Benadryl, Chlor-Trimeton, Claritin, Contac, NasalCrom, Sudafed Aspirin, Advil, Aleve, Ibuprofen, Naprosyn, Tylenol, Midol, Pamprin, Premysyn PMS AXID AR, Gas-X, Maalox, Mylanta, Tums, Pepcid AC, Prilosec OTC, Tagamet HB, Zantac 75 Glucosamine, Chondroitin Bacitracin, Neosporin, Triple antibiotic ointment Femstat 3, Gynelotrimin, Mycelex-7, Monistat 3, Vagistat-1 Ex-Lax, Immodium AD, Kaopectate, Pepto-Bismol Lamisil AT, Lotramin AF, Micatin Actifed, Allerest, Benadryl, Claritin, Chlor-Trimeton, Contac, Drixoral, Sudafed, Tavist, Triaminic Bactine, Benadryl, Caldecort, Caladryl, Calamine, Cortaid, Hydrocortisone, Lanacort, Lamisil AT, Lotramin AF Bronitin Mist, Bronkaid, Bronkolixer, Primatene Abreva Cream, Herpecin Actifed, Advil Cold and Sinus, Afrin, Alka Seltzer Cold and Flu, Afrinol, Aleve Cold and Sinus, Children’s Advil Cold, Contac, Dayquil, Dimetane, Dristan Long-Lasting, Drixoral, Neo-Synephrine 12-Hour, Nyquil, Otrivin, Pediacare, Sudafed, Tavist-D, Thera-flu, Triaminic, Tylenol Cold and Flu, Cough Drops , Nasal Sprays, Lozenges H3328 4010 FC 08_085_R3 10/2008

Allergy Prevention and Treatment Analgesics/Antipyretics Antacids and Acid Reducers Anti-arthritics Antibiotics (topical) Anticandial (yeast) Antidiarrheal and Laxatives Antifungal Antihistamines Anti-itch Lotions and Creams Asthma Medicines Cold Sore/Fever Blister Cold, Flu, Decongestant and Sinus Remedies

Type/Class of Drug or Product Contact Lens Supplies Cough Suppressants or Expectorants Dehydration Dental/Denture Care Diaper Rash Ear Care Eye Care First Aid/Medical Supplies

Fluoride Rinse/Pills Foot Care Hand Sanitizers

Hemorrhoidal Preparations Home Diagnostic Tests or Kits

Lactose Intolerance Supplements Medicated Lip Products Menstrual Cycle Migraine Relief Motion Sickness Nasal Strips


Examples Cleaning and soaking solutions, Lens storage cases Robitussin, Vicks 44, Chloraseptic, Mucinex, Cough drops, throat lozenges Pedialyte Orajel, Anbesol, Poligrip Balmax, Desitin Ear drops, Ear wax removal Eye drops, Reading glasses, Eye patches Antiseptics, Witch Hazel, Peroxide, Bandages, First aid kits, Cold/hot packs for injuries, Joint supports (ankle, elbow, knee, wrist), Rubbing alcohol, Ace wraps, Splints, Thermometers, Liquid adhesives Act, Colgate Phos-Flur Arch and insole supports, Callous removers, Athlete’s Foot products (see anti-fungal), Bunion, blister and corn treatments Purell, Germ-X, Nexcare This does not include soaps, lotions or other personal hygiene items that include sanitizing ingredients; they are not eligible. Preparation H, Hemorrhoid, Tronolane Blood pressure (monitor and related equipment), Cholesterol, Diabetic equipment and supplies, Colorectal screenings, HIV test, Pregnancy tests DairyCare, Dairy Relief, Lactaid, Lacteeze, Lactrase Blistex Medicated Lip Ointment, Carmex Medicated Lip Balm, Neosporin Lip Treatment Midol, Pamprin, Premysyn PMS Advil Migraine, Motrin Migraine, Excedrin Dramamine, Marizine, Bonine Breathe Right, Snorezz Note: Nasal strips to alleviate snoring or reduce nasal congestion are eligible. Advil, Aleve, Ibuprofen, Motrin, Naprosyn, Naproxen

Members enrolled in Fidelis Medicare Advantage or Fidelis Dual Advantage, must pay for the OTC, obtain a receipt and submit the receipt and Flex Benefit Reimbursement form to us to get reimbursed. The 2009 Flex benefit amount is: Fidelis Medicare Advantage without Prescription Drugs Fidelis Medicare Advantage Fidelis Medicare Advantage Flex Fidelis Dual Advantage Fidelis Dual Advantage Flex $200 annually $250 annually $830 annually $1,350 annually $3,500 annually

Members enrolled in Fidelis Medicare Advantage Part B Reduction are not eligible for the OTC reimbursement benefit.

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