new! over-the-counter (otc) coverage, effective jan. 1, 2019...we recently changed our list of...

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We recently changed our list of covered over-the-counter products (OTC) for our patients who are UnitedHealthcare Community Plan members. We made this change to help achieve the Triple Aim of improved health care services, health outcomes and overall cost of care. This is a state-wide initiative required by Nebraska Medicaid. What This Means Starting Jan. 1, 2019, only OTC products that are rebatable by Centers for Medicare and Medicaid (CMS) will be covered by Nebraska Medicaid. Next Steps Please encourage your patients who are our plan members to use products on the Preferred Drug List, and provide them with a new prescription for these items. Covered OTC products are listed below. For your quick reference, the following is a list of covered OTC products 00113038810 12 HR NASAL SPR 0.05% 24385030411 12 HR NASAL SPR 0.05% 00904676130 12HOUR NASAL SPR 0.05% 46122038576 24 HR NASAL SPR ALLERGY 70000036101 24HR ALLERGY TAB 180MG 70000036102 24HR ALLERGY TAB 180MG 70000036103 24HR ALLERGY TAB 180MG 70000036104 24HR ALLERGY TAB 180MG 49348037954 3 DAY VAGINL CRE 2% 51672206200 3 DAY VAGINL CRE 2% 63868019725 3 DAY VAGNAL CRE 4% 00067208601 4-WAY FAST SPR 1% 46122006271 8 HOUR PAIN TAB 650MG 46122006278 8 HOUR PAIN TAB 650MG 49348092410 8 HOUR PAIN TAB 650MG 70000018001 8 HOUR PAIN TAB 650MG 70000018002 8 HOUR PAIN TAB 650MG 70000018003 8 HOUR PAIN TAB 650MG 70000018004 8 HOUR PAIN TAB 650MG 70000030601 8 HOUR PAIN TAB 650MG 00135020001 ABREVA CRE 10% 00135020003 ABREVA CRE 10% 00135020005 ABREVA CRE 10% 00713011801 ACEPHEN SUP 120MG NDC PRODUCT_LABEL_NAME New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019 We’re Here to Help. If you have questions, please call Provider Services at the number listed on the back of the member’s ID card. Thank you.

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Page 1: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

We recently changed our list of covered over-the-counter products (OTC) for our patients who are UnitedHealthcare Community Plan members. We made this change to help achieve the Triple Aim of improved health care services, health outcomes and overall cost of care. This is a state-wide initiative required by Nebraska Medicaid.

What This Means Starting Jan. 1, 2019, only OTC products that are rebatable by Centers for Medicare and Medicaid (CMS) will be covered by Nebraska Medicaid. Next Steps Please encourage your patients who are our plan members to use products on the Preferred Drug List, and provide them with a new prescription for these items. Covered OTC products are listed below.

For your quick reference, the following is a list of covered OTC products

00113038810 12 HR NASAL SPR 0.05% 24385030411 12 HR NASAL SPR 0.05% 00904676130 12HOUR NASAL SPR 0.05% 46122038576 24 HR NASAL SPR ALLERGY 70000036101 24HR ALLERGY TAB 180MG 70000036102 24HR ALLERGY TAB 180MG 70000036103 24HR ALLERGY TAB 180MG 70000036104 24HR ALLERGY TAB 180MG 49348037954 3 DAY VAGINL CRE 2% 51672206200 3 DAY VAGINL CRE 2% 63868019725 3 DAY VAGNAL CRE 4% 00067208601 4-WAY FAST SPR 1% 46122006271 8 HOUR PAIN TAB 650MG 46122006278 8 HOUR PAIN TAB 650MG 49348092410 8 HOUR PAIN TAB 650MG 70000018001 8 HOUR PAIN TAB 650MG 70000018002 8 HOUR PAIN TAB 650MG 70000018003 8 HOUR PAIN TAB 650MG 70000018004 8 HOUR PAIN TAB 650MG 70000030601 8 HOUR PAIN TAB 650MG 00135020001 ABREVA CRE 10% 00135020003 ABREVA CRE 10% 00135020005 ABREVA CRE 10% 00713011801 ACEPHEN SUP 120MG

NDC

PRODUCT_LABEL_NAME

New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019

We’re Here to Help. If you have questions, please call Provider Services at the number listed on the back of the member’s ID card. Thank you.

Page 2: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00713011812 ACEPHEN SUP 120MG 00713011850 ACEPHEN SUP 120MG 00713016401 ACEPHEN SUP 325MG 00713016412 ACEPHEN SUP 325MG 00713016450 ACEPHEN SUP 325MG 00713016501 ACEPHEN SUP 650MG 00713016506 ACEPHEN SUP 650MG 00713016512 ACEPHEN SUP 650MG 00713016550 ACEPHEN SUP 650MG 58657052016 ACETAMIN LIQ 160/5ML 00121065700 ACETAMIN SOL 160/5ML 00121065705 ACETAMIN SOL 160/5ML 66689005401 ACETAMIN SOL 160/5ML 66689005499 ACETAMIN SOL 160/5ML 00121131400 ACETAMIN SOL 325MG 00121131411 ACETAMIN SOL 325MG 66689005501 ACETAMIN SOL 325MG 66689005599 ACETAMIN SOL 325MG 00121197100 ACETAMIN SOL 650/20.3 00121197121 ACETAMIN SOL 650/20.3 66689005601 ACETAMIN SOL 650/20.3 66689005699 ACETAMIN SOL 650/20.3 45802073200 ACETAMIN SUP 120MG 45802073230 ACETAMIN SUP 120MG 45802073233 ACETAMIN SUP 120MG 45802073030 ACETAMIN SUP 650MG 45802073032 ACETAMIN SUP 650MG 45802073033 ACETAMIN SUP 650MG 49483034001 ACETAMIN TAB 325MG 49483034010 ACETAMIN TAB 325MG 51645070301 ACETAMIN TAB 325MG 51645070310 ACETAMIN TAB 325MG 51645070399 ACETAMIN TAB 325MG 63739044001 ACETAMIN TAB 325MG 00536117201 ACETAMIN TAB 500MG 00536117210 ACETAMIN TAB 500MG 00904672024 ACETAMIN TAB 500MG 00904672040 ACETAMIN TAB 500MG 00904672051 ACETAMIN TAB 500MG 00904672059 ACETAMIN TAB 500MG 00904672060 ACETAMIN TAB 500MG 00904672080 ACETAMIN TAB 500MG 00904673059 ACETAMIN TAB 500MG 00904673060 ACETAMIN TAB 500MG 00904673061 ACETAMIN TAB 500MG 00904673080 ACETAMIN TAB 500MG 51645070501 ACETAMIN TAB 500MG 51645070510 ACETAMIN TAB 500MG 51645070601 ACETAMIN TAB 500MG 51645070610 ACETAMIN TAB 500MG

Page 3: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

70000015001 ACETAMIN TAB 500MG 70000015002 ACETAMIN TAB 500MG 70000015003 ACETAMIN TAB 500MG 70000015101 ACETAMIN TAB 500MG 70000015102 ACETAMIN TAB 500MG 70000015103 ACETAMIN TAB 500MG 70000015104 ACETAMIN TAB 500MG 70000015301 ACETAMIN TAB 500MG 70000031201 ACETAMIN TAB 500MG 70000031202 ACETAMIN TAB 500MG 68084077725 ACETAMIN TAB 650MG 68084077795 ACETAMIN TAB 650MG 70000030901 ACETAMIN JR CHW 160MG

00904673151 ACETAMIN PM TAB 25-500MG 51645070905 ACETAMIN PM TAB 25-500MG 62011033901 ACETAMINOPHE CHW 160MG 70000031001 ACETAMINOPHE CHW 160MG 00904671950 ACETAMINOPHE TAB 325MG

Page 4: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00904671960 ACETAMINOPHE TAB 325MG 50268005211 ACETAMINOPHE TAB 650MG 50268005215 ACETAMINOPHE TAB 650MG 00121178100 ACETAMINOPHN SUS 160/5ML 00121178105 ACETAMINOPHN SUS 160/5ML 00904676620 ACETAMINOPHN SUS 160/5ML 45802020126 ACETAMINOPHN SUS 160/5ML 45802020326 ACETAMINOPHN SUS 160/5ML 68094001559 ACETAMINOPHN SUS 160/5ML 68094001561 ACETAMINOPHN SUS 160/5ML 68094001562 ACETAMINOPHN SUS 160/5ML 68094058658 ACETAMINOPHN SUS 160/5ML 68094058758 ACETAMINOPHN SUS 160/5ML 68094058759 ACETAMINOPHN SUS 160/5ML 68094058761 ACETAMINOPHN SUS 160/5ML 68094058762 ACETAMINOPHN SUS 160/5ML 68094058859 ACETAMINOPHN SUS 325MG 68094058862 ACETAMINOPHN SUS 325MG 70000015201 ACETAMINOPHN TAB 325MG 70000015202 ACETAMINOPHN TAB 325MG 70000015203 ACETAMINOPHN TAB 325MG 70000015204 ACETAMINOPHN TAB 325MG 49483034101 ACETAMINOPHN TAB 500MG 49483034105 ACETAMINOPHN TAB 500MG 49483034110 ACETAMINOPHN TAB 500MG 49483034142 ACETAMINOPHN TAB 500MG 49483034150 ACETAMINOPHN TAB 500MG 63868071430 ACID CONTROL TAB 10MG 46122004162 ACID CONTROL TAB 150MG 46122004171 ACID CONTROL TAB 150MG 46122022462 ACID CONTROL TAB 150MG 63868048625 ACID CONTROL TAB 20MG 00904536560 ACID GONE CHW 00904772714 ACID GONE SUS 70000023201 ACID REDUCER CAP 20.6MGDR 70000023202 ACID REDUCER CAP 20.6MGDR 70000023203 ACID REDUCER CAP 20.6MGDR 37205068163 ACID REDUCER CHW COMPLETE 00113014165 ACID REDUCER TAB 10MG 36800014165 ACID REDUCER TAB 10MG 36800014172 ACID REDUCER TAB 10MG 37205061465 ACID REDUCER TAB 10MG 46122020565 ACID REDUCER TAB 10MG 46122039465 ACID REDUCER TAB 10MG 46122039472 ACID REDUCER TAB 10MG 49348012812 ACID REDUCER TAB 10MG 49348012813 ACID REDUCER TAB 10MG

Page 5: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348012844 ACID REDUCER TAB 10MG 00113085202 ACID REDUCER TAB 150MG 00113085251 ACID REDUCER TAB 150MG 00113085271 ACID REDUCER TAB 150MG 49348010904 ACID REDUCER TAB 150MG 49348010954 ACID REDUCER TAB 150MG 51660035160 ACID REDUCER TAB 150MG 62011028201 ACID REDUCER TAB 150MG 00113019402 ACID REDUCER TAB 20MG 24385038551 ACID REDUCER TAB 20MG 24385038563 ACID REDUCER TAB 20MG 24385038571 ACID REDUCER TAB 20MG 36800019402 ACID REDUCER TAB 20MG 36800019451 ACID REDUCER TAB 20MG 36800019471 ACID REDUCER TAB 20MG 37205086163 ACID REDUCER TAB 20MG 46122016878 ACID REDUCER TAB 20MG 49348081705 ACID REDUCER TAB 20MG 49348081709 ACID REDUCER TAB 20MG 00113087665 ACID REDUCER TAB 75MG 46122022365 ACID REDUCER TAB 75MG 46122022372 ACID REDUCER TAB 75MG 49348013612 ACID REDUCER TAB 75MG 49348013644 ACID REDUCER TAB 75MG 51660035230 ACID REDUCER TAB 75MG 51660035260 ACID REDUCER TAB 75MG 62011028301 ACID REDUCER TAB 75MG 62011028302 ACID REDUCER TAB 75MG 00536105656 ACNE MEDICAT GEL 10% 00536105556 ACNE MEDICAT GEL 5% 00536105875 ACNE MEDICAT LOT 10% 00536105775 ACNE MEDICAT LOT 5% 62011012201 ADVANCED SUS ANTACID 51285010388 AFTERA TAB 1.5MG 69536010388 AFTERA TAB 1.5MG 17478006235 AKWA TEARS OIN OP 50991078360 ALA-HIST IR TAB 2MG 49348097410 ALCOHOL PREP PAD 6-70% 29978091860 ALEVAZOL OIN 1% 00113018926 ALL DAY ALLG SOL 1MG/ML 00113050326 ALL DAY ALLG SOL 1MG/ML 00904637220 ALL DAY ALLG SOL 1MG/ML 36800018926 ALL DAY ALLG SOL 1MG/ML 46122002026 ALL DAY ALLG SOL 1MG/ML 70000021501 ALL DAY ALLG SOL 1MG/ML 46122010126 ALL DAY ALLG SOL 5MG/5ML 49348007834 ALL DAY ALLG SOL 5MG/5ML

Page 6: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348032634 ALL DAY ALLG SOL 5MG/5ML 49348093434 ALL DAY ALLG SOL 5MG/5ML 62011028501 ALL DAY ALLG SOL 5MG/5ML 62011032201 ALL DAY ALLG SOL 5MG/5ML 62011032301 ALL DAY ALLG SOL 5MG/5ML 70000018601 ALL DAY ALLG SOL 5MG/5ML 70000021401 ALL DAY ALLG SOL 5MG/5ML 70677001401 ALL DAY ALLG SOL 5MG/5ML 70677001501 ALL DAY ALLG SOL 5MG/5ML 00113945839 ALL DAY ALLG TAB 10MG 00113945866 ALL DAY ALLG TAB 10MG 00113945895 ALL DAY ALLG TAB 10MG 00904585243 ALL DAY ALLG TAB 10MG 00904585246 ALL DAY ALLG TAB 10MG 00904585260 ALL DAY ALLG TAB 10MG 00904585289 ALL DAY ALLG TAB 10MG 36800045813 ALL DAY ALLG TAB 10MG 36800045839 ALL DAY ALLG TAB 10MG 36800045847 ALL DAY ALLG TAB 10MG 36800045866 ALL DAY ALLG TAB 10MG 36800045887 ALL DAY ALLG TAB 10MG 36800045895 ALL DAY ALLG TAB 10MG 62011005201 ALL DAY ALLG TAB 10MG 62011031301 ALL DAY ALLG TAB 10MG 62011031302 ALL DAY ALLG TAB 10MG 62011031303 ALL DAY ALLG TAB 10MG 70000014801 ALL DAY ALLG TAB 10MG 70000014802 ALL DAY ALLG TAB 10MG 70000014803 ALL DAY ALLG TAB 10MG 70000014804 ALL DAY ALLG TAB 10MG 70677000601 ALL DAY ALLG TAB 10MG 70677000602 ALL DAY ALLG TAB 10MG 70677000603 ALL DAY ALLG TAB 10MG 24385049071 ALL DAY PAIN TAB 220MG 24385049078 ALL DAY PAIN TAB 220MG 36800036862 ALL DAY PAIN TAB 220MG 36800036871 ALL DAY PAIN TAB 220MG 36800036878 ALL DAY PAIN TAB 220MG 36800036882 ALL DAY PAIN TAB 220MG 36800049062 ALL DAY PAIN TAB 220MG 36800049071 ALL DAY PAIN TAB 220MG 36800049078 ALL DAY PAIN TAB 220MG 70000017102 ALL DAY PAIN TAB 220MG 70000017103 ALL DAY PAIN TAB 220MG 70000020101 ALL DAY PAIN TAB 220MG 70000020102 ALL DAY PAIN TAB 220MG 70000020103 ALL DAY PAIN TAB 220MG

Page 7: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00536109301 ALL DAY RELF TAB 220MG 00536109306 ALL DAY RELF TAB 220MG 00536109401 ALL DAY RELF TAB 220MG 00536109406 ALL DAY RELF TAB 220MG 36800047526 ALL-DAY ALLG SOL 5MG/5ML 46122016752 ALLER/CONGES TAB 10-240MG 00536100601 ALLER-CHLOR TAB 4MG 00536100610 ALLER-CHLOR TAB 4MG 00536100635 ALLER-CHLOR TAB 4MG 00113057122 ALLER-EASE TAB 180MG 00113057139 ALLER-EASE TAB 180MG 00113057195 ALLER-EASE TAB 180MG 00113042553 ALLER-EASE TAB 60MG 00536109201 ALLERGY TAB 10MG 00904572872 ALLERGY TAB 10MG 00904572887 ALLERGY TAB 10MG 00904572889 ALLERGY TAB 10MG 00904001259 ALLERGY TAB 4MG 00904001280 ALLERGY TAB 4MG 70000016001 ALLERGY TAB 4MG 70000016002 ALLERGY TAB 4MG 46122036126 ALLERGY CHLD LIQ 12.5/5ML 70000012501 ALLERGY CHLD SYP 5MG/5ML 62011007101 ALLERGY REL/ TAB DECONGES 62011007102 ALLERGY REL/ TAB DECONGES 00113046262 ALLERGY RELF CAP 25MG 70000014401 ALLERGY RELF CAP 25MG 70000020701 ALLERGY RELF CAP 25MG 70000020702 ALLERGY RELF CAP 25MG 70677000201 ALLERGY RELF CAP 25MG 00113037926 ALLERGY RELF LIQ 12.5/5ML 49348004534 ALLERGY RELF LIQ 12.5/5ML 49348004537 ALLERGY RELF LIQ 12.5/5ML 62011028401 ALLERGY RELF LIQ 12.5/5ML 70000024501 ALLERGY RELF LIQ 12.5/5ML 70000024502 ALLERGY RELF LIQ 12.5/5ML 70000024601 ALLERGY RELF LIQ 12.5/5ML 49348018229 ALLERGY RELF SPR 50MCG 49348018243 ALLERGY RELF SPR 50MCG 62011026901 ALLERGY RELF SPR 50MCG 62011026902 ALLERGY RELF SPR 50MCG 70000011001 ALLERGY RELF SPR 50MCG 49348068603 ALLERGY RELF TAB 1.34MG 00113061239 ALLERGY RELF TAB 10MG 00113061246 ALLERGY RELF TAB 10MG 00113061260 ALLERGY RELF TAB 10MG 00113061265 ALLERGY RELF TAB 10MG

Page 8: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

24385016152 ALLERGY RELF TAB 10MG 24385054053 ALLERGY RELF TAB 10MG 36800061246 ALLERGY RELF TAB 10MG 36800061265 ALLERGY RELF TAB 10MG 36800061276 ALLERGY RELF TAB 10MG 36800061287 ALLERGY RELF TAB 10MG 49348081856 ALLERGY RELF TAB 10MG 51660052601 ALLERGY RELF TAB 10MG 51660052605 ALLERGY RELF TAB 10MG 51660052653 ALLERGY RELF TAB 10MG 51660052731 ALLERGY RELF TAB 10MG 70000021301 ALLERGY RELF TAB 10MG 70000021302 ALLERGY RELF TAB 10MG 70000021303 ALLERGY RELF TAB 10MG 70000021304 ALLERGY RELF TAB 10MG 70000021305 ALLERGY RELF TAB 10MG 70000031701 ALLERGY RELF TAB 10MG 70000021201 ALLERGY RELF TAB 180MG 70000021202 ALLERGY RELF TAB 180MG 70000021203 ALLERGY RELF TAB 180MG 00113047953 ALLERGY RELF TAB 25MG 00113047962 ALLERGY RELF TAB 25MG 00113047978 ALLERGY RELF TAB 25MG 62011031001 ALLERGY RELF TAB 25MG 70000013601 ALLERGY RELF TAB 25MG 70000013602 ALLERGY RELF TAB 25MG 70000013603 ALLERGY RELF TAB 25MG 62011031101 ALLERGY RELF TAB 4MG 37205034888 ALLERGY RELF TAB D-24 70000016201 ALLERGY RELF TAB D-24 70000016202 ALLERGY RELF TAB D-24 51660072415 ALLERGY RELF TAB DECONGES 51660072456 ALLERGY RELF TAB DECONGES 51660072469 ALLERGY RELF TAB DECONGES 49483024201 ALLERGY-TIME TAB 4MG 49483024210 ALLERGY-TIME TAB 4MG 52544023912 ALLRGY RLF-D TAB 10-240MG 52544023954 ALLRGY RLF-D TAB 10-240MG 00536101101 ALMACONE CHW 00536002583 ALMACONE SUS 00536001583 ALMACONE DBL SUS STRENGTH 24385008334 ALOE VERA/ GEL LIDOCAIN 43553325102 ALOE VESTA OIN 2% 43553325105 ALOE VESTA OIN 2% 43553000302 ALOE VESTA OIN CLEAR 2% 43553000305 ALOE VESTA OIN CLEAR 2% 00536009185 ALUM HYDROX SUS 320/5ML

Page 9: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

46122015175 ANT/ANTI-GAS CHW 1000-60 00113048547 ANTACID CHW 500MG 00536104815 ANTACID CHW 500MG 68084098832 ANTACID CHW 500MG 68084098833 ANTACID CHW 500MG 00113046880 ANTACID CHW 750MG 00113048980 ANTACID CHW 750MG 24385010680 ANTACID CHW 750MG 37205070680 ANTACID CHW 750MG 46122031972 ANTACID CHW 750MG 00113085140 ANTACID SUS 00113058840 ANTACID SUS ANTI-GAS 36800058840 ANTACID SUS MAX ST 37205053540 ANTACID SUS MAX ST 37205053640 ANTACID SUS MAX ST 37205031440 ANTACID SUS REG ST 37205053040 ANTACID FAST SUS ACTING 36800085140 ANTACID FAST SUS RELIEF 36800034040 ANTACID PLUS SUS ANTI-GAS 00113034040 ANTACID PLUS SUS GAS REL 00113035740 ANTACID PLUS SUS GAS REL 36800035740 ANTACID PLUS SUS GAS REL 00536199553 ANTI-DANDRUF SHA 1% 37205034466 ANTIFUNGAL AER 1% 00904072236 ANTIFUNGAL CRE 1% 37205019710 ANTIFUNGAL CRE 1% 00472073514 ANTIFUNGAL CRE 2% 00472073542 ANTIFUNGAL CRE 2% 00472073556 ANTIFUNGAL CRE 2% 53329007964 ANTIFUNGAL CRE 2% 70000032301 ANTIFUNGAL POW 2% 00536515026 ANTI-FUNGAL POW 1% 24385046072 ANTI-GAS CAP 180MG 00113054164 ANTI-ITCH CRE 1% 00113097364 ANTI-ITCH CRE 1% 24385021003 ANTI-ITCH CRE 2-0.1% 36800050602 ANTI-ITCH CRE 2-0.1% 37205027810 ANTI-ITCH CRE 2-0.1% 51672208902 ANTI-ITCH CRE 2-0.1% 63868021801 ANTI-ITCH CRE 2-0.1% 46122014310 ANTI-ITCH LOT 0.5-0.5% 36800021830 ANTI-ITCH LOT 1-0.1% 37205033816 ANTI-ITCH SPR 2% 63868006045 ANTISEPTIC LIQ PAIN REL 00904768822 ANU-MED SUP 50268005311 APAP/ASA/ TAB CAFFEINE 50268005315 APAP/ASA/ TAB CAFFEINE

Page 10: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00536101506 APAP/DIPHEN TAB 25-500MG 00536111825 ARTH PAIN CRE 0.075% 24385016553 ARTHRICREAM CRE 10% 49348088384 ARTHRICREAM CRE 10% 00113054462 ARTHRTS PAIN TAB 650MG 00113054471 ARTHRTS PAIN TAB 650MG 00113054478 ARTHRTS PAIN TAB 650MG 00904576960 ARTHRTS PAIN TAB 650MG 24385062971 ARTHRTS PAIN TAB 650MG 24385062978 ARTHRTS PAIN TAB 650MG 36800054462 ARTHRTS PAIN TAB 650MG 36800054471 ARTHRTS PAIN TAB 650MG 36800054478 ARTHRTS PAIN TAB 650MG 46122017081 ARTHRTS PAIN TAB 650MG 49348092110 ARTHRTS PAIN TAB 650MG 51660033301 ARTHRTS PAIN TAB 650MG 62011002601 ARTHRTS PAIN TAB 650MG 62011033701 ARTHRTS PAIN TAB 650MG 63868008901 ARTHRTS PAIN TAB 650MG 63868008950 ARTHRTS PAIN TAB 650MG 70677001801 ARTHRTS PAIN TAB 650MG 70677001901 ARTHRTS PAIN TAB 650MG 00536108691 ARTIFI TEARS OIN OP 00536108494 ARTIFI TEARS SOL 1.4% OP 17478006012 ARTIFI TEARS SOL 1.4% OP 24385000605 ARTIFICIAL SOL TEARS 62107002726 ASPIR-81 TAB 81MG EC 62107002732 ASPIR-81 TAB 81MG EC 00113025968 ASPIRIN CHW 81MG 00113027468 ASPIRIN CHW 81MG 00113046708 ASPIRIN CHW 81MG 00113046768 ASPIRIN CHW 81MG 00536100836 ASPIRIN CHW 81MG 00536100862 ASPIRIN CHW 81MG 00904404073 ASPIRIN CHW 81MG 16103036605 ASPIRIN CHW 81MG 16103036611 ASPIRIN CHW 81MG 36800025968 ASPIRIN CHW 81MG 63739043401 ASPIRIN CHW 81MG 70000017001 ASPIRIN CHW 81MG 00574703412 ASPIRIN SUP 300MG 00574703612 ASPIRIN SUP 600MG 00113041678 ASPIRIN TAB 325MG 00113041687 ASPIRIN TAB 325MG 00113041690 ASPIRIN TAB 325MG 00536105301 ASPIRIN TAB 325MG 00536105305 ASPIRIN TAB 325MG

Page 11: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00536105429 ASPIRIN TAB 325MG 00536330501 ASPIRIN TAB 325MG 00904671260 ASPIRIN TAB 325MG 16103036508 ASPIRIN TAB 325MG 16103036511 ASPIRIN TAB 325MG 49483001110 ASPIRIN TAB 325MG 51645071601 ASPIRIN TAB 325MG 51645071610 ASPIRIN TAB 325MG 70000025301 ASPIRIN TAB 325MG 70000025302 ASPIRIN TAB 325MG 70000025303 ASPIRIN TAB 325MG 00536114801 ASPIRIN TAB 325MG EC 00536331310 ASPIRIN TAB 325MG EC 00904201159 ASPIRIN TAB 325MG EC 00904201380 ASPIRIN TAB 325MG EC 16103035708 ASPIRIN TAB 325MG EC 16103035711 ASPIRIN TAB 325MG EC 36800042902 ASPIRIN TAB 325MG EC 49483033101 ASPIRIN TAB 325MG EC 49483033110 ASPIRIN TAB 325MG EC 62011004001 ASPIRIN TAB 325MG EC 63739052301 ASPIRIN TAB 325MG EC 70000023701 ASPIRIN TAB 325MG EC 70000023702 ASPIRIN TAB 325MG EC 00536100410 ASPIRIN TAB 81MG EC 00536100441 ASPIRIN TAB 81MG EC 00536114941 ASPIRIN TAB 81MG EC 16103035609 ASPIRIN TAB 81MG EC 16103035611 ASPIRIN TAB 81MG EC 36800003018 ASPIRIN TAB 81MG EC 63739052201 ASPIRIN TAB 81MG EC 63739052210 ASPIRIN TAB 81MG EC 70000017801 ASPIRIN TAB 81MG EC 00904628880 ASPIRIN LOW CHW 81MG 00904628889 ASPIRIN LOW CHW 81MG 00904679480 ASPIRIN LOW CHW 81MG 00904679489 ASPIRIN LOW CHW 81MG 36800027468 ASPIRIN LOW CHW 81MG 36800046768 ASPIRIN LOW CHW 81MG 49483033463 ASPIRIN LOW CHW 81MG 63868024036 ASPIRIN LOW CHW 81MG 70000010201 ASPIRIN LOW CHW 81MG 70000010301 ASPIRIN LOW CHW 81MG 70000010303 ASPIRIN LOW CHW 81MG 00904671318 ASPIRIN LOW TAB 81MG EC 00904675180 ASPIRIN LOW TAB 81MG EC 36800002712 ASPIRIN LOW TAB 81MG EC

Page 12: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

46122018076 ASPIRIN LOW TAB 81MG EC 46122018087 ASPIRIN LOW TAB 81MG EC 49483038710 ASPIRIN LOW TAB 81MG EC 49483038712 ASPIRIN LOW TAB 81MG EC 49483048110 ASPIRIN LOW TAB 81MG EC 49483048112 ASPIRIN LOW TAB 81MG EC 62011000301 ASPIRIN LOW TAB 81MG EC 62011001901 ASPIRIN LOW TAB 81MG EC 62011001902 ASPIRIN LOW TAB 81MG EC 63868036320 ASPIRIN LOW TAB 81MG EC 63868036336 ASPIRIN LOW TAB 81MG EC 70000021801 ASPIRIN LOW TAB 81MG EC 00904770418 ASPIR-LOW TAB 81MG EC 00904770480 ASPIR-LOW TAB 81MG EC 00113015473 ATH FOOT SPR AER 1% 46122038021 ATHLETE FOOT AER 2% 70000032101 ATHLETE FOOT AER 2% 24385020501 ATHLETE FOOT CRE 1% 24385020503 ATHLETE FOOT CRE 1% 49348079072 ATHLETE FOOT CRE 1% 37205094199 ATHLETE FOOT CRE AF 70000012701 BACK & BODY TAB 500-32.5 70000012702 BACK & BODY TAB 500-32.5 00904203524 BANOPHEN CAP 25MG 00904530660 BANOPHEN CAP 25MG 00904530680 BANOPHEN CAP 25MG 00904530760 BANOPHEN CAP 50MG 00904530780 BANOPHEN CAP 50MG 00904535431 BANOPHEN CRE 2-0.1% 00904122800 BANOPHEN LIQ 12.5/5ML 00904517416 BANOPHEN LIQ 12.5/5ML 00904555124 BANOPHEN TAB 25MG 00904555159 BANOPHEN TAB 25MG 00225061023 BENZEDREX INH 51224040010 BENZOYL PER AER 5.3% 45802030801 BENZOYL PER GEL 10% 45802030896 BENZOYL PER GEL 10% 45802010196 BENZOYL PER GEL 2.5% 45802021601 BENZOYL PER GEL 5% 45802021696 BENZOYL PER GEL 5% 45802031801 BENZOYL PER LIQ 10% WASH 45802031834 BENZOYL PER LIQ 10% WASH 67405083005 BENZOYL PER LIQ 10% WASH 67405083008 BENZOYL PER LIQ 10% WASH 45802028001 BENZOYL PER LIQ 5% WASH 45802028034 BENZOYL PER LIQ 5% WASH 67405082505 BENZOYL PER LIQ 5% WASH

Page 13: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

67405082508 BENZOYL PER LIQ 5% WASH 67405083506 BENZOYL PER LOT 6% 67405083512 BENZOYL PER LOT 6% 00713010901 BISAC-EVAC SUP 10MG 00713010905 BISAC-EVAC SUP 10MG 00713010906 BISAC-EVAC SUP 10MG 00713010908 BISAC-EVAC SUP 10MG 00713010910 BISAC-EVAC SUP 10MG 00713010912 BISAC-EVAC SUP 10MG 00713010950 BISAC-EVAC SUP 10MG 00574705012 BISACODYL SUP 10MG 00574705050 BISACODYL SUP 10MG 00904640761 BISACODYL TAB 5MG EC 00904674860 BISACODYL TAB 5MG EC 00904674880 BISACODYL TAB 5MG EC 00904792760 BISACODYL TAB 5MG EC 00904792780 BISACODYL TAB 5MG EC 37205012863 BISACODYL TAB 5MG EC 49483000301 BISACODYL TAB 5MG EC 49483000310 BISACODYL TAB 5MG EC 49483000355 BISACODYL TAB 5MG EC 00904505812 BISCOLAX SUP 10MG 00904505860 BISCOLAX SUP 10MG 00536106139 BLUE GEL 2% 00536111248 BUDESONIDE SUS 32MCG 46122038976 BUDESONIDE SUS 32MCG 60505612902 BUDESONIDE SUS 32MCG 51672210002 BUTENAFINE CRE 1% 51672210008 BUTENAFINE CRE 1% 00113059523 CAL ANTACID CHW 1000MG 62011029401 CAL ANTACID CHW 1000MG 62011030001 CAL ANTACID CHW 1000MG 62011028001 CAL ANTACID CHW 750MG 62011029501 CAL ANTACID CHW 750MG 36800033630 CALAMINE MED LOT 1-8% 36800059523 CALC ANTACID CHW 1000MG 00113047847 CALC ANTACID CHW 500MG 00904641292 CALC ANTACID CHW 500MG 36800048547 CALC ANTACID CHW 500MG 49348095721 CALC ANTACID CHW 500MG 51645073515 CALC ANTACID CHW 500MG 62011028101 CALC ANTACID CHW 500MG 00113017980 CALC ANTACID CHW 750MG 00536104922 CALC ANTACID CHW 750MG 00536105022 CALC ANTACID CHW 750MG 36800017980 CALC ANTACID CHW 750MG 36800046880 CALC ANTACID CHW 750MG

Page 14: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

36800048980 CALC ANTACID CHW 750MG 62011022901 CALC ANTACID CHW 750MG 62011030101 CALC ANTACID CHW 750MG 49348010621 CALCIUM ANTA CHW 500MG 49348010821 CALCIUM ANTA CHW 500MG 49348009434 CALCIUM ANTA CHW 750MG 00054311763 CALCIUM CARB SUS 1250/5ML 00121076616 CALCIUM CARB SUS 1250/5ML 00121476605 CALCIUM CARB SUS 1250/5ML 00054412025 CALCIUM CARB TAB 1250MG 00054812025 CALCIUM CARB TAB 1250MG 00536102410 CALCIUM CARB TAB 648MG 00054026220 CALCIUM GLUC TAB 500MG 00054026225 CALCIUM GLUC TAB 500MG 24385007282 CALDYPHEN LOT 1-8% 37205013030 CALDYPHEN LOT 1-8% 24385043930 CALDYPHEN LOT CLEAR 37205028130 CALDYPHEN LOT CLEAR 00536100715 CAL-GEST CHW 500MG 00904776021 CALLERGY LOT CLEAR 59528033102 CALPHRON TAB 667MG 00536252525 CAPSAICIN CRE 0.025% 46122011203 CAPSAICIN LIQ 0.15% 00884289301 CASTELLANI LIQ PAINT 00884299301 CASTELLANI LIQ PAINT/CL 63824074316 CEPACOL CGH LOZ 5-7.5MG 00781528464 CETIRIZINE CHW 10MG 47335034483 CETIRIZINE CHW 10MG 59746028632 CETIRIZINE CHW 10MG 00781528306 CETIRIZINE CHW 5MG 00781528364 CETIRIZINE CHW 5MG 47335034383 CETIRIZINE CHW 5MG 59746028532 CETIRIZINE CHW 5MG 00904676520 CETIRIZINE SOL 1MG/ML 45802097426 CETIRIZINE SOL 1MG/ML 51672208808 CETIRIZINE SOL 1MG/ML 68094000459 CETIRIZINE SOL 1MG/ML 68094000462 CETIRIZINE SOL 1MG/ML 51672210208 CETIRIZINE SOL 5MG/5ML 54838055240 CETIRIZINE SOL 5MG/5ML 62011009301 CETIRIZINE SOL 5MG/5ML 00378363701 CETIRIZINE TAB 10MG 00378363705 CETIRIZINE TAB 10MG 00536104105 CETIRIZINE TAB 10MG 00536408807 CETIRIZINE TAB 10MG 00536408888 CETIRIZINE TAB 10MG 00781168401 CETIRIZINE TAB 10MG

Page 15: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00904585261 CETIRIZINE TAB 10MG 00904671740 CETIRIZINE TAB 10MG 00904671741 CETIRIZINE TAB 10MG 00904671743 CETIRIZINE TAB 10MG 00904671746 CETIRIZINE TAB 10MG 00904671760 CETIRIZINE TAB 10MG 00904671772 CETIRIZINE TAB 10MG 00904671786 CETIRIZINE TAB 10MG 16571040210 CETIRIZINE TAB 10MG 16571040250 CETIRIZINE TAB 10MG 16714027102 CETIRIZINE TAB 10MG 16714027103 CETIRIZINE TAB 10MG 16714079901 CETIRIZINE TAB 10MG 16714079902 CETIRIZINE TAB 10MG 16714079903 CETIRIZINE TAB 10MG 16714079904 CETIRIZINE TAB 10MG 45802091939 CETIRIZINE TAB 10MG 45802091987 CETIRIZINE TAB 10MG 51079059701 CETIRIZINE TAB 10MG 51079059720 CETIRIZINE TAB 10MG 51660093901 CETIRIZINE TAB 10MG 51660093930 CETIRIZINE TAB 10MG 51660093954 CETIRIZINE TAB 10MG 51660093990 CETIRIZINE TAB 10MG 55111069990 CETIRIZINE TAB 10MG 60505263301 CETIRIZINE TAB 10MG 60505263308 CETIRIZINE TAB 10MG 60687016501 CETIRIZINE TAB 10MG 60687016511 CETIRIZINE TAB 10MG 62011030701 CETIRIZINE TAB 10MG 00378363501 CETIRIZINE TAB 5MG 00781168301 CETIRIZINE TAB 5MG 16571040110 CETIRIZINE TAB 5MG 60505263201 CETIRIZINE TAB 5MG 63868043004 CHILD ALLRGY SOL 5MG/5ML 62107002636 CHILD ASA LS CHW 81MG 54838010440 CHILD SILFED LIQ 15MG/5ML 54838010470 CHILD SILFED LIQ 15MG/5ML 24385037926 CHLD ALLERGY LIQ 12.5/5ML 36800037926 CHLD ALLERGY LIQ 12.5/5ML 36800037934 CHLD ALLERGY LIQ 12.5/5ML 63868082354 CHLD ALLERGY LIQ 12.5/5ML 00904546335 CHLD IBUPRFN DRO 40MG/ML 24385054934 CHLD IBUPROF SUS 100/5ML 54838014440 CHLD SILAPAP LIQ 160/5ML 54838014470 CHLD SILAPAP LIQ 160/5ML 54838014480 CHLD SILAPAP LIQ 160/5ML

Page 16: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

58809036301 CHLORPHEN SR TAB 12MG 00135008969 CITRUCEL POW ORANGE 00135008971 CITRUCEL POW ORANGE 00135009070 CITRUCEL POW SF ORANG 00135009074 CITRUCEL POW SF ORANG 00135009075 CITRUCEL POW SF ORANG 00135019901 CITRUCEL TAB 500MG 00135019902 CITRUCEL TAB 500MG 00135019907 CITRUCEL TAB 500MG 00113030602 CLEARLAX POW 00113030603 CLEARLAX POW 36800030601 CLEARLAX POW 36800030602 CLEARLAX POW 36800030603 CLEARLAX POW 37205061271 CLEARLAX POW 37205061272 CLEARLAX POW 37205061273 CLEARLAX POW 00472022041 CLOTRIMAZOLE CRE 1% 00472022063 CLOTRIMAZOLE CRE 1% 00472035056 CLOTRIMAZOLE CRE 1% 00904782231 CLOTRIMAZOLE CRE 1% 00904782236 CLOTRIMAZOLE CRE 1% 37205076010 CLOTRIMAZOLE CRE 1% 45802043401 CLOTRIMAZOLE CRE 1% 45802043411 CLOTRIMAZOLE CRE 1% 49348027972 CLOTRIMAZOLE CRE 1% 51672200201 CLOTRIMAZOLE CRE 1% 51672200202 CLOTRIMAZOLE CRE 1% 49348079376 CLOTRIMAZOLE CRE 1% VAG 51672200306 CLOTRIMAZOLE CRE 1% VAG 36800006200 CLOTRIMAZOLE CRE 2% 24385011009 CLOTRIMAZOLE CRE 3 DAY 51672203701 CLOTRIMAZOLE SOL 1% 70211070408 COATS ALOE LOT LIN 10% 70211070433 COATS ALOE LOT LIN 10% 67618010110 COLACE CAP 100MG 67618010130 COLACE CAP 100MG 67618010152 COLACE CAP 100MG 67618010160 COLACE CAP 100MG 70000018901 COLD RELIEF LIQ CHILDREN 00113090626 COLD/ALLERGY ELX CHILDREN 36800090626 COLD/ALLERGY ELX CHILDREN 62011006201 COLD/ALLERGY ELX CHILDREN 70000018801 COLD/ALLERGY ELX CHILDREN 46122018162 COLD/ALLERGY TAB 4-10MG 00113098726 COLD/COUGH ELX CHILD 36800098726 COLD/COUGH ELX CHILD

Page 17: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

63868008701 COMP ALLERGY CAP 25MG 63868008724 COMP ALLERGY CAP 25MG 00536112197 COOL THERAPY GEL PAIN 70000033201 CORN & CALLU LIQ 70000026801 COUGH DROPS LOZ 5.4MG 70000026501 COUGH DROPS LOZ 5.8MG 70000026901 COUGH DROPS LOZ 5.8MG 70000029001 COUGH DROPS LOZ 5.8MG 70000026601 COUGH DROPS LOZ 7.5MG 70000026701 COUGH DROPS LOZ 7.6MG 57782039726 CROMOLYN SOD SPR 5.2/ACT 53329009101 CURAD HYDRO CRE 1% 36800028251 DAYHIST ALRG TAB 12 HOUR 67112090350 DECARA CAP 10000UNT 00113005452 DECONGESTANT TAB 120MG ER 00113205460 DECONGESTANT TAB 120MG ER 36800005452 DECONGESTANT TAB 120MG ER 36800005460 DECONGESTANT TAB 120MG ER 49348036101 DECONGESTANT TAB 120MG ER 70677000101 DECONGESTANT TAB 120MG ER 63824021366 DELSYM COUGH LIQ CONGS DM 63824021466 DELSYM COUGH LIQ CONGS DM 00067094915 DESENEX SHAK POW 2% 00067094930 DESENEX SHAK POW 2% 45802005003 DIBUCAINE OIN 1% 00299491015 DIFFERIN GEL 0.1% 00299491045 DIFFERIN GEL 0.1% 00904646220 DIMAPHEN ELX CHILDREN 00904646320 DIMAPHEN DM ELX 2.5-1-5 45802035803 DIPHEN/ZINC CRE 2-0.1% 00536101001 DIPHENHIST CAP 25MG 00536077085 DIPHENHIST LIQ 12.5/5ML 00536077097 DIPHENHIST LIQ 12.5/5ML 00536101601 DIPHENHIST TAB 25MG 00185064801 DIPHENHYDRAM CAP 25MG 00185064810 DIPHENHYDRAM CAP 25MG 00904530661 DIPHENHYDRAM CAP 25MG 42806064801 DIPHENHYDRAM CAP 25MG 42806064810 DIPHENHYDRAM CAP 25MG 66424002001 DIPHENHYDRAM CAP 25MG 66424002010 DIPHENHYDRAM CAP 25MG 00185064901 DIPHENHYDRAM CAP 50MG 00185064910 DIPHENHYDRAM CAP 50MG 00904205661 DIPHENHYDRAM CAP 50MG 42806064901 DIPHENHYDRAM CAP 50MG 42806064910 DIPHENHYDRAM CAP 50MG 66424002101 DIPHENHYDRAM CAP 50MG

Page 18: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

66424002110 DIPHENHYDRAM CAP 50MG 69367018730 DIPHENHYDRAM LIQ 6.25MG 49483006101 DIPHENHYDRAM TAB 25MG 49483006110 DIPHENHYDRAM TAB 25MG 50383077110 DOCU LIQ 50MG/5ML 50383077111 DOCU LIQ 50MG/5ML 50383077116 DOCU LIQ 50MG/5ML 24385043578 DOCUSATE CAL CAP 240MG 16103038408 DOCUSATE SOD CAP 100MG 16103038411 DOCUSATE SOD CAP 100MG 45802048678 DOCUSATE SOD CAP 100MG 60687012901 DOCUSATE SOD CAP 100MG 60687012911 DOCUSATE SOD CAP 100MG 00121054410 DOCUSATE SOD LIQ 50MG/5ML 46122039943 DOCUSATE SOD LIQ 50MG/5ML 51645075001 DOCUSATE SOD TAB 100MG 51645075010 DOCUSATE SOD TAB 100MG 62107003301 DOCUSIL CAP 100MG 62107003310 DOCUSIL CAP 100MG 17433988405 DOCUSOL KIDS ENE 100MG/5M 17433987805 DOCUSOL MINI ENE 17433988305 DOCUSOL PLUS ENE 20-283 00904645561 DOK CAP 100MG 00904645760 DOK CAP 100MG 00904645780 DOK CAP 100MG 00904645859 DOK CAP 250MG 00904586960 DOK TAB 100MG 00904564361 DOK PLUS TAB 8.6-50MG 00904205112 DRIMINATE TAB 50MG 00904205159 DRIMINATE TAB 50MG 00536035510 DSS/SENNA TAB 8.6-50MG 62107003001 DUCODYL TAB 5MG EC 62107003010 DUCODYL TAB 5MG EC 00597005238 DULCOLAX SUP 10MG 00597001211 DULCOLAX TAB 5MG EC 00597001250 DULCOLAX TAB 5MG EC 00597001626 DULCOLAX SS CAP 100MG 50268087011 E-400 CAP 400UNIT 50268087013 E-400 CAP 400UNIT 00904662735 EAR DROPS DRO 6.5% 36800083533 EARWAX SOL REMOVAL 62011016701 EARWAX REMV SOL 6.5% OT 62011016901 EARWAX REMV SOL 6.5% OT 50102011101 ECONTRA EZ TAB 1.5MG 50102011112 ECONTRA EZ TAB 1.5MG 50102021111 ECONTRA OS TAB 1.5MG 50102021116 ECONTRA OS TAB 1.5MG

Page 19: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

62107002801 ECPIRIN TAB 325MG EC 62107002832 ECPIRIN TAB 325MG EC 00485025401 ED A-HIST TAB 4-10MG 00485009402 ED CHLORPED LIQ 2MG/ML 00485009804 ED CHLORPED SYP JR 00485009816 ED CHLORPED SYP JR 00485005708 ED-APAP LIQ 80MG/2.5 68047014316 ENDACOF-DM LIQ 2.5-1-5 36800000202 ENEMA ENE SINGLE 36800000236 ENEMA ENE SINGLE 70000010801 ENEMA READY- ENE TO-USE 70000010802 ENEMA READY- ENE TO-USE 00536741551 ENEMA READY- ENE -TO-USE 00904632078 ENEMA READY- ENE -TO-USE 17433987603 ENEMEEZ MINI ENE 17433987703 ENEMEEZ PLUS ENE 20-283 63868089810 ENTERIC ASA TAB 325MG 50844022712 EQ ASPIRIN TAB 325MG EC 00113089801 ESOMEPRA MAG CAP 20MG DR 00113089802 ESOMEPRA MAG CAP 20MG DR 00113089803 ESOMEPRA MAG CAP 20MG DR 00536113113 ESOMEPRA MAG CAP 20MG DR 00536113171 ESOMEPRA MAG CAP 20MG DR 00536113188 ESOMEPRA MAG CAP 20MG DR 46122039703 ESOMEPRA MAG CAP 20MG DR 46122039704 ESOMEPRA MAG CAP 20MG DR 46122039774 ESOMEPRA MAG CAP 20MG DR 62011033201 ESOMEPRA MAG CAP 20MG DR 62011033202 ESOMEPRA MAG CAP 20MG DR 62011033203 ESOMEPRA MAG CAP 20MG DR 70677001601 ESOMEPRA MAG CAP 20MG DR 70677001603 ESOMEPRA MAG CAP 20MG DR 00067200020 EXCEDRIN TAB EX ST 00067200024 EXCEDRIN TAB EX ST 00067200050 EXCEDRIN TAB EX ST 00067200077 EXCEDRIN TAB EX ST 00067203924 EXCEDRIN TAB MIGRAINE 00067203950 EXCEDRIN TAB MIGRAINE 00067203977 EXCEDRIN TAB MIGRAINE 00067203991 EXCEDRIN TAB MIGRAINE 00067203992 EXCEDRIN TAB MIGRAINE 00067000512 EX-LAX CHW 15MG 00067000524 EX-LAX CHW 15MG 00067000548 EX-LAX CHW 15MG 00067000308 EX-LAX TAB 15MG 00067000330 EX-LAX TAB 15MG 00067001624 EX-LAX TAB MAX ST

Page 20: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00536097085 EXTRA ACTION SYP 100-10/5 00536097097 EXTRA ACTION SYP 100-10/5 62011010401 EYE DROPS DRO ADV RELF 00536100294 EYE DROPS SOL 0.05% OP 00093274865 FAMOTIDINE TAB 10MG 00093274892 FAMOTIDINE TAB 10MG 00093274894 FAMOTIDINE TAB 10MG 62011014201 FAMOTIDINE TAB 10MG 62011014301 FAMOTIDINE TAB 20MG 16103035911 FERROUS SULF TAB 325MG 16103038208 FERROUS SULF TAB 325MG 16103038211 FERROUS SULF TAB 325MG 69367016620 FERROUS SULF TAB 325MG EC 51672211502 FEVERALL SUP 120MG 51672211504 FEVERALL SUP 120MG 51672211602 FEVERALL SUP 325MG 51672211604 FEVERALL SUP 325MG 51672211704 FEVERALL SUP 650MG 51672211402 FEVERALL INF SUP 80MG 51672211404 FEVERALL INF SUP 80MG 00378078205 FEXOFENADINE TAB 180MG 00378078293 FEXOFENADINE TAB 180MG 00536106615 FEXOFENADINE TAB 180MG 00904621448 FEXOFENADINE TAB 180MG 00904621452 FEXOFENADINE TAB 180MG 00904671110 FEXOFENADINE TAB 180MG 00904671146 FEXOFENADINE TAB 180MG 00904671152 FEXOFENADINE TAB 180MG 00904671189 FEXOFENADINE TAB 180MG 36800057113 FEXOFENADINE TAB 180MG 36800057122 FEXOFENADINE TAB 180MG 36800057139 FEXOFENADINE TAB 180MG 36800057175 FEXOFENADINE TAB 180MG 36800057195 FEXOFENADINE TAB 180MG 45802057178 FEXOFENADINE TAB 180MG 49348096856 FEXOFENADINE TAB 180MG 50268031611 FEXOFENADINE TAB 180MG 50268031615 FEXOFENADINE TAB 180MG 51079054801 FEXOFENADINE TAB 180MG 51079054820 FEXOFENADINE TAB 180MG 55111078401 FEXOFENADINE TAB 180MG 55111078430 FEXOFENADINE TAB 180MG 62011023301 FEXOFENADINE TAB 180MG 62011031501 FEXOFENADINE TAB 180MG 62011031502 FEXOFENADINE TAB 180MG 63868014130 FEXOFENADINE TAB 180MG 70677000801 FEXOFENADINE TAB 180MG

Page 21: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

70677000802 FEXOFENADINE TAB 180MG 00378078105 FEXOFENADINE TAB 60MG 00378078191 FEXOFENADINE TAB 60MG 36800042553 FEXOFENADINE TAB 60MG 45802042578 FEXOFENADINE TAB 60MG 51079054701 FEXOFENADINE TAB 60MG 51079054720 FEXOFENADINE TAB 60MG 62011031401 FEXOFENADINE TAB 60MG 70677000701 FEXOFENADINE TAB 60MG 00904250091 FIBER TAB 625MG 00113047775 FIBER LAXATV TAB 625MG 36800047775 FIBER LAXATV TAB 625MG 36800047792 FIBER LAXATV TAB 625MG 37205021375 FIBER LAXATV TAB 625MG 37205037278 FIBER LAXTIV CAP 0.52GM 24385046678 FIBER THERAP TAB 500MG 24385012576 FIBER-CAPS TAB 625MG 00536430605 FIBER-LAX TAB 625MG 00536430608 FIBER-LAX TAB 625MG 00536430611 FIBER-LAX TAB 625MG 46122011521 FIRST AID SPR 20% 00132020140 FLEET ENE 00132020142 FLEET ENE 00132020145 FLEET ENE 00132020220 FLEET ENE PED 00132070336 FLEET BISACO ENE 10/30ML 00132018582 FLEET LIQUID ENE GLYCERIN 00132030140 FLEET OIL ENE 00135057602 FLONASE ALGY SPR 50MCG 00135057603 FLONASE ALGY SPR 50MCG 00135057604 FLONASE ALGY SPR 50MCG 00135057614 FLONASE ALGY SPR 50MCG 00135057615 FLONASE ALGY SPR 50MCG 00135057616 FLONASE ALGY SPR 50MCG 00135058201 FLONASE ALGY SPR 50MCG 00135058202 FLONASE ALGY SPR 50MCG 00135061502 FLONASE SENS SUS 27.5MCG 00135061503 FLONASE SENS SUS 27.5MCG 00135061504 FLONASE SENS SUS 27.5MCG 00135061505 FLONASE SENS SUS 27.5MCG 00135061601 FLONASE SENS SUS 27.5MCG 00536109170 FLUTICASONE SPR 50MCG 00536109194 FLUTICASONE SPR 50MCG 36800002801 FLUTICASONE SPR 50MCG 36800022201 FLUTICASONE SPR 50MCG 46122033805 FLUTICASONE SPR 50MCG 60505616701 FLUTICASONE SPR 50MCG

Page 22: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

63868013812 FLUTICASONE SPR 50MCG 00884549301 FUNGOID TINC KIT 00884029301 FUNGOID TINC SOL 2% 00113042860 GAS RELIEF CAP 125MG 00904660636 GAS RELIEF CAP 125MG 00904671446 GAS RELIEF CAP 125MG 24385042865 GAS RELIEF CAP 125MG 49348007309 GAS RELIEF CAP 125MG 62011030401 GAS RELIEF CAP 125MG 00113065772 GAS RELIEF CAP 180MG 00904557252 GAS RELIEF CAP 180MG 36800012550 GAS RELIEF CAP 180MG 49348048912 GAS RELIEF CAP 180MG 00536102008 GAS RELIEF CHW 125MG 00536101901 GAS RELIEF CHW 80MG 37205011278 GAS RELIEF CHW 80MG 00536222075 GAS RELIEF DRO 20/0.3ML 00904589430 GAS RELIEF DRO 20/0.3ML 46122005103 GAS RELIEF DRO 20/0.3ML 49348074027 GAS RELIEF DRO 20/0.3ML 62011018701 GAS RELIEF DRO 20/0.3ML 36800088210 GAS RELIEF DRO 40/0.6ML 00067627510 GAS-X CAP 125MG 00067627520 GAS-X CAP 125MG 00067627550 GAS-X CAP 125MG 00067627572 GAS-X CAP 125MG 00067627582 GAS-X CAP 125MG 00067627418 GAS-X CAP 180MG 00067627450 GAS-X CAP 180MG 00067011701 GAS-X EX-STR CHW 125MG 00067011718 GAS-X EX-STR CHW 125MG 00067011748 GAS-X EX-STR CHW 125MG 00067012918 GAS-X EX-STR CHW 125MG 00067113324 GAS-X EX-STR CHW 125MG 43386031208 GAVILAX POW 43386031214 GAVILAX POW 00135009626 GAVISCON CHW 00135009826 GAVISCON CHW EX-STR 00135043003 GAVISCON CHW EX-STR 00135009441 GAVISCON SUS 00135009442 GAVISCON SUS 00135009541 GAVISCON SUS 00135057401 GAVISCON SUS CHERRY 00078042947 GENTEAL GEL 0.3% 00078042957 GENTEAL GEL 0.3% 00065041880 GENTEAL TEAR SOL MILD 00065041881 GENTEAL TEAR SOL MILD

Page 23: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00065806301 GENTEAL TEAR SOL MOD PF 00065042636 GENTEAL TEAR SOL MODERATE 00065042637 GENTEAL TEAR SOL MODERATE 00065041663 GENTEAL TEAR SOL PF 46122038451 GENTLE LAXAT SUP 10MG 58657050508 GG/DM SYP 100-10/5 00904671015 GLUCOSE CHW 4GM 00132007912 GLYCERIN SUP 2GM 00132007924 GLYCERIN SUP 2GM 00132007950 GLYCERIN SUP 2GM 62175019015 GLYCOLAX POW 3350 NF 62175019031 GLYCOLAX POW 3350 NF 46122038841 GNP ACETAMIN CAP 500MG 46122043078 GNP ACETAMIN TAB 325MG 24385099865 GNP ALL DAY TAB ALLERGY 24385099874 GNP ALL DAY TAB ALLERGY 24385099875 GNP ALL DAY TAB ALLERGY 24385046262 GNP ALLERGY CAP 25MG 24385046278 GNP ALLERGY CAP 25MG 46122042762 GNP ALLERGY CAP 25MG 46122044078 GNP ALLERGY CAP 25MG 46122044262 GNP ALLERGY CAP 25MG 46122042589 GNP ALLERGY CHW 12.5MG 46122004022 GNP ALLERGY TAB 180MG 46122004061 GNP ALLERGY TAB 180MG 46122004065 GNP ALLERGY TAB 180MG 46122004075 GNP ALLERGY TAB 180MG 24385047962 GNP ALLERGY TAB 25MG 24385047978 GNP ALLERGY TAB 25MG 46122044162 GNP ALLERGY TAB 25MG 24385046362 GNP ALLERGY TAB 4MG 24385046378 GNP ALLERGY TAB 4MG 46122015078 GNP ANTACID CHW 160-105 46122015347 GNP ANTACID CHW 550-110 24385035640 GNP ANTACID SUS ANTI-GAS 24385036240 GNP ANTACID SUS CHERRY 46122043240 GNP ANTACID SUS CHERRY 46122043440 GNP ANTACID SUS COOLMINT 46122043140 GNP ANTACID SUS ORIGINAL 46122043340 GNP ANTACID SUS REG ST 24385002868 GNP ASPIRIN CHW 81MG 24385027868 GNP ASPIRIN CHW 81MG 24385036468 GNP ASPIRIN CHW 81MG 46122029278 GNP ASPIRIN TAB 325MG 24385042902 GNP ASPIRIN TAB 325MG EC 24385042990 GNP ASPIRIN TAB 325MG EC 24385090378 GNP BISA-LAX TAB 5MG EC

Page 24: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

46122011321 GNP BURN SPR RELIEF 24385051726 GNP CLD/ALLE ELX CHILDREN 24385051734 GNP CLD/ALLE ELX CHILDREN 46122001452 GNP CLEARLAX PAK 3350 NF 46122001431 GNP CLEARLAX POW 46122001433 GNP CLEARLAX POW 46122001438 GNP CLEARLAX POW 46122001471 GNP CLEARLAX POW 24385024154 GNP COLD&HOT OIN EXT ST 24385051926 GNP COLD/CGH ELX CHILD 24385018351 GNP DAYHIST TAB 1.34MG 46122042862 GNP DECONGE TAB 30MG 46122043863 GNP DUAL ACT CHW BERRY 46122043963 GNP DUAL ACT CHW COOLMINT 24385050305 GNP EAR SYS SOL 6.5% OT 46122016128 GNP ENEMA ENE 46122016136 GNP ENEMA ENE 46122036428 GNP ENEMA ENE 46122036436 GNP ENEMA ENE 24385007705 GNP EYE DRO 46122037605 GNP EYE DROP DRO 0.4-0.3% 24385007505 GNP EYE DROP SOL 0.05% OP 46122037705 GNP EYE DROP SOL 0.5% OP 24385030789 GNP GAS RELF CHW 125MG 24385011878 GNP GAS RELF CHW 80MG 46122038278 GNP HEADACHE TAB EXTRA ST 24385002103 GNP HYDROCOR CRE 1% PLUS 24385036962 GNP LAXATIVE TAB 25MG 24385019365 GNP LAXATIVE TAB 5MG EC 24385090363 GNP LAXATIVE TAB 5MG EC 46122042963 GNP LAXATIVE TAB 5MG EC 46122045021 GNP LIDOCAIN PAD 4% 24385034040 GNP MASANTI SUS MAX ST 24385035740 GNP MASANTI SUS REG ST 24385036571 GNP MIGRAINE TAB RELIEF 24385036578 GNP MIGRAINE TAB RELIEF 24385033240 GNP MILK MAG SUS 24385039640 GNP MILK MAG SUS 46122043540 GNP MILK MAG SUS CHERRY 46122043640 GNP MILK MAG SUS MINT 46122043740 GNP MILK MAG SUS ORIGINAL 24385001121 GNP MUSCLE CRE RUB 24385006710 GNP NASAL SPR 0.05% 24385035210 GNP NASAL SPR 0.05% 46122016510 GNP NASAL SPR 0.05% 46122016511 GNP NASAL SPR 0.05% 46122014903 GNP NASAL SPR 1%

Page 25: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

24385039010 GNP NOSE DRO 1% 46122041971 GNP PAIN PM TAB 25-500MG 46122037805 GNP REDNESS SOL RELIEF 46122039678 GNP SENNA TAB 8.6MG 46122033765 GNP URINARY TAB 95MG 00121148800 GUAIFENESIN LIQ 100/5ML 00121148810 GUAIFENESIN LIQ 100/5ML 00121223200 GUAIFENESIN LIQ 100/5ML 00121223215 GUAIFENESIN LIQ 100/5ML 58657050916 GUAIFENESIN LIQ 100/5ML 00121174400 GUAIFENESIN SOL 100/5ML 00121174405 GUAIFENESIN SOL 100/5ML 50383006307 GUAIFENESIN SOL 100/5ML 50383006312 GUAIFENESIN SOL 200/10ML 50383006318 GUAIFENESIN SOL 300/15ML 00121063800 GUAIFENESIN SYP DM 00121063805 GUAIFENESIN SYP DM 00121127600 GUAIFENESIN SYP DM 00121127610 GUAIFENESIN SYP DM 00904515460 GUAIFENESIN TAB 200MG 50268038211 GUAIFENESIN TAB 200MG 50268038215 GUAIFENESIN TAB 200MG 51672201002 HC/ALOE CRE 0.5% 36800035571 HEADACHE TAB 25-500MG 70000014601 HEADACHE TAB RELIEF 70000025801 HEADACHE TAB RELIEF 00113035571 HEADACHE PM TAB 25-500MG 37205067771 HEADACHE PM TAB 25-500MG 46122013471 HEADACHE PM TAB 25-500MG 70000030301 HEADACHE PM TAB 500-25MG 68084043098 HEALTHYLAX POW 68084043099 HEALTHYLAX POW

Page 26: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

36800085271 HEARTBURN TAB 150MG 36800095009 HEARTBURN TAB 150MG 36800095062 HEARTBURN TAB 150MG 24385011165 HEARTBURN TAB 200MG 00904578017 HEARTBURN TAB 20MG 00904578051 HEARTBURN TAB 20MG 00904552952 HEARTBURN TAB RELIEF 00904552987 HEARTBURN TAB RELIEF 36800002239 HEARTBURN TAB RELIEF 00536103413 HEARTBURN TR CAP 15MG 00536103488 HEARTBURN TR CAP 15MG 70000025501 HEARTBURN TR CAP 24H 20MG 70000025502 HEARTBURN TR CAP 24H 20MG 70000025503 HEARTBURN TR CAP 24H 20MG 00113094424 HEMORRHOIDAL CRE 36800094424 HEMORRHOIDAL CRE MAX ST 24385042106 HEMORRHOIDAL GEL COOLING 00113018816 HEMORRHOIDAL OIN 36800049916 HEMORRHOIDAL OIN 45802018816 HEMORRHOIDAL OIN 46122010346 HEMORRHOIDAL OIN 62011029601 HEMORRHOIDAL OIN 00113027953 HEMORRHOIDAL SUP 00536118612 HEMORRHOIDAL SUP 00536138912 HEMORRHOIDAL SUP 36800027953 HEMORRHOIDAL SUP 36800027962 HEMORRHOIDAL SUP 63868020812 HEMORRHOIDAL SUP 28595080208 HISTEX SYP 2.5MG/5 28595080130 HISTEX PD DRO 0.938MG 62011026401 HM ALLERGY CAP 25MG 62011026402 HM ALLERGY CAP 25MG 62011030901 HM ALLERGY CAP 25MG 62011005801 HM ALLERGY TAB 25MG 62011005901 HM ALLERGY TAB 4MG 62011029201 HM ANTACID SUS 62011014801 HM ANTACID SUS ANTI-GAS 62011014901 HM ANTACID SUS ANTI-GAS 62011033301 HM ARTHRITIS CRE 10% 62011033801 HM ARTHRTS TAB 650MG 62011002101 HM ASPIRIN CHW 81MG 62011002801 HM ASPIRIN CHW 81MG 62011021201 HM ASPIRIN CHW 81MG 62011002001 HM ASPIRIN TAB 325MG 62011002002 HM ASPIRIN TAB 325MG 62011002003 HM ASPIRIN TAB 325MG 62011015304 HM CLEARLAX POW

Page 27: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

62011028701 HM CLEARLAX POW 62011028702 HM CLEARLAX POW 62011006301 HM COLD/CGH ELX CHILDREN 62011019601 HM DRY EYE SOL RELIEF 62011019101 HM ENEMA ENE R-T-U 62011027101 HM ENEMA ENE R-T-U 62011027102 HM ENEMA ENE R-T-U 62011010901 HM EPSOM GRA SALT 62011010201 HM EYE DROPS SOL 0.05% OP 62011010001 HM EYE DROPS SOL RED RELF 62011005301 HM FIBER CAP 0.52GM 62011013301 HM FIBER POW 28.3% 62011013501 HM FIBER POW 30.9% 62011013601 HM FIBER POW 48.57% 62011013701 HM FIBER POW 58.6% 62011013401 HM FIBER TAB 500MG 62011018901 HM GAS RELF CHW 125MG 62011029101 HM GAS RELF CHW 80MG 62011009601 HM HYDROCORT CRE 1% PLUS 62011033401 HM IBUPROFEN CHW 100MG 62011001401 HM IBUPROFEN TAB 200MG 62011001402 HM IBUPROFEN TAB 200MG 62011001403 HM IBUPROFEN TAB 200MG 62011001407 HM IBUPROFEN TAB 200MG 62011001501 HM IBUPROFEN TAB 200MG 62011001502 HM IBUPROFEN TAB 200MG 62011001503 HM IBUPROFEN TAB 200MG 62011021301 HM IBUPROFEN TAB 200MG 62011022201 HM IBUPROFEN TAB 200MG 62011022202 HM IBUPROFEN TAB 200MG 62011033501 HM IBUPROFEN TAB PM 62011027701 HM LAXATIVE TAB 5MG 62011027702 HM LAXATIVE TAB 5MG 62011027703 HM LAXATIVE TAB 5MG 62011024301 HM MIGRAINE TAB FORMULA 62011008001 HM NASAL SPR 0.05%

Page 28: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

62011021501 HM NIGHTTIME TAB 25MG 62011034301 HM NIGHTTIME TAB 25MG 62011008501 HM NOSE DRO 1% 62011032901 HM PAIN RLF PAD THERAPY 62011033601 HM PAIN RLF TAB 650MG 62011023001 HM RPD MELT TAB 160MG 62011032801 HM SALONPAS DIS PAIN RLF 62011028901 HM SENNA TAB 8.6MG 62011036301 HM SENNA TAB 8.6MG 62011029001 HM SENNA-S TAB 8.6-50MG 62011034401 HM SLEEP AID TAB 25MG 62011034201 HM Z-SLEEP CAP 25MG 62011021001 HM Z-SLEEP LIQ 50MG/30 00168001431 HYDROCORT CRE 0.5% 24385019003 HYDROCORT CRE 0.5% 00168015408 HYDROCORT CRE 1% 00168015431 HYDROCORT CRE 1% 00472034356 HYDROCORT CRE 1% 00904762331 HYDROCORT CRE 1% 37205016210 HYDROCORT CRE 1% 45802043803 HYDROCORT CRE 1% 45802043805 HYDROCORT CRE 1% 51672201301 HYDROCORT CRE 1% 51672201302 HYDROCORT CRE 1% 51672206302 HYDROCORT CRE 1% 51672206902 HYDROCORT CRE 1% 00168001631 HYDROCORT OIN 0.5% 00168018131 HYDROCORT OIN 1% 00472034556 HYDROCORT OIN 1% 24385027603 HYDROCORT OIN 1% 45802027603 HYDROCORT OIN 1% 51672201802 HYDROCORT OIN 1% 00472033956 HYDROCORT/ CRE ALOE 1% 24385027403 HYDROCORT/ CRE ALOE 1% 37205027210 HYDROCORT/ CRE ALOE 1% 62011009501 HYDROCORT/ CRE ALOE 1% 00536107997 HYDROSKIN LOT 1% 00904791451 IBU-200 TAB 200MG 00904791459 IBU-200 TAB 200MG 00904791480 IBU-200 TAB 200MG 37205043610 IBU-DROPS DRO 50/1.25 00536114730 IBUPROFEN CAP 200MG 24385049941 IBUPROFEN CAP 200MG 24385049958 IBUPROFEN CAP 200MG 36800004840 IBUPROFEN CAP 200MG 36800019840 IBUPROFEN CAP 200MG 62011001601 IBUPROFEN CAP 200MG

Page 29: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

70000036001 IBUPROFEN CAP 200MG 70000036002 IBUPROFEN CAP 200MG 70000036003 IBUPROFEN CAP 200MG 00113005705 IBUPROFEN DRO 50/1.25 24385055010 IBUPROFEN DRO 50/1.25 36800005705 IBUPROFEN DRO 50/1.25 36800025510 IBUPROFEN DRO 50/1.25 45802005705 IBUPROFEN DRO 50/1.25 45963012523 IBUPROFEN DRO 50/1.25 45963012524 IBUPROFEN DRO 50/1.25 49348037469 IBUPROFEN DRO 50/1.25 49348064227 IBUPROFEN DRO 50/1.25 62011000401 IBUPROFEN DRO 50/1.25 62011001201 IBUPROFEN DRO 50/1.25 63868007630 IBUPROFEN DRO 50/1.25 70000029801 IBUPROFEN DRO 50/1.25 00113016626 IBUPROFEN SUS 100/5ML 00113066026 IBUPROFEN SUS 100/5ML 00113068526 IBUPROFEN SUS 100/5ML 00113089726 IBUPROFEN SUS 100/5ML 00113089734 IBUPROFEN SUS 100/5ML 00121183605 IBUPROFEN SUS 100/5ML 00472176094 IBUPROFEN SUS 100/5ML 00472176098 IBUPROFEN SUS 100/5ML 00472176394 IBUPROFEN SUS 100/5ML 00472176494 IBUPROFEN SUS 100/5ML 00904530909 IBUPROFEN SUS 100/5ML 00904530920 IBUPROFEN SUS 100/5ML 00904557720 IBUPROFEN SUS 100/5ML 24385000926 IBUPROFEN SUS 100/5ML 24385000934 IBUPROFEN SUS 100/5ML 24385036126 IBUPROFEN SUS 100/5ML 24385036134 IBUPROFEN SUS 100/5ML 24385037226 IBUPROFEN SUS 100/5ML 24385090526 IBUPROFEN SUS 100/5ML 24385090534 IBUPROFEN SUS 100/5ML 36800016626 IBUPROFEN SUS 100/5ML 36800066026 IBUPROFEN SUS 100/5ML 36800068526 IBUPROFEN SUS 100/5ML 36800089726 IBUPROFEN SUS 100/5ML 45802013326 IBUPROFEN SUS 100/5ML 45802014026 IBUPROFEN SUS 100/5ML 45802089726 IBUPROFEN SUS 100/5ML 45802089734 IBUPROFEN SUS 100/5ML 46122011026 IBUPROFEN SUS 100/5ML 49348022934 IBUPROFEN SUS 100/5ML 49348022937 IBUPROFEN SUS 100/5ML

Page 30: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348049934 IBUPROFEN SUS 100/5ML 49348050034 IBUPROFEN SUS 100/5ML 49348087634 IBUPROFEN SUS 100/5ML 51672213001 IBUPROFEN SUS 100/5ML 51672213008 IBUPROFEN SUS 100/5ML 62011001001 IBUPROFEN SUS 100/5ML 62011001101 IBUPROFEN SUS 100/5ML 62011003001 IBUPROFEN SUS 100/5ML 62011003002 IBUPROFEN SUS 100/5ML 62011003003 IBUPROFEN SUS 100/5ML 62011021401 IBUPROFEN SUS 100/5ML 63868075618 IBUPROFEN SUS 100/5ML 63868075818 IBUPROFEN SUS 100/5ML 68094049458 IBUPROFEN SUS 100/5ML 68094049459 IBUPROFEN SUS 100/5ML 68094049461 IBUPROFEN SUS 100/5ML 68094049462 IBUPROFEN SUS 100/5ML 68094050359 IBUPROFEN SUS 100/5ML 68094050361 IBUPROFEN SUS 100/5ML 68094050362 IBUPROFEN SUS 100/5ML 68094060059 IBUPROFEN SUS 100/5ML 68094060061 IBUPROFEN SUS 100/5ML 68094060062 IBUPROFEN SUS 100/5ML 70000018101 IBUPROFEN SUS 100/5ML 70000018102 IBUPROFEN SUS 100/5ML 70000025901 IBUPROFEN SUS 100/5ML 70000026201 IBUPROFEN SUS 100/5ML 70000026301 IBUPROFEN SUS 100/5ML 70000026302 IBUPROFEN SUS 100/5ML 70000026303 IBUPROFEN SUS 100/5ML 70000026401 IBUPROFEN SUS 100/5ML 70000026402 IBUPROFEN SUS 100/5ML 00113007471 IBUPROFEN TAB 200MG 00113007478 IBUPROFEN TAB 200MG 00113051771 IBUPROFEN TAB 200MG 00113060452 IBUPROFEN TAB 200MG 00113060462 IBUPROFEN TAB 200MG 00113060471 IBUPROFEN TAB 200MG 00113060478 IBUPROFEN TAB 200MG 00113060490 IBUPROFEN TAB 200MG 00113064762 IBUPROFEN TAB 200MG 00113064771 IBUPROFEN TAB 200MG 00113064778 IBUPROFEN TAB 200MG 00536108801 IBUPROFEN TAB 200MG 00536108802 IBUPROFEN TAB 200MG 00536108805 IBUPROFEN TAB 200MG 00536108806 IBUPROFEN TAB 200MG

Page 31: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00536108901 IBUPROFEN TAB 200MG 00904791251 IBUPROFEN TAB 200MG 00904791259 IBUPROFEN TAB 200MG 00904791461 IBUPROFEN TAB 200MG 00904791580 IBUPROFEN TAB 200MG 24385005878 IBUPROFEN TAB 200MG 24385005882 IBUPROFEN TAB 200MG 24385060471 IBUPROFEN TAB 200MG 24385060478 IBUPROFEN TAB 200MG 24385060490 IBUPROFEN TAB 200MG 24385064771 IBUPROFEN TAB 200MG 24385064778 IBUPROFEN TAB 200MG 36800007471 IBUPROFEN TAB 200MG 36800007478 IBUPROFEN TAB 200MG 36800018383 IBUPROFEN TAB 200MG 36800051771 IBUPROFEN TAB 200MG 36800051778 IBUPROFEN TAB 200MG 36800060462 IBUPROFEN TAB 200MG 36800060471 IBUPROFEN TAB 200MG 36800060478 IBUPROFEN TAB 200MG 36800060485 IBUPROFEN TAB 200MG 36800060490 IBUPROFEN TAB 200MG 36800064762 IBUPROFEN TAB 200MG 36800064771 IBUPROFEN TAB 200MG 36800064778 IBUPROFEN TAB 200MG 36800064790 IBUPROFEN TAB 200MG 49348019609 IBUPROFEN TAB 200MG 49348019610 IBUPROFEN TAB 200MG 49348019635 IBUPROFEN TAB 200MG 49348070604 IBUPROFEN TAB 200MG 49348070609 IBUPROFEN TAB 200MG 49348070610 IBUPROFEN TAB 200MG 49348070614 IBUPROFEN TAB 200MG 49348070616 IBUPROFEN TAB 200MG 49483060101 IBUPROFEN TAB 200MG 49483060110 IBUPROFEN TAB 200MG 53329067730 IBUPROFEN TAB 200MG 53746014001 IBUPROFEN TAB 200MG 53746014010 IBUPROFEN TAB 200MG 66424039610 IBUPROFEN TAB 200MG 70000017501 IBUPROFEN TAB 200MG 70000017502 IBUPROFEN TAB 200MG 70000017503 IBUPROFEN TAB 200MG 70000017504 IBUPROFEN TAB 200MG 70000017505 IBUPROFEN TAB 200MG 70000017507 IBUPROFEN TAB 200MG 70000017601 IBUPROFEN TAB 200MG

Page 32: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

70000017602 IBUPROFEN TAB 200MG 70000017603 IBUPROFEN TAB 200MG 70000017604 IBUPROFEN TAB 200MG 70000017605 IBUPROFEN TAB 200MG 70000017606 IBUPROFEN TAB 200MG 70000028801 IBUPROFEN TAB 200MG 70000029101 IBUPROFEN TAB 200MG 70000029201 IBUPROFEN TAB 200MG 70000030801 IBUPROFEN TAB 200MG 00472176194 IBUPROFEN CH SUS 100/5ML 49348063904 IBUPROFEN IB CHW 100MG 00113046162 IBUPROFEN JR CHW 100MG 24385054662 IBUPROFEN JR CHW 100MG 36800046162 IBUPROFEN JR CHW 100MG 46122001062 IBUPROFEN JR CHW 100MG 70000023901 IBUPROFEN JR CHW 100MG 70000024001 IBUPROFEN JR CHW 100MG 00113005058 IBUPROFEN PM TAB 200-38MG 00113005060 IBUPROFEN PM TAB 200-38MG 24385093758 IBUPROFEN PM TAB 200-38MG 24385093760 IBUPROFEN PM TAB 200-38MG 36800005027 IBUPROFEN PM TAB 200-38MG 36800005058 IBUPROFEN PM TAB 200-38MG 36800005060 IBUPROFEN PM TAB 200-38MG 46122014571 IBUPROFEN PM TAB 200-38MG 49348087359 IBUPROFEN PM TAB 200-38MG 70000015701 IBUPROFEN PM TAB 200-38MG 70000024801 IBUPROFEN PM TAB 200-38MG 00998040815 ISOPTO TEARS SOL 0.5% OP 00113062264 ITCH RELIEF CRE EX ST 46122011421 ITCH RELIEF SPR 2-0.1% 00225049533 ITCH-X GEL 1-10% 00225051651 ITCH-X SPR 00113069590 JOCK ITCH AER 1% 00904645959 KAO-TIN CAP 240MG 00224184103 KONSYL POW 30.9% 00224184180 KONSYL POW 30.9% 00224185507 KONSYL POW 60.3% 00224185530 KONSYL POW 60.3% 00224185581 KONSYL POW 60.3% 00224185582 KONSYL POW 60.3% 00224186628 KONSYL POW 60.3% 00224186680 KONSYL POW 60.3% 00224185606 KONSYL POW 71.67% 00224185680 KONSYL POW 71.67% 00224180124 KONSYL DAILY POW 100% 00224180184 KONSYL DAILY POW 100%

Page 33: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00224180180 KONSYL DAILY POW 100% 00224180181 KONSYL DAILY POW 100% 00224185281 KONSYL DAILY POW 28.3% 00224185280 KONSYL DAILY POW 28.3% 00224188481 KONSYL DAILY POW 60.3% 00224050090 KONSYL FIBER TAB 625MG 00224180188 KONSYL ORIG POW 100% 00224182280 KONSYL-D POW 52.3% 00067611446 LAMISIL AF AER 1% 00067810012 LAMISIL AT CRE 1% 00067810030 LAMISIL AT CRE 1% 00067811412 LAMISIL AT CRE 1% 00067629283 LAMISIL AT SPR 1% 00067629383 LAMISIL AT SPR 1% 00113011702 LANSOPRAZOLE CAP 15MG DR 36800011702 LANSOPRAZOLE CAP 15MG DR 36800011703 LANSOPRAZOLE CAP 15MG DR 37205066106 LANSOPRAZOLE CAP 15MG DR 37205066115 LANSOPRAZOLE CAP 15MG DR 37205066174 LANSOPRAZOLE CAP 15MG DR 45802024501 LANSOPRAZOLE CAP 15MG DR 45802024502 LANSOPRAZOLE CAP 15MG DR 45802024503 LANSOPRAZOLE CAP 15MG DR 46122010703 LANSOPRAZOLE CAP 15MG DR 46122010704 LANSOPRAZOLE CAP 15MG DR 46122010774 LANSOPRAZOLE CAP 15MG DR 49348030146 LANSOPRAZOLE CAP 15MG DR 49348030161 LANSOPRAZOLE CAP 15MG DR 62011016801 LANSOPRAZOLE CAP 15MG DR 62011016803 LANSOPRAZOLE CAP 15MG DR 00536135501 LAXATIVE SUP 10MG 00536135512 LAXATIVE SUP 10MG 37205029462 LAXATIVE TAB 25MG 00536114263 LEVONORGESTR TAB 1.5MG 36800086634 LICE KILLING SHA 00113086626 LICE KILLING SHA 0.33-4% 00904252820 LICE KILLING SHA 0.33-4% 37205016526 LICE KILLING SHA 0.33-4% 49348044334 LICE KILLING SHA 0.33-4% 62011011902 LICE KILLING SHA 0.33-4% 36800095526 LICE TREATMT LOT 1% 49348015078 LICE TREATMT LOT 1% 24385011603 LICE TREATMT SHA 0.33-4% 46122010846 LICE TRTMNT LIQ 1% 62011025501 LICE TRTMNT LIQ 1% 63824091600 LICEMD KIT COMPLETE 39328002415 LIDOCAINE CRE 4%

Page 34: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

39328002430 LIDOCAINE CRE 4% 39328002455 LIDOCAINE CRE 4% 47781057047 LIDOCAINE CRE 4% 47781057072 LIDOCAINE CRE 4% 47781057073 LIDOCAINE CRE 4% 39328002515 LIDOCAINE CRE 5% 39328002530 LIDOCAINE CRE 5% 47781057172 LIDOCAINE CRE 5% 47781057173 LIDOCAINE CRE 5% 75834011330 LIDOCAINE CRE 5% 75834014130 LIDOCAINE CRE 5% 47781057089 LIDOCAINE KIT 4% 00904649235 LIQUITEARS SOL 49483068607 LORATADINE CAP 10MG 49483068630 LORATADINE CAP 10MG 70000021701 LORATADINE CAP 10MG 51660075331 LORATADINE CHW 5MG 51660075431 LORATADINE CHW 5MG 00121084910 LORATADINE SOL 10/10ML 00121084940 LORATADINE SOL 10/10ML 00904663220 LORATADINE SOL 5MG/5ML 36800009208 LORATADINE SOL 5MG/5ML 46122042326 LORATADINE SOL 5MG/5ML 51672209208 LORATADINE SOL 5MG/5ML 51672213108 LORATADINE SOL 5MG/5ML 54838055840 LORATADINE SOL 5MG/5ML 24385053126 LORATADINE SYP 5MG/5ML 49348033334 LORATADINE SYP 5MG/5ML 49348063634 LORATADINE SYP 5MG/5ML 51672207308 LORATADINE SYP 5MG/5ML 51672208508 LORATADINE SYP 5MG/5ML 62011018101 LORATADINE SYP 5MG/5ML 62011030501 LORATADINE SYP 5MG/5ML 62011034801 LORATADINE SYP 5MG/5ML 00781507701 LORATADINE TAB 10MG 00904579361 LORATADINE TAB 10MG 00904685261 LORATADINE TAB 10MG 16714048201 LORATADINE TAB 10MG 16714048202 LORATADINE TAB 10MG 16714048203 LORATADINE TAB 10MG 24385047152 LORATADINE TAB 10MG 24385047178 LORATADINE TAB 10MG 24385047199 LORATADINE TAB 10MG 45802065065 LORATADINE TAB 10MG 45802065078 LORATADINE TAB 10MG 45802065087 LORATADINE TAB 10MG 46122015865 LORATADINE TAB 10MG

Page 35: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348011201 LORATADINE TAB 10MG 49348011213 LORATADINE TAB 10MG 49348011244 LORATADINE TAB 10MG 50268048811 LORATADINE TAB 10MG 50268048815 LORATADINE TAB 10MG 51079024601 LORATADINE TAB 10MG 51079024620 LORATADINE TAB 10MG 60505014701 LORATADINE TAB 10MG 60505014708 LORATADINE TAB 10MG 62011025801 LORATADINE TAB 10MG 62011025802 LORATADINE TAB 10MG 62011025803 LORATADINE TAB 10MG 62011025804 LORATADINE TAB 10MG 63868015101 LORATADINE TAB 10MG 63868015110 LORATADINE TAB 10MG 63868015130 LORATADINE TAB 10MG 68084024801 LORATADINE TAB 10MG 68084024811 LORATADINE TAB 10MG 49348054301 LORATA-DINE TAB D 24HR 49348054357 LORATA-DINE TAB D 24HR 00904583315 LORATADINE-D TAB 10-240MG 00904583348 LORATADINE-D TAB 10-240MG 63868015410 LORATADINE-D TAB 10-240MG 62011025401 LUBRIC TEARS SOL 0.4-0.3% 46122020204 LUBRICANT OIN EYE 00113032365 LUBRICATING DRO 0.5% 49348032944 LUBRICATING DRO 0.5% 62011020301 LUBRICATING DRO 0.5% 49348014929 LUBRICATING SOL 0.4-0.3% 00113089665 LUBRICNT EYE DRO 0.4-0.3% 00536109994 LUBRICNT EYE DRO 0.4-0.3% 00536110494 LUBRICNT EYE DRO 0.4-0.3% 36800089665 LUBRICNT EYE DRO 0.4-0.3% 37205076265 LUBRICNT EYE DRO 0.4-0.3% 00904632946 LUBRICNT EYE DRO 0.5% OP 00904632951 LUBRICNT EYE DRO 0.5% OP 46122019565 LUBRICNT EYE DRO 0.5% OP 36800062610 MAG CITRATE SOL CHERRY 49348050449 MAG CITRATE SOL CHERRY 62011017400 MAG CITRATE SOL CHERRY 63868094210 MAG CITRATE SOL CHERRY 00904630477 MAG CITRATE SOL LEMON 24385067510 MAG CITRATE SOL LEMON 49348069649 MAG CITRATE SOL LEMON 62011016601 MAG CITRATE SOL LEMON 63868093510 MAG CITRATE SOL LEMON 70000031801 MAG CITRATE SOL LEMON

Page 36: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

70677005101 MAG CITRATE SOL LEMON 00603020922 MAG OXIDE TAB 400MG 58657012012 MAG OXIDE TAB 400MG 00121176030 MAG-AL LIQ 00121176130 MAG-AL PLUS LIQ 00121176230 MAG-AL PLUS LIQ XS 59528050805 MAGNEBIND TAB 300 00904672602 MAJOR-PREP OIN HEMORRHO 00904198760 MAPAP CAP 500MG 00904664524 MAPAP CHW 160MG 00904198500 MAPAP LIQ 160/5ML 00904198516 MAPAP LIQ 160/5ML 00904198520 MAPAP LIQ 160/5ML 00904198251 MAPAP TAB 325MG 00904198259 MAPAP TAB 325MG 00904198260 MAPAP TAB 325MG 00904198261 MAPAP TAB 325MG 00904198280 MAPAP TAB 325MG 00904198324 MAPAP TAB 500MG 00904198340 MAPAP TAB 500MG 00904198359 MAPAP TAB 500MG 00904198380 MAPAP TAB 500MG 00904198394 MAPAP TAB 500MG 00904198860 MAPAP TAB 500MG 00904581660 MAPAP TAB 500MG/RR 00904584709 MAPAP APAP LIQ 500/15ML 00904579146 MAPAP CHILD TAB 80MG RT 00904653620 MAPAP CHILDR SUS 160/5ML 00904765151 MAPAP PM TAB 25-500MG 16103038708 MECLIZINE CHW 25MG 16103038711 MECLIZINE CHW 25MG 51645099401 MECLIZINE CHW 25MG 51645099410 MECLIZINE CHW 25MG 00536101710 MECLIZINE TAB 12.5MG 00536117801 MECLIZINE TAB 12.5MG 00536117810 MECLIZINE TAB 12.5MG 16103038608 MECLIZINE TAB 12.5MG 16103038611 MECLIZINE TAB 12.5MG 70000014501 MENSTRUAL TAB PAIN RLF 58657053530 M-HIST PD LIQ 0.625/ML 00904511571 MI-ACID CHW 00904000414 MI-ACID SUS 00904000514 MI-ACID SUS MAX ST 00904506860 MI-ACID GAS CHW 80MG 00472073041 MICONAZOLE CRE 2% 00472073063 MICONAZOLE CRE 2% 00536113428 MICONAZOLE CRE 2%

Page 37: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00713025237 MICONAZOLE CRE 2% 51672200101 MICONAZOLE CRE 2% 51672200102 MICONAZOLE CRE 2% 51672203506 MICONAZOLE CRE 2% 00713019757 MICONAZOLE SUP 100MG 36800019900 MICONAZOLE 1 KIT 36800073745 MICONAZOLE 1 KIT 00113091600 MICONAZOLE 1 KIT 1200-2% 70000031501 MICONAZOLE 1 KIT 1200-2% 36800007009 MICONAZOLE 3 CRE 4% 36800098200 MICONAZOLE 3 KIT COMBINAT 49348064573 MICONAZOLE 3 KIT COMBINAT 00113008100 MICONAZOLE 3 KIT COMBO PK 00904541501 MICONAZOLE 3 KIT COMBO PK 24385060602 MICONAZOLE 3 KIT COMBO PK 36800008100 MICONAZOLE 3 KIT COMBO PK 37205058903 MICONAZOLE 3 KIT COMBO PK 49348035543 MICONAZOLE 3 KIT COMBO PK 00113082529 MICONAZOLE 7 CRE 2% 00904773445 MICONAZOLE 7 CRE 2% 24385059029 MICONAZOLE 7 CRE 2% 36800082529 MICONAZOLE 7 CRE 2% 49348053077 MICONAZOLE 7 CRE 2% 49348087277 MICONAZOLE 7 CRE 2% 63868019845 MICONAZOLE 7 CRE 2% 00113021429 MICONAZOLE 7 CRE TUBE/KIT 00472173607 MICONAZOLE 7 SUP 100MG 46122003927 MICONAZORB POW AF 2% 46122044427 MICONAZORB POW AF 2% 00113037462 MIGRAINE TAB FORMULA 00113037478 MIGRAINE TAB FORMULA 36800037462 MIGRAINE TAB FORMULA 36800037478 MIGRAINE TAB FORMULA 70000024701 MIGRAINE TAB RELIEF 70000024702 MIGRAINE TAB RELIEF 00113039640 MILK OF MAGN SUS 00121043130 MILK OF MAGN SUS 00536247083 MILK OF MAGN SUS 00536247085 MILK OF MAGN SUS 36800039640 MILK OF MAGN SUS 00904078814 MILK OF MAGN SUS 1200/15 00904078816 MILK OF MAGN SUS 1200/15 36800033240 MILK OF MAGN SUS 1200/15 49348017138 MILK OF MAGN SUS 1200/15 49348030539 MILK OF MAGN SUS 1200/15 49348030739 MILK OF MAGN SUS 1200/15 49348030839 MILK OF MAGN SUS 1200/15

Page 38: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

66689005301 MILK OF MAGN SUS 2400/30 66689005399 MILK OF MAGN SUS 2400/30 00054356749 MILK OF MAGN SUS 2400MG 00054356761 MILK OF MAGN SUS 2400MG 00121052710 MILK OF MAGN SUS 2400MG 37205083340 MILK OF MAGN SUS 400/5ML 62011012301 MILK OF MAGN SUS 400/5ML 62011012401 MILK OF MAGN SUS 400/5ML 63868031012 MILK OF MAGN SUS 400/5ML 63868078757 MILK OF MAGN SUS 400/5ML 63868078857 MILK OF MAGN SUS 400/5ML 36800094940 MILK OF MAGN SUS CHERRY 00113033240 MILK OF MAGN SUS FRSH MNT 00904078914 MILK OF MAGN SUS MINT 37205083440 MILK OF MAGN SUS MINT 00067206708 MINERAL ICE GEL 2% 00067206716 MINERAL ICE GEL 2% 00067206735 MINERAL ICE GEL 2% 46122036328 MINERAL OIL ENE 62011027001 MINERAL OIL ENE 70000010901 MINERAL OIL ENE 00904572114 MINTOX SUS 00904572514 MINTOX SUS MAX ST 00904047860 MINTOX PLUS CHW 00904670060 MINTOX PLUS CHW 00225036011 MOBISYL CRE 10% 00225036035 MOBISYL CRE 10% 62011003501 MOTION RELF TAB 25MG 62011034501 MOTION RELF TAB 25MG 62011034101 MOTION SICK TAB 50MG 24385038851 MOTION SICK TAB 25MG 49348036367 MOTION SICK TAB 25MG 70677002601 MOTION SICK TAB 25MG 24385000412 MOTION SICK TAB 50MG 49348007002 MOTION SICK TAB 50MG 62011003601 MOTION SICK TAB 50MG 70000025001 MOTION SICK TAB 50MG 70677002201 MOTION SICK TAB 50MG 49483033301 MOTION-TIME CHW 25MG 49483033310 MOTION-TIME CHW 25MG 70000013101 MUC/CGH RELF LIQ 5-100MG 63824092605 MUCINEX ALLR TAB 180MG 63824092610 MUCINEX ALLR TAB 180MG 63824092630 MUCINEX ALLR TAB 180MG 63824092640 MUCINEX ALLR TAB 180MG 63824028664 MUCINEX CGH LIQ 5-100MG 63824028564 MUCINEX CHLD LIQ 100/5ML

Page 39: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

63824001966 MUCINEX DM LIQ 20-400 63824012775 MUCINEX FF SPR 0.05% 70000012901 MUCUS REL DM LIQ 5-100/5 24385098226 MUCUS RELIEF LIQ 100/5ML 36800028826 MUCUS RELIEF LIQ 100/5ML 00113041926 MUCUS RELIEF LIQ 5-100MG 24385098526 MUCUS RELIEF LIQ 5-100MG 36800041926 MUCUS RELIEF LIQ 5-100MG 49348082834 MUCUS RELIEF LIQ 5-100MG 70000025101 MUCUS RELIEF TAB 200MG 36800051526 MUCUS+CHST LIQ 100/5ML 49348013534 MUCUS+CHST LIQ 100/5ML 49348013537 MUCUS+CHST LIQ 100/5ML 70000029901 MUCUS+CHST LIQ 100/5ML 70000029902 MUCUS+CHST LIQ 100/5ML 45802017453 MUSCLE RUB CRE 62011020901 MUSCLE RUB CRE 70000020801 MUSCLE RUB CRE 4-10-30% 70000023801 MUSCLE RUB CRE 4-10-30% 62756072060 MY CHOICE TAB 1.5MG 68180085211 MY WAY TAB 1.5MG 68180085212 MY WAY TAB 1.5MG 00065008515 NAPHCON-A SOL OP 00065008542 NAPHCON-A SOL OP 36800074206 NAPROXEN SOD CAP 220MG 36800074227 NAPROXEN SOD CAP 220MG 36800074258 NAPROXEN SOD CAP 220MG 36800074260 NAPROXEN SOD CAP 220MG 46122003858 NAPROXEN SOD CAP 220MG 46122003860 NAPROXEN SOD CAP 220MG 46122028360 NAPROXEN SOD CAP 220MG 62011024901 NAPROXEN SOD CAP 220MG 00113090162 NAPROXEN SOD TAB 220MG 00113436862 NAPROXEN SOD TAB 220MG 00113436871 NAPROXEN SOD TAB 220MG 00113436878 NAPROXEN SOD TAB 220MG 45802049071 NAPROXEN SOD TAB 220MG 45802049078 NAPROXEN SOD TAB 220MG 46122030971 NAPROXEN SOD TAB 220MG 46122030978 NAPROXEN SOD TAB 220MG 49348030609 NAPROXEN SOD TAB 220MG 49348030610 NAPROXEN SOD TAB 220MG 49483060901 NAPROXEN SOD TAB 220MG 49483060905 NAPROXEN SOD TAB 220MG 62011001701 NAPROXEN SOD TAB 220MG 62011001702 NAPROXEN SOD TAB 220MG 63868046501 NAPROXEN SOD TAB 220MG

Page 40: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

63868046550 NAPROXEN SOD TAB 220MG 00113006510 NASAL SPR 0.05% 00113030410 NASAL 12 HR SPR 0.05% 36800006510 NASAL 12 HR SPR 0.05% 36800030410 NASAL 12 HR SPR 0.05% 36800081710 NASAL 12 HR SPR 0.05% 70000020401 NASAL ALLGY SPR 55MCG/AC 00113044301 NASAL ALLRGY SPR 55MCG/AC 00536185085 NASAL DECON SYP 30MG/5ML 00536185097 NASAL DECONG LIQ 30MG/5ML 00904571130 NASAL DECONG SPR 0.05% 00904571135 NASAL DECONG SPR 0.05% 51672203003 NASAL DECONG SPR 0.05% 51672203005 NASAL DECONG SPR 0.05% 00113009423 NASAL DECONG TAB 10MG 00113009468 NASAL DECONG TAB 10MG 00113009489 NASAL DECONG TAB 10MG 24385060368 NASAL DECONG TAB 10MG 24385060389 NASAL DECONG TAB 10MG 36800009423 NASAL DECONG TAB 10MG 36800009468 NASAL DECONG TAB 10MG 36800009489 NASAL DECONG TAB 10MG 49348070007 NASAL DECONG TAB 10MG 49348070048 NASAL DECONG TAB 10MG 62011007701 NASAL DECONG TAB 10MG 62011007702 NASAL DECONG TAB 10MG 70000012601 NASAL DECONG TAB 10MG 70000012602 NASAL DECONG TAB 10MG 62011008701 NASAL DECONG TAB 120MG ER 62011030601 NASAL DECONG TAB 120MG ER 70000016401 NASAL DECONG TAB 120MG ER 00113043262 NASAL DECONG TAB 30MG 00113243262 NASAL DECONG TAB 30MG 00113243267 NASAL DECONG TAB 30MG 00113243280 NASAL DECONG TAB 30MG 00536360735 NASAL DECONG TAB 30MG 24385043262 NASAL DECONG TAB 30MG 24385043280 NASAL DECONG TAB 30MG 36800043262 NASAL DECONG TAB 30MG 36800043267 NASAL DECONG TAB 30MG 62011031201 NASAL DECONG TAB 30MG 62011031202 NASAL DECONG TAB 30MG 62011031203 NASAL DECONG TAB 30MG 70000013501 NASAL DECONG TAB 30MG 70000013502 NASAL DECONG TAB 30MG 70677000501 NASAL DECONG TAB 30MG 70677000502 NASAL DECONG TAB 30MG

Page 41: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

70677000503 NASAL DECONG TAB 30MG 00113064810 NASAL FOUR SOL 1% 36800064810 NASAL FOUR SOL 1% 45802041059 NASAL RELIEF SPR 0.05% 37205066620 NAT FIBER POW 28.3% 24385030127 NAT FIBER POW 48.57% 37205066513 NAT FIBER POW 48.57% 00904519965 NAT FIBER POW THERAPY 00904519966 NAT FIBER POW THERAPY 63868025710 NAT VEG LAX TAB 8.6MG 00904649335 NATURAL BAL SOL TEARS 63868000214 NATURA-LAX POW 3350 NF 63868000230 NATURA-LAX POW 3350 NF 00536108794 NATURES SOL TEARS 00904520065 NATURL FIBER POW 28.3% 00904520066 NATURL FIBER POW 28.3% 37205066710 NATURL FIBER POW 58.6% 16714080901 NEW DAY TAB 1.5MG 49483001401 NIACIN CAP 250MG SR 49483001410 NIACIN CAP 250MG SR 49483001801 NIACIN CAP 500MG SR 63868061132 NIGHT TIME TAB 25MG 24385043126 NIGHTTIME TAB 25MG 24385043178 NIGHTTIME TAB 25MG 36800038810 NO DRIP NASL SPR 0.05% 63868015824 NON-ASA JR TAB 160MG 63868017526 NON-ASPIRIN SUS 160/5ML 63868017626 NON-ASPIRIN SUS 160/5ML 63868050350 NON-ASPIRIN TAB 500MG 63868050701 NON-ASPIRIN TAB 500MG 63868098710 NON-ASPIRIN TAB 500MG/RR 63868098750 NON-ASPIRIN TAB 500MG/RR 55111039727 OMEPRAZOLE CAP 20.6MGDR 55111039733 OMEPRAZOLE CAP 20.6MGDR 55111039752 OMEPRAZOLE CAP 20.6MGDR 63868017715 OMEPRAZOLE CAP 20.6MGDR 63868017742 OMEPRAZOLE CAP 20.6MGDR 00113091530 OMEPRAZOLE TAB 20MG 00113091555 OMEPRAZOLE TAB 20MG 00113091574 OMEPRAZOLE TAB 20MG 00904583441 OMEPRAZOLE TAB 20MG 00904583442 OMEPRAZOLE TAB 20MG 00904583471 OMEPRAZOLE TAB 20MG 36800091501 OMEPRAZOLE TAB 20MG 36800091503 OMEPRAZOLE TAB 20MG 36800091530 OMEPRAZOLE TAB 20MG 36800091555 OMEPRAZOLE TAB 20MG 36800091574 OMEPRAZOLE TAB 20MG 37205083715 OMEPRAZOLE TAB 20MG 45802088830 OMEPRAZOLE TAB 20MG

Page 42: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

45802088855 OMEPRAZOLE TAB 20MG 46122002903 OMEPRAZOLE TAB 20MG 46122002904 OMEPRAZOLE TAB 20MG 46122002974 OMEPRAZOLE TAB 20MG 46122002999 OMEPRAZOLE TAB 20MG 46122028104 OMEPRAZOLE TAB 20MG 46122028174 OMEPRAZOLE TAB 20MG 49348084646 OMEPRAZOLE TAB 20MG 49348084661 OMEPRAZOLE TAB 20MG 49348084678 OMEPRAZOLE TAB 20MG 62011015701 OMEPRAZOLE TAB 20MG 62011015702 OMEPRAZOLE TAB 20MG 62011015703 OMEPRAZOLE TAB 20MG 70000035601 OMEPRAZOLE TAB 20MG 70000035602 OMEPRAZOLE TAB 20MG 70000035603 OMEPRAZOLE TAB 20MG 70000035604 OMEPRAZOLE TAB 20MG 62756071860 OPCICON TAB 1.5MG 00904633435 OPTI-CLEAR SOL 0.05% 00113200312 OPTION 2 TAB 1.5MG 00536110145 PAIN CRE RELIEVNG 00536012285 PAIN & FEVER SOL 160/5ML 00536012297 PAIN & FEVER SOL 160/5ML 00113002026 PAIN & FEVER SUS 160/5ML 00113016110 PAIN & FEVER SUS 160/5ML 00113021226 PAIN & FEVER SUS 160/5ML 00113059010 PAIN & FEVER SUS 160/5ML 00113060826 PAIN & FEVER SUS 160/5ML 00113094610 PAIN & FEVER SUS 160/5ML

Page 43: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00113895926 PAIN & FEVER SUS 160/5ML 36800020226 PAIN & FEVER SUS 160/5ML 36800039726 PAIN & FEVER SUS 160/5ML 36800059016 PAIN & FEVER SUS 160/5ML 36800075926 PAIN & FEVER SUS 160/5ML 36800076616 PAIN & FEVER SUS 160/5ML 36800095926 PAIN & FEVER SUS 160/5ML 46122004203 PAIN & FEVER SUS 160/5ML 46122005603 PAIN & FEVER SUS 160/5ML 46122021026 PAIN & FEVER SUS 160/5ML 46122021226 PAIN & FEVER SUS 160/5ML 46122032226 PAIN & FEVER SUS 160/5ML 46122032326 PAIN & FEVER SUS 160/5ML 49348008130 PAIN & FEVER SUS 160/5ML 49348009334 PAIN & FEVER SUS 160/5ML 49348011934 PAIN & FEVER SUS 160/5ML 49348012334 PAIN & FEVER SUS 160/5ML 49348032534 PAIN & FEVER SUS 160/5ML 49348043030 PAIN & FEVER SUS 160/5ML 62011000101 PAIN & FEVER SUS 160/5ML 62011000201 PAIN & FEVER SUS 160/5ML 62011018301 PAIN & FEVER SUS 160/5ML 62011024601 PAIN & FEVER SUS 160/5ML 62011024701 PAIN & FEVER SUS 160/5ML 70000014301 PAIN & FEVER SUS 160/5ML 70000017301 PAIN & FEVER SUS 160/5ML 70000020501 PAIN & FEVER SUS 160/5ML 70000030501 PAIN & FEVER SUS 160/5ML 00536322201 PAIN & FEVER TAB 325MG 00536322210 PAIN & FEVER TAB 325MG 00536321801 PAIN & FEVER TAB 500MG 00536323101 PAIN & FEVER TAB 500MG 00536323110 PAIN & FEVER TAB 500MG 70000018501 PAIN REL PTC PAD 5% 46122042462 PAIN RELIEF CHW 160MG 46122035734 PAIN RELIEF LIQ 500/15ML 46122031346 PAIN RELIEF SUS 160/5ML 46122034046 PAIN RELIEF SUS 160/5ML 63868017418 PAIN RELIEF SUS 160/5ML 63868083560 PAIN RELIEF SUS 160/5ML 00113043771 PAIN RELIEF TAB 25-500MG 36800043771 PAIN RELIEF TAB 25-500MG 36800043778 PAIN RELIEF TAB 25-500MG 46122017971 PAIN RELIEF TAB 25-500MG 46122024778 PAIN RELIEF TAB 325MG 46122039078 PAIN RELIEF TAB 325MG 63868008210 PAIN RELIEF TAB 325MG

Page 44: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00113002562 PAIN RELIEF TAB 500MG 00113002571 PAIN RELIEF TAB 500MG 00113002578 PAIN RELIEF TAB 500MG 00113018771 PAIN RELIEF TAB 500MG 00113018778 PAIN RELIEF TAB 500MG 00113022771 PAIN RELIEF TAB 500MG 00113048452 PAIN RELIEF TAB 500MG 00113048462 PAIN RELIEF TAB 500MG 00113048471 PAIN RELIEF TAB 500MG 00113048478 PAIN RELIEF TAB 500MG 00113048490 PAIN RELIEF TAB 500MG 24385014571 PAIN RELIEF TAB 500MG 24385048447 PAIN RELIEF TAB 500MG 24385048471 PAIN RELIEF TAB 500MG 24385048478 PAIN RELIEF TAB 500MG 24385048490 PAIN RELIEF TAB 500MG 36800022771 PAIN RELIEF TAB 500MG 36800022778 PAIN RELIEF TAB 500MG 36800048447 PAIN RELIEF TAB 500MG 36800048462 PAIN RELIEF TAB 500MG 36800048471 PAIN RELIEF TAB 500MG 36800048478 PAIN RELIEF TAB 500MG 36800048490 PAIN RELIEF TAB 500MG 62011002301 PAIN RELIEF TAB 500MG 62011002302 PAIN RELIEF TAB 500MG 62011002303 PAIN RELIEF TAB 500MG 62011002701 PAIN RELIEF TAB 500MG 62011004901 PAIN RELIEF TAB 500MG 63868008405 PAIN RELIEF TAB 500MG 63868008410 PAIN RELIEF TAB 500MG 63868008424 PAIN RELIEF TAB 500MG 00113021771 PAIN RELIEF TAB 650MG 49348014010 PAIN RELIEVE TAB 25-500 62011025001 PAIN RELIEVE TAB 25-500 49348015109 PAIN RELIEVE TAB 25-500MG 63868032501 PAIN RELIEVE TAB 25-500MG 63868032550 PAIN RELIEVE TAB 25-500MG 70000014901 PAIN RELIEVE TAB 25-500MG 70000014902 PAIN RELIEVE TAB 25-500MG 70000014903 PAIN RELIEVE TAB 25-500MG 49348097310 PAIN RELIEVE TAB 325MG 49348097316 PAIN RELIEVE TAB 325MG 62011003201 PAIN RELIEVE TAB 325MG 62011003202 PAIN RELIEVE TAB 325MG 49348004209 PAIN RELIEVE TAB 500MG 49348004210 PAIN RELIEVE TAB 500MG 49348004214 PAIN RELIEVE TAB 500MG

Page 45: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348073009 PAIN RELIEVE TAB 500MG 49348073010 PAIN RELIEVE TAB 500MG 49348099810 PAIN RELIEVE TAB 500MG 70000016901 PAIN RELIEVI CRE 10% 62011025601 PAIN RELIEVR TAB 25-500MG 00904513559 PAIN RELIEVR TAB PLUS 00536111196 PAIN/FEVER SUS 160/5ML 00145098505 PANOXYL WASH LIQ 10% 00145266005 PANOXYL-4 LIQ CREM WSH 00132065501 PEDIA-LAX CHW 400MG 00132010624 PEDIA-LAX LIQ 50MG 00132008112 PEDIA-LAX SUP 1GM 00904602576 PEG 3350 POW 00904642213 PEG 3350 POW 00904642281 PEG 3350 POW 00904642286 PEG 3350 POW 00536105224 PEG3350 POW 00536105227 PEG3350 POW 00536105284 PEG3350 POW 00536114397 PETROLATUM OIN 42% 00536114398 PETROLATUM OIN 42% 00904573182 PETROLEUM GEL JELLY 16103034803 PHARBEDRYL CAP 25MG 16103034808 PHARBEDRYL CAP 25MG 16103034811 PHARBEDRYL CAP 25MG 16103034711 PHARBEDRYL CAP 50MG 16103035307 PHARBETOL TAB 325MG 16103035308 PHARBETOL TAB 325MG 16103035311 PHARBETOL TAB 325MG 16103037606 PHARBETOL TAB 500MG 16103037608 PHARBETOL TAB 500MG 16103037611 PHARBETOL TAB 500MG 51285014619 PLAN B TAB 1.5MG 51285016288 PLAN B TAB 1.5MG 69536016288 PLAN B TAB 1.5MG 11534018019 POLYETH GLYC POW 3350 NF 11534018028 POLYETH GLYC POW 3350 NF 11534018050 POLYETH GLYC POW 3350 NF 45802086801 POLYETH GLYC POW 3350 NF 45802086802 POLYETH GLYC POW 3350 NF 45802086803 POLYETH GLYC POW 3350 NF 51079030601 POLYETH GLYC POW 3350 NF 51079030630 POLYETH GLYC POW 3350 NF 62175019507 POLYETH GLYC POW 3350 NF 62175019515 POLYETH GLYC POW 3350 NF 62175019531 POLYETH GLYC POW 3350 NF 69784018001 POLYETH GLYC POW 3350 NF

Page 46: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

69784018010 POLYETH GLYC POW 3350 NF 69784018014 POLYETH GLYC POW 3350 NF 69784018030 POLYETH GLYC POW 3350 NF 00067628614 PREVACID 24H CAP 15MG DR 00067628628 PREVACID 24H CAP 15MG DR 00067628642 PREVACID 24H CAP 15MG DR 00037682315 PROCTOFOAM AER NS 1% 62107000201 PROVIL TAB 200MG 62107000250 PROVIL TAB 200MG 24385005452 PSEUDOEPHEDR TAB 120MG ER 45802010752 PSEUDOEPHEDR TAB 120MG ER 46122016660 PSEUDOEPHEDR TAB 120MG ER 51660020469 PSEUDOEPHEDR TAB 120MG ER 45802043262 PSEUDOEPHEDR TAB 30MG 50844021114 PSEUDOEPHEDR TAB 30MG 00574402511 PURALUBE OIN 00574402520 PURALUBE OIN 00574402535 PURALUBE OIN 53329001411 PURE&GENTLE ENE 63868013214 QC ALLERGY TAB 10MG 63868013230 QC ALLERGY TAB 10MG 63868013290 QC ALLERGY TAB 10MG 63868004715 QC ANTACID CHW 500MG 63868069457 QC ANTACID SUS 63868071257 QC ANTACID SUS ANTI-GAS 63868009150 QC APAP 8 HR TAB 650MG 63868035203 QC ASPIRIN TAB 325MG 63868035210 QC ASPIRIN TAB 325MG 63868038045 QC ENEMA ENE 63868038090 QC ENEMA ENE 63868048501 QC HEADACHE TAB RELIEF 63868079050 QC IBUPROFEN TAB 200MG 63868079150 QC IBUPROFEN TAB 200MG 63868098350 QC IBUPROFEN TAB 200MG 63868032808 QC LAXATIVE SUP 10MG 63868030906 QC LIDOCAINE PAD RLF 4% 63868093816 QC MINERAL OIL HEAVY 63868014310 QC SUPHEDRIN TAB 120MG SR 00904635024 RANITIDINE TAB 150MG 00904635051 RANITIDINE TAB 150MG 00904671624 RANITIDINE TAB 150MG 00904671651 RANITIDINE TAB 150MG 55111040434 RANITIDINE TAB 150MG 00904671546 RANITIDINE TAB 75MG 00904671552 RANITIDINE TAB 75MG 55111013160 RANITIDINE TAB 75MG 00023050601 REFRESH DRO OP

Page 47: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00023050650 REFRESH DRO OP 00023545910 REFRESH GEL OPTIVE 00023430710 REFRESH SOL OPTIVE 00023430720 REFRESH SOL OPTIVE 00023449130 REFRESH SOL OPTIVE 00023455430 REFRESH CELL GEL 1% OP 00023031204 REFRESH LACR OIN OP 00023031207 REFRESH LACR OIN OP 00023920515 REFRESH LIQU DRO 1% OP 00023577330 REFRESH OPT SOL MEGA-3 00023341630 REFRESH OPTI DRO 0.5-0.9% 00023341660 REFRESH OPTI DRO 0.5-0.9% 00023324001 REFRESH OPTI DRO 0.5-0.9% 00023324015 REFRESH OPTI DRO 0.5-0.9% 00023024004 REFRESH P.M. OIN OP 00023040330 REFRESH PLUS DRO 0.5% OP 00023040350 REFRESH PLUS DRO 0.5% OP 00023040370 REFRESH PLUS DRO 0.5% OP 00023079801 REFRESH TEAR DRO 0.5% OP 00023079815 REFRESH TEAR DRO 0.5% OP 00536444554 REGULOID POW 28.3% 00536444589 REGULOID POW 28.3% 00536444454 REGULOID POW 48.57% 00536444489 REGULOID POW 48.57% 00536187516 REGULOID POW 58.6% 00536187579 REGULOID POW 58.6% 00536188116 REGULOID POW 58.6% 00536188179 REGULOID POW 58.6% 53329016204 REMEDY CRE ANTIFUNG 00904005300 ROBAFEN DM SYP 100-10/5 00904005309 ROBAFEN DM SYP 100-10/5 00904005316 ROBAFEN DM SYP 100-10/5 00904630620 ROBAFEN DM SYP 100-10/5 00536194583 RULOX SUS 00485020404 RYNEX DM LIQ 00485020416 RYNEX DM LIQ 00485020216 RYNEX PE ELX 00485020616 RYNEX PSE LIQ 00884259215 SALACTIC FIL SOL 17% 00884519215 SAL-PLANT GEL 17% 00145062805 SARNA LOT 00145063005 SARNA SENSIT LOT 1% 24385067827 SCALP RELIEF LIQ 3% 63824086015 SCALPICIN LIQ 3% 63824085015 SCALPICIN SOL 1% 00536196297 SEBEX SHA 00536590401 SENEXON TAB 8.6MG

Page 48: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00536590410 SENEXON TAB 8.6MG 00536408601 SENEXON-S TAB 8.6-50MG 00904643480 SENNA TAB 8.6MG 51645085101 SENNA TAB 8.6MG 51645085110 SENNA TAB 8.6MG 51645085199 SENNA TAB 8.6MG 36800078601 SENNA LAX TAB 8.6MG 49348016510 SENNA LAXATI TAB 8.6MG 00904633961 SENNA PLUS TAB 8.6-50MG 24385050572 SENNA PLUS TAB 8.6-50MG 46122034372 SENNA PLUS TAB 8.6-50MG 51645085001 SENNA PLUS TAB 8.6-50MG 51645085006 SENNA PLUS TAB 8.6-50MG 51645085010 SENNA PLUS TAB 8.6-50MG 51645085099 SENNA PLUS TAB 8.6-50MG 00224186060 SENNA PROMPT CAP 9-500MG 00224186081 SENNA PROMPT CAP 9-500MG 63739043201 SENNA/DSS TAB 8.6-50MG 63739043210 SENNA/DSS TAB 8.6-50MG 00904652261 SENNA-LAX TAB 8.6MG 24385040471 SENNA-LAX TAB 8.6MG 36800016260 SENNA-S TAB 8.6-50MG 60258095106 SENNA-S TAB 8.6-50MG 16103036308 SENNA-TABS TAB 8.6MG 16103036311 SENNA-TABS TAB 8.6MG 49483008001 SENNA-TIME TAB 8.6MG 49483008010 SENNA-TIME TAB 8.6MG 49483008101 SENNA-TIME S TAB 8.6-50MG 49483008110 SENNA-TIME S TAB 8.6-50MG 62107003101 SENNO TAB 8.6MG 67618030010 SENOKOT TAB 8.6MG 67618030020 SENOKOT TAB 8.6MG 67618030050 SENOKOT TAB 8.6MG 67618012012 SENOKOT EXTR TAB 17.2MG 67618031001 SENOKOT S TAB 8.6-50MG 67618031030 SENOKOT S TAB 8.6-50MG 67618031060 SENOKOT S TAB 8.6-50MG 54838011680 SILACE LIQ 10MG/ML 54838010780 SILACE SYP 60/15ML 54838013540 SILADRYL ALR LIQ 12.5/5ML 54838013570 SILADRYL ALR LIQ 12.5/5ML 54838013580 SILADRYL ALR LIQ 12.5/5ML 54838013840 SILTUSS DAS LIQ 100/5ML 54838020940 SILTUSSIN-DM SYP ALC FREE 54838020970 SILTUSSIN-DM SYP ALC FREE 54838020980 SILTUSSIN-DM SYP ALC FREE 00536360408 SIMETHICONE CAP 180MG

Page 49: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

51645087006 SIMETHICONE CHW 125MG 51645086001 SIMETHICONE CHW 80MG 00113088210 SIMETHICONE DRO 20/0.3ML 37205011910 SIMETHICONE DRO 40/0.6ML 00113081710 SINUS NASAL SPR 0.05% 62011007901 SINUS NASAL SPR 0.05% 70000013201 SINUS RELIEF SOL 1% 00904427451 SLEEP TAB 25MG 70000024201 SLEEP AID CAP 25MG 70000014201 SLEEP AID CAP 50MG 70000017401 SLEEP AID LIQ 50MG/30 70000017402 SLEEP AID LIQ 50MG/30 70000031101 SLEEP AID LIQ 50MG/30 00113043162 SLEEP AID TAB 25MG 00113044164 SLEEP AID TAB 25MG 00113044173 SLEEP AID TAB 25MG 24385044164 SLEEP AID TAB 25MG 36800015178 SLEEP AID TAB 25MG 36800043162 SLEEP AID TAB 25MG 36800043167 SLEEP AID TAB 25MG 36800044164 SLEEP AID TAB 25MG 49348057406 SLEEP AID TAB 25MG 62011003701 SLEEP AID TAB 25MG 70000024401 SLEEP AID TAB 25MG 70000024901 SLEEP AID TAB 25MG 70677002501 SLEEP AID TAB 25MG 46122020430 SLEEP TIME LIQ 50MG/30 00113005253 SLEEPTIME CAP 25MG 00113018630 SLEEPTIME LIQ 50MG/30 00113018640 SLEEPTIME LIQ 50MG/30 49348024644 SM ACID REDU TAB 200MG 49348093912 SM ALL DAY TAB ALLERGY 49348098446 SM ALL DAY TAB ALLERGY 70677000301 SM ALLERGY TAB 25MG 49348098310 SM ALLERGY TAB 25MG RLF 49348002504 SM ALLERGY TAB 4MG 70677000401 SM ALLERGY TAB 4MG 49348095916 SM ANTACID CHW 1000MG 49348015339 SM ANTACID SUS ADVANCED 49348030239 SM ANTACID SUS ADVANCED 49348001939 SM ANTACID/ SUS ANTIGAS 49348015529 SM ANTIFUNGL CRE 1% 49348068972 SM ANTIFUNGL CRE 2% 49348085472 SM ANTI-ITCH CRE 2-0.1% 49348049807 SM ASPIRIN CHW 81MG 49348075707 SM ASPIRIN CHW 81MG 49348000110 SM ASPIRIN TAB 325MG

Page 50: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348000114 SM ASPIRIN TAB 325MG 49348000123 SM ASPIRIN TAB 325MG 49348093782 SM ASPIRIN TAB 325MG EC 49348098015 SM ASPIRIN TAB 81MG EC 49348098023 SM ASPIRIN TAB 81MG EC 49348098053 SM ASPIRIN TAB 81MG EC 49348098115 SM ASPIRIN TAB 81MG EC 49348033736 SM CALDYPHEN LOT 1-8% 49348061036 SM CALDYPHEN LOT CLEAR 49348001636 SM CASTOR OIL 100% 49348019107 SM CHILD ASA CHW 81MG 49348077734 SM CLD/ALRGY ELX CHILDREN 49348089350 SM CLEARLAX POW 49348089370 SM CLEARLAX POW 49348077534 SM COLD/CGH ELX DM CHILD 49348096029 SM EAR DRO 6.5% OT 49348018520 SM ENEMA ENE 49348018614 SM ENEMA ENE 49348018620 SM ENEMA ENE 49348001863 SM EPSOM GRA SALT 49348001875 SM EPSOM GRA SALT 49348069729 SM EYE DRO 49348004765 SM FIBER POW 28.3% 49348009168 SM FIBER POW 28.3% 49348016665 SM FIBER POW 48.57% 49348016693 SM FIBER POW 48.57% 49348009092 SM FIBER POW 58.6% 49348019013 SM FIBER TAB 625MG 49348054110 SM FIBER LAX TAB 500MG 49348086348 SM GAS REL CHW 125MG 49348018810 SM GAS RELF CHW 80MG 49348014707 SM GAS RELIE CHW 80MG 49348003205 SM GENTLE TAB LAXATIVE 49348003210 SM GENTLE TAB LAXATIVE 49348052172 SM HYDROCORT CRE 1% 49348052178 SM HYDROCORT CRE 1% 49348044172 SM HYDROCORT CRE 1% PLUS 49348052272 SM HYDROCORT OIN 1% 49348056859 SM IBUPROFEN CAP 200MG 70677004601 SM IBUPROFEN CAP 200MG 49348072709 SM IBUPROFEN TAB 200MG 49348072710 SM IBUPROFEN TAB 200MG 49348092710 SM IBUPROFEN TAB 200MG 49348019304 SM LAXATIVE TAB 25MG 49348012619 SM LICE SOLN KIT 49348094729 SM LUBRICANT DRO 0.4-0.3% 49348083361 SM MICON 7 SUP 100MG

Page 51: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348050610 SM MIGRAINE TAB RELIEF 49348042684 SM MUSCLE CRE RUB 49348013027 SM NASAL SPR 0.05% 49348023027 SM NASAL SPR 0.05% 49348023127 SM NASAL SPR 0.05% 49348002827 SM NASAL 12H SPR 0.05% 70677002401 SM NIGHTTIME TAB 25MG 49348019727 SM NOSE DRO 1% 49348011610 SM PAIN REL CAP 500MG 70677001701 SM PAIN RLVR TAB 650MG 49348089429 SM REDNESS DRO RELIEF 49348006304 SM RPD MELT TAB 160MG 70677004101 SM SENNA LAX TAB 8.6MG 49348015619 SM SENNA-S TAB 8.6-50MG 49348047104 SM SLEEP AID TAB 25MG 49348018719 SM STOOL TAB SOFTENER 49348086134 SM TUSSIN SYP DM 49348086137 SM TUSSIN SYP DM 49348001734 SM TUSSIN DM SYP 100-10/5 49348001737 SM TUSSIN DM SYP 100-10/5 49348001739 SM TUSSIN DM SYP 100-10/5 49348094102 SM URINARY TAB PAIN MAX 64980018210 SODIUM BICAR TAB 10GR 00536104610 SODIUM BICAR TAB 325MG 00536104710 SODIUM BICAR TAB 650MG 00904567516 SOLUBLE FIB POW THERAPY 53329008057 SOOTHE&COOL CRE INZO 2% 53329008058 SOOTHE&COOL CRE INZO 2% 00904630521 SORE THROAT SPR 1.4% 46122026530 SORE THROAT SPR 1.4% 46122027830 SORE THROAT SPR 1.4%

Page 52: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

49348099136 SORE THROAT SPR 1.4% 63868081155 SORE THROAT SPR 1.4% 70000027701 SORE THROAT SPR 1.4% 69536028136 ST JOSEPH CHW LOW 81MG 00536338101 STIM LAXAT TAB 5MG EC 00536338110 STIM LAXAT TAB 5MG EC 00113048672 STOOL SOFTNR CAP 100MG 00536106210 STOOL SOFTNR CAP 100MG 00536106229 STOOL SOFTNR CAP 100MG 36800023825 STOOL SOFTNR CAP 100MG 46122023172 STOOL SOFTNR CAP 100MG 46122023178 STOOL SOFTNR CAP 100MG 46122023185 STOOL SOFTNR CAP 100MG 46122045178 STOOL SOFTNR CAP 100MG 49348012105 STOOL SOFTNR CAP 100MG 49348048310 STOOL SOFTNR CAP 100MG 49348048319 STOOL SOFTNR CAP 100MG 49348048390 STOOL SOFTNR CAP 100MG 62011022401 STOOL SOFTNR CAP 100MG 63868011625 STOOL SOFTNR CAP 100MG 66424003010 STOOL SOFTNR CAP 100MG 70677003401 STOOL SOFTNR CAP 100MG 00536106501 STOOL SOFTNR CAP 240MG 00536106505 STOOL SOFTNR CAP 240MG 00536106510 STOOL SOFTNR CAP 240MG 49348012210 STOOL SOFTNR CAP 240MG 00536106401 STOOL SOFTNR CAP 250MG 00536106410 STOOL SOFTNR CAP 250MG 46122026378 STOOL SOFTNR CAP 250MG 62011024401 STOOL SOFTNR CAP 250MG 46122040043 STOOL SOFTNR SYP 60/15ML 62011028601 STOOL SOFTNR TAB 100MG 36800008401 STOOL SOFTNR TAB 8.6-50MG 46122034478 STOOL SOFTNR TAB 8.6-50MG 62011027301 STOOL SOFTNR TAB 8.6-50MG 63868013510 STOOL SOFTNR TAB 8.6-50MG 63868013760 STOOL SOFTNR TAB 8.6-50MG 00904580315 SUDOGEST TAB 120MG ER 00904505324 SUDOGEST TAB 30MG 00904505359 SUDOGEST TAB 30MG 00904633860 SUDOGEST TAB 30MG 00904535124 SUDOGEST TAB 4-60MG 00904535196 SUDOGEST TAB 4-60MG 00904512546 SUDOGEST TAB 60MG 00904512559 SUDOGEST TAB 60MG 00904573349 SUDOGEST PE TAB 10MG 00904573373 SUDOGEST PE TAB 10MG

Page 53: New! Over-the-counter (OTC) Coverage, Effective Jan. 1, 2019...We recently changed our list of covered over-the-counter products (OTC) for our patients whoare UnitedHealthcare Community

00168012691 SWIM EAR LIQ 95% OTIC 00065047401 SYSTANE GEL 0.3% 00065050935 SYSTANE OIN 00065042915 SYSTANE SOL 00065042921 SYSTANE SOL 00065042930 SYSTANE SOL 00065048110 SYSTANE COMP SOL 0.6% 00065045407 SYSTANE GEL DRO 0.4-0.3% 00065043133 SYSTANE PF SOL 00065143105 SYSTANE ULTR SOL 00065143201 SYSTANE ULTR SOL PF 00065143206 SYSTANE ULTR SOL PF 62107005201 TACTINAL TAB 325MG 62107005210 TACTINAL TAB 325MG 62107005001 TACTINAL TAB 500MG 62107005010 TACTINAL TAB 500MG 62107005101 TACTINAL TAB 500MG 62107005110 TACTINAL TAB 500MG 51285010088 TAKE ACTION TAB 1.5MG 69536020088 TAKE ACTION TAB 1.5MG 70000015901 TENSION TAB 500-65MG 70000015902 TENSION TAB 500-65MG 00536111728 TERBINAFINE CRE 1% 24385052403 TERBINAFINE CRE 1% 24385052405 TERBINAFINE CRE 1% 51672208001 TERBINAFINE CRE 1% 51672208002 TERBINAFINE CRE 1% 00178032003 THERA-GESIC CRE 00178032005 THERA-GESIC CRE 00178035003 THERA-GESIC CRE PLUS 24385022540 THERAPEUTIC GEL 2% 24385037482 TIOCONAZOLE OIN 6.5% VAG 36800042654 TIOCONAZOLE OIN 6.5% VAG 37205029603 TIOCONAZOLE OIN 6.5% VAG 49348050859 TIOCONAZOLE OIN 6.5% VAG 24385003203 TOLNAFTATE CRE 1% 51672202001 TOLNAFTATE CRE 1% 51672202002 TOLNAFTATE CRE 1% 63868010446 TOLNAFTATE CRE 1% 00904072645 TOLNAFTATE POW 1% 00536101801 TRAVEL SICK CHW 25MG 00536101810 TRAVEL SICK CHW 25MG 63868016012 TRAVEL SICK TAB 50MG 45802010901 TRIAMCINOLON AER 55MCG/AC 00904201559 TRI-BUFF ASA TAB 325MG 70000014701 TRI-BUFF ASA TAB 325MG 69367018650 TRIPROLIDINE LIQ 0.313MG

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69784010201 TRIPROLIDINE LIQ 0.625/ML 69367018530 TRIPROLIDINE LIQ 0.625MG 45802035653 TROLAMINE CRE SAL 10% 00135007003 TUMS CHW 500MG 00135007027 TUMS CHW 500MG 00135007048 TUMS CHW 500MG 00135007127 TUMS CHW 500MG 00135007148 TUMS CHW 500MG 00135061101 TUMS CHW 500MG 00135060601 TUMS CHEWY CHW BITES 00135060602 TUMS CHEWY CHW BITES 00135056001 TUMS CHW DEL CHW 1177MG 00135056901 TUMS CHW DEL CHW 1177MG 00135007625 TUMS E-X CHW 750MG 00135014001 TUMS E-X CHW 750MG 00135014003 TUMS E-X CHW 750MG 00135015405 TUMS E-X CHW 750MG 00135017802 TUMS E-X CHW 750MG 00135017803 TUMS E-X CHW 750MG 00135017808 TUMS E-X CHW 750MG 00135017809 TUMS E-X CHW 750MG 00135017824 TUMS E-X CHW 750MG 00135007401 TUMS EXTRA CHW 750MG 00135007407 TUMS EXTRA CHW 750MG 00135007422 TUMS EXTRA CHW 750MG 00135007424 TUMS EXTRA CHW 750MG 00135007425 TUMS EXTRA CHW 750MG 00135007446 TUMS EXTRA CHW 750MG 00135015501 TUMS EXTRA CHW 750MG 00135046901 TUMS KIDS CHW 750MG 00135024302 TUMS SMOOTHI CHW 750MG 00135024502 TUMS SMOOTHI CHW 750MG 00135024601 TUMS SMOOTHI CHW 750MG 00135024602 TUMS SMOOTHI CHW 750MG 00135024607 TUMS SMOOTHI CHW 750MG 00135045603 TUMS SMOOTHI CHW 750MG 00135011814 TUMS ULTRA CHW 1000MG 00135011883 TUMS ULTRA CHW 1000MG 00135018002 TUMS ULTRA CHW 1000MG 00135018014 TUMS ULTRA CHW 1000MG 00135018102 TUMS ULTRA CHW 1000MG 00135018105 TUMS ULTRA CHW 1000MG 00135018114 TUMS ULTRA CHW 1000MG 00135022801 TUMS ULTRA CHW 1000MG 00135061201 TUMS ULTRA CHW 1000MG 00135061202 TUMS ULTRA CHW 1000MG 00135062401 TUMS+GAS CHW 750-80MG 62011008901 TUSSIN ADULT LIQ 100/5ML 62011008902 TUSSIN ADULT LIQ 100/5ML 36800029626 TUSSIN CF LIQ MAX/M-S

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36800029634 TUSSIN CF LIQ MAX/M-S 46122013834 TUSSIN CF LIQ MAX/M-S 00113035926 TUSSIN DM SYP 100-10/5 00113035934 TUSSIN DM SYP 100-10/5 00113206126 TUSSIN MUCUS LIQ 100/5ML 46122029926 TUSSIN MUCUS LIQ 100/5ML 46122029934 TUSSIN MUCUS LIQ 100/5ML 49348007644 URINARY PAIN TAB 95MG 63868011730 URINARY PAIN TAB 95MG 70000024301 URINARY PAIN TAB 95MG 70000024101 URINARY PAIN TAB 97.5MG 58809048550 VANACLEAR PD LIQ 0.313MG 58809050130 VANAHIST PD LIQ 0.625MG 58809064330 VANAMINE PD LIQ 6.25/ML 00536115359 VITAMIN LIQ MINERAL 63044040101 VITAMIN D3 CAP 10000UNT 71321080130 VITAMIN E DRO 15/0.3ML 24385023663 WART REMOVER LIQ 17% 46122036229 WART REMOVER LIQ 17% 70000032901 WART REMOVER LIQ 17% 23359001204 WEE CARE SUS 15/1.25 36800017465 WOMANS LAXAT TAB 5MG EC 00597012150 ZANTAC TAB 150MG 00597012190 ZANTAC TAB 150MG 00597012213 ZANTAC TAB 75MG 00597012254 ZANTAC TAB 75MG 00145150103 ZEASORB-AF POW 2% 00145150605 ZEASORB-AF POW 2% 63044003060 ZIKS ARTHRIT CRE RELIEF