Over-the-Counter (OTC)
Benefit Catalog
As a member of Keystone VIP Choice, you have a quarterly over-the-counter (OTC) benefit
which allows you to order OTC products such as bandages, cold and allergy medicines,
pain relievers, and vitamins, at no cost to you. Please check your Summary of Benefits or
Evidence of Coverage to see what your quarterly benefit amount is. Benefit amounts do
not roll over, so be sure to use them before the end of every quarter. Ordering is easy. Just
call the toll-free number or fill out and mail the order form provided. Your order will be
shipped directly to your door.
You can order OTC products without having to talk with your doctor, but we always
recommend that you talk with your doctor before starting a new product regimen.
Keystone VIP Choice is an HMO-SNP plan with a Medicare contract and a contract with the
Pennsylvania Medicaid program. Enrollment in Keystone VIP Choice depends on contract
renewal. This plan is available to anyone who has both Medical Assistance from the state and
Medicare. This information is not a complete description of benefits. Contact the plan for
more information. Limitations, copayments and restrictions may apply. Benefits may change
on January 1 of each year.
Y0093_CAT_2442_NM
HELPFUL INFORMATION
• You can place your order by mail or phone. To place an order by mail, please mail your order
form to OTC Servicing Center, P.O. Box 267067, Weston, FL 33326. To place your order
over the phone, OTC advocates are available Monday – Friday, 8 a.m. to 8 p.m. ET, at
1-800-580-7187 (TTY 711).
• After your order is placed, please allow seven to 10 business days for delivery.
Returns are not accepted.
• OTC items are available through mail order only. Products may not be purchased at a local retail
pharmacy or through any source other than the Keystone VIP Choice OTC Benefit Catalog.
• If you disenroll from Keystone VIP Choice, your OTC benefit will automatically terminate.
• Orders may only be placed by a member, a member’s authorized representative who has been
verbally approved by the member at the time of the order, or a member’s power of attorney
representative whose name is on file.
• OTC products are intended for members’ use only. Keystone VIP Choice prohibits the purchase
of OTC items for family members and friends.
• We encourage you to use your full quarterly benefit amount in one order. This benefit amount
does not roll over from quarter to quarter.
• If you place your order using an order form, your order total will be applied to the quarter
in which we receive your form. For example, if you mail your order form on June 29, but we
receive it on July 1, your order total will be applied to your July (or 3rd-quarter) benefit, not
your June (or 2nd-quarter) benefit.
• If you’re getting close to the end of the quarter and you do not think your order form will be
received in time, please call in your order. Our OTC advocates are available to take your order
Monday – Friday, from 8 a.m. – 8 p.m. Eastern Time (ET), at 1-800-580-7187 (TTY 711).
• Your quarterly order total may not exceed the quarterly benefit amount. You may not use cash,
checks, money orders, or any other form of personal payment to purchase items under this
OTC benefit.
• Items in the OTC Benefit Catalog may change throughout the year. A copy of this catalog
is also available on the Keystone VIP Choice website at www.keystonevipchoice.com.
For up-to-date information, please call our OTC advocates Monday – Friday,
from 8 a.m. – 8 p.m. ET, at 1-800-580-7187 (TTY 711).
AHVIPCPA-1522-16
PRODUCT
PRODUCT
NUMBER
PACKAGING
ALLERGY, COLD, FLU DECONGESTANT, AND SINUS TREATMENTS
All-day allergy tablets*
1090
All-night cold and flu
1361
14 count
6 oz
OTC
PRODUCT
STRENGTH
PRICING
10 mg
6.25 mg, 15 mg,
500 mg
4 mg
—
5.8 mg
5 mg
200 mg, 10 ml
25 mg
25 mg
$10.00
$10.00
60 count
200 mg
100 count
10 mg
30 count
400 mg, 20 mg
24 count 10 mg, 5 mg, 325 mg
1 oz
.05%
1.5 oz
0.65%
1 count
—
36 count
10 mg
$11.00
$21.00
$11.00
$10.00
$9.00
$9.00
$40.00
$9.00
12 oz
150 count
30 count
28 count
—
500 mg
10 mg
20 mg
$10.00
$10.00
$10.00
$30.00
45 gm
1 kit
1%
2%
$11.00
$18.00
Chlorpheniramine maleate
1008
Cough and cold for high blood pressure
1166
Cough drops, cherry
1056
Cough drops, sugar free, cherry
1182
Cough syrup, expectorant
1054
Diphenhist® (antihistamine)
1308
Diphenhydramine hydrochloride
1009
(HCL; antihistamine)
Guaifenesin cough expectorant
1180
®
Loratadine (generic Claritin )
1611
Mucus relief dextromethorphan (DM)
1178
Multi-symptom cold formula
1357
Nasal decongestant spray, 12 hour
1091
Nasal saline spray
1052
Personal steam inhaler‡
1792
Sudogest™ PE
1352
ANTACIDS AND ACID REDUCERS
Antacid or anti-gas liquid
1006
Chewable antacid
1346
Famotidine*
1108
Omeprazole *D
1110
ANTICANDIAL (YEAST) PRODUCTS
Clotrimazole vaginal cream with applicator*
1115
Micanozole 3-day treatment
1117
ANTIDIARRHEAL, LAXATIVE, AND DIGESTIVE HEALTH PRODUCTS
Bismatrol (bismuth subsalicylate)
1045
100 count
16 count
30 count
25 count
4 oz
100 count
24 count
$9.00
$10.00
$9.00
$9.00
$10.00
$10.00
$5.00
30 count
262 mg
$10.00
Docusate sodium
Glycerin suppository
Lactase capsules
Loperamide HCL *D
1126
1125
1067
1133
100 count
25 count
60 count
12 count
100 mg
2 gm
9000 FCC units
2 mg
$7.00
$10.00
$14.00
$9.00
Milk of magnesia
Natural vegetable laxative
Pink bismuth
Polycarbophil (fiber tablets)
Senna Plus
ANTIFUNGAL AND ANTI-ITCH PRODUCTS
Clotrimazole antifungal athlete’s foot cream
Diphenhydramine HCL and zinc acetate
Hydrocortisone cream
Terbinafine HCL tube
Tolnaftate cream
1011
1340
1318
1012
1130
12 oz
13 oz
8 oz
90 count
60 count
400 mg
—
525 mg, 30 ml
625 mg
8.6 mg, 50 mg
$10.00
$14.00
$11.00
$14.00
$10.00
1047
1140
1074
1046
1064
1 oz
1 oz
1 oz
0.5 oz
1.25 oz
1%
—
1%
1%
1%
$10.00
$9.00
$4.00
$11.00
$10.00
PRODUCT
PRODUCT
NUMBER
COLD SORE AND OTHER MEDICATED LIP PRODUCTS
Abreva®
Herpecin L® lip balm
DENTAL OR DENTURE CARE
Denture cleaning tablets
Fixodent®
Interdental Flossups®
Oral pain relief
Rechargeable toothbrush
Toothbrush, Colgate®, adult soft
Toothbrush, Tek Pro™, straight soft
Toothpaste, Pepsodent®
Water jet
IN-HOME DIAGNOSTIC SUPPLIES
Desktop automatic blood pressure monitor‡
Desktop talking blood pressure monitor
(8.7” to 13.4”)‡
Replacement cuff for desktop talking monitor‡
EAR CARE PRODUCTS
Cotton-tipped swabs
Ear drops
Ear wax removal system
EYE CARE PRODUCTS
Artificial tears eye drops
Artificial tears ointment
Clear eyes®
Eye drops (redness relief)
Multipurpose contact lens solution
FIRST AID AND MEDICAL SUPPLIES
Alcohol pads*
Ankle support
Bacitracin ointment
Bandages*
Bathtub safety rail
Digital ear thermometer
Digital thermometer
Elastic bandage 2” x 5 yd *B
Elastic bandage 3” x 5 yd *B
Elastic bandage 4” x 5 yd *B
Elastic bandage 6” x 5 yd *B
First aid kit
First aid kit
Hot or cold pack
Hydrogen peroxide
Insect repellent spray (DEET)
Isopropyl alcohol, wintergreen
Men’s compression socks, black, large *B‡
PACKAGING
OTC
PRODUCT
STRENGTH
PRICING
1152
1153
2 gm
0.1 oz
10%
1%
$30.00
$13.00
1032
1187
1751
1286
1450
1413
1412
1414
1744
40 count
0.75 oz
90 count
0.5 oz
1
1
1
5.5 oz
1
—
—
—
20%
—
—
—
—
—
$10.00
$10.00
$8.00
$8.00
$37.00
$9.00
$9.00
$9.00
$39.00
1253
1503
1
1
—
—
$35.00
$34.00
1504
1
—
$23.00
1742
1190
1363
300 count
15 ml
15 ml
—
6.5%
—
$7.00
$10.00
$10.00
1192
1194
1199
1061
1468
0.5 oz
3.5 gm
0.2 oz
15 ml
4 oz
—
—
—
0.05%
—
$10.00
$11.00
$11.00
$10.00
$11.00
1200
1225
1020
1344
1730
1285
1063
1207
1209
1211
1213
1215
1738
1062
Box/100
1
1 oz
60 count
1
1
1 count
1
1
1
1
75 pieces
175 pieces
1 small pack
and 1 large pack
16 oz
4 oz
16 oz
1 pair
70%
—
500 U/gm
—
—
—
—
—
—
—
—
—
—
—
$9.00
$13.00
$7.00
$10.00
$38.00
$28.00
$8.00
$9.00
$9.00
$9.00
$9.00
$13.00
$19.00
$10.00
3%
30%
70%
15 – 20 mmHg
$5.00
$15.00
$10.00
$20.00
1228
1796
1229
1399
PRODUCT
Men’s compression socks, white, medium *B‡
Men’s compression socks, white, large *B‡
Neosporin® Plus
Raised toilet seat
Tape, paper surgical (1” x 10 yd)*
Toilet safety rails‡
Triple antibiotic ointment
Women’s compression socks, black,
small (4 – 5) *B
Women’s compression socks, black,
medium (5.5 – 7.5) *B
Women’s compression socks, black,
large (8 – 10.5) *B
Women’s compression socks, nude,
small (4 – 5) *B
Women’s compression socks, nude,
medium (5.5 – 7.5) *B
Women’s compression socks, nude,
large (8 – 10.5) *B
HEMORRHOID PREPARATIONS
Hemorrhoid ointment
Pre-moistened hemorrhoid pads
MOTION SICKNESS TREATMENTS
Driminate™
PAIN RELIEVERS AND FEVER REDUCERS
Acetaminophen
Acetaminophen
Arthritis pain reliever
Aspirin
Aspirin, enteric-coated
Aspirin (low dose)
Capsaicin
Ibuprofen
Migraine relief
Naproxen
Nighttime pain reliever, extra strength
Pain relief patches
Pain-relieving muscle rub
PEDICULICIDE
Lice treatment shampoo
PERSONAL CARE PRODUCTS
Acne gel 10% benzoyl peroxide
Aloe vera cream
Ammonium lactate*
Hand sanitizer
Sunscreen lotion
OTC
PRODUCT
STRENGTH
PRICING
PRODUCT
NUMBER
PACKAGING
1400
1401
1326
1729
1217
1779
1014
1409
1 pair
1 pair
0.5 oz
1
1 count
1 set
1 oz
1 pair
15 – 20 mmHg
15 – 20 mmHg
—
—
—
—
—
8 – 15 mmHg
$20.00
$20.00
$14.00
$36.00
$9.00
$42.00
$6.00
$13.00
1410
1 pair
8 – 15 mmHg
$13.00
1411
1 pair
8 – 15 mmHg
$13.00
1406
1 pair
8 – 15 mmHg
$13.00
1407
1 pair
8 – 15 mmHg
$13.00
1408
1 pair
8 – 15 mmHg
$13.00
1066
1364
2 oz
100 count
—
—
$10.00
$11.00
1263
12 count
50 mg
$9.00
1001
1105
1311
1095
1096
1002
1367
1004
1365
1097
1332
1739
1475
100 count
50 count
100 count
100 count
100 count
120 count
2 oz
100 count
100 count
100 count
100 count
5/box
2 oz
325 mg
500 mg
650 mg
325 mg
325 mg
81 mg
0.025%
200 mg
250 mg, 65 mg
220 mg
—
—
2.50%
$9.00
$9.00
$16.00
$9.00
$10.00
$5.00
$11.00
$6.00
$11.00
$14.00
$11.00
$14.00
$8.00
1271
4 oz
—
$10.00
1076
1070
1368
1065
1284
1.5 oz
8 oz
8 oz
8 oz
3.5 oz
10%
—
12%
62%
SPF 30
$10.00
$7.00
$14.00
$9.00
$9.00
PRODUCT
SLEEP AIDS
Nasal strips, medium – large
Nasal strips, small – medium
Sleep tablets
SMOKING CESSATION PRODUCTS
Nicorelief™ gum‡
Nicotine lozenges‡
Nicotine patch, step 1‡
Nicotine patch, step 2‡
Nicotine patch, step 3‡
VITAMINS AND MINERALS
Calcium and vitamin D‡
Calcium carbonate‡
Daily multivitamins with minerals‡
Ferrous sulfate‡
Fish oil tablets‡
Glucosamine and chondroitin‡
Magnesium oxide‡
Daily multivitamin‡
Vitamin A‡
Vitamin B-1‡
Vitamin B-12‡
Vitamin B-12‡
Vitamin B-6‡
Vitamin B complex‡
Vitamin C‡
Vitamin D‡
Vitamin D‡
Vitamin E‡
WART REMOVERS
Wart remover (liquid)
OTC
PRODUCT
STRENGTH
PRICING
PRODUCT
NUMBER
PACKAGING
1725
1724
1276
30 count
30 count
50 count
—
—
25 mg
$16.00
$16.00
$10.00
1372
1281
1369
1370
1371
50 count
72 count
14 count
14 count
14 count
4 mg
4 mg
21 mg/24 hr
14 mg/24 hr
7 mg/24 hr
$23.00
$45.00
$37.00
$37.00
$37.00
1373
1291
1385
1376
1741
1003
1377
1393
1379
1016
1381
1389
1380
1382
1017
1390
1383
1384
60 count
60 count
100 count
100 count
60 count
60 count
100 count
100 count
100 count
100 count
100 count
100 count
100 count
100 count
100 count
100 count
100 count
100 count
600 mg/400 u
600 mg
—
325 mg
1000 mg
200 mg, 250 mg
250 mg
—
10 mu
100 mg
1000 mcg
500 mcg
50 mg
—
500 mg
1000 iu
400 iu
400 iu
$9.00
$10.00
$10.00
$9.00
$12.00
$14.00
$11.00
$10.00
$10.00
$10.00
$13.00
$10.00
$10.00
$10.00
$10.00
$10.00
$10.00
$13.00
1075
9 ml
17%
$11.00
*These items may also be covered by the plan, or Medicare if you are not enrolled in the plan,
if your health care provider determines them to be medically necessary.
‡ Dual-purpose items are medicines and products that can be used for either a medical condition
or for general health and well-being.
In certain circumstances, some items in this catalog may also be covered under your Medicare Part B
(medical) benefit or Part D (pharmacy) benefit. These items have a *B or a *D after their names.
For example, alcohol pads are covered under Part D if they are used for administering insulin.
For all other purposes, this item is covered under your OTC benefit.
See the other side of this panel for your
Keystone VIP Choice
Over-the-Counter (OTC) Benefit Order Form.
Information on how to place your
OTC order can be found on the back cover.
Over-the-Counter (OTC)
Benefit Order Form
If you have questions or would like to place an order over the phone, OTC advocates are available
Monday – Friday, from 8 a.m. to 8 p.m. ET, at 1-800-580-7187 (TTY 711).
To place an order by mail, please mail your order form to OTC Servicing Center, P.O. Box 267067,
Weston, FL 33326.
COMPLETE YOUR INFORMATION BELOW
Date of birth
Member ID number (found on health ID card)
Last name
First name
MI
Street name
Street number
Apartment or suite number
State
City
ZIP code
Please check this box if this is a new address: □
Email
Daytime phone
PRODUCT SELECTION
Your quarterly order total may not exceed the quarterly benefit amount. Cash, checks, money
orders, or any other form of personal payment to purchase items are not accepted under this
OTC benefit.
ITEM NUMBER
PRODUCT NAME
QUANTITY
PRICE
TOTAL ORDER $
If you use an order form, your order total will be applied to the quarter in which we receive your form. For example,
if you mail your order form on June 29, but we receive it on July 1, your order total will be applied to your July
(or third-quarter) benefit, not your June (or second-quarter) benefit.