HP140TC
2014 Over-the-Counter
Benefits At NO COST To You!
Receive $25 every month
in Over-the-Counter Drugs & Supplies.
After paying your monthly plan premium. Limitations and restrictions may apply.
H1660_14229 Accepted
H6750_14230 Accepted
Item Brand
1A Chlor-Trimeton
1B Benadryl Elixir
Generic Comparable
(1) Allergies
Chlorpheniramine Maleate 4mg
Diphenhydramine HCl 12.5mg
24
118ml
$4
$3
1C Benadryl Caps
Diphenhydramine HCI 25mg
24
$3
1D Ayr Nasal
44ml
$3
100
100
60g
24
35g
50
120
50
36
5
100
$4
$3
$9
$3
$3
$7
$3
$5
$3
$8
$7
96
100
30
12
$5
$5
$9
$6
12
30
$6
$5
5A Anusol
5B Preparation H
Deep Sea Nasal Spray Saline 0.65%
(2) Analgesics
Acetaminophen tablets 500mg
Asprin 325mg
Trixaicin Crm 0.025% (casaicin)
Ibuprofen 200mg FC Tab
Muscle Rub 35g
Naproxen Sodium 220mg CPL
Asprin EC (delayed reased) 81mg
Acetaminophen 500mg & Diphenhydramine 25mg
Aspirin Low dose 81mg Chewable
Cold and Hot Patch
Headache Formula-Aspirin/Acetaminophen/Caffeine
(3) Antacids
Calcium Carbonate Chewable Antacid
Acid Gas Relief tablets
Ranitidine Tablets 75mg
Effervescent pain relief
(4) Anti-Diarrheals
Loperamide 2mg
Pink Bismuth Tablets (chewable)
(5) Anti-Hemorrhoidals
Hydrocortisone oint. USP 1%
Prompt Relief Hem Ointment
28g
57g
$6
$7
5C Preparation H Suppositories
Hemorrhoidal Supositories
12
$13
6A Robitussin Sugar-free Dm
6B Vicks
6C Mucinex Dm
6D Afrin nasal Spray
6E Cough Drops
6F Robitussin
6G Sudafed PE Tablets
6H Sinus Congestion & Pain
(6) Cough/Cold
Sugar-free cough syrup
Medicated Chest Rub
Mucinex DM 600mg
Nasal Spray
Cough Drops, Cherry or Honeylemon
DmQ-Tussin DM
Nasal Decongestant PE Max Strength
Sinus-Acetaminophen/Phenylphrine HCl
118ml
100g
20
15ml
30
118ml
36
24
$5
$6
$20
$3
$3
$3
$5
$5
2A Tylenol Ex 500mg
2B Bayer Asprin
2C Zostrix
2E Advil
2F Ben Gay
2G Aleve
2H Asprin Low Dose 81mg
2I Tylenol PM
2J Aspirin Low dose Chewable
2K Icy Hot Patch
2L Excedrin
3A Tums-Ex
3B Mylicon-Adults
3C Zantac 75
3D Alka Seltzer
4A Imodium
4B Pepto Bismol
qty.
price
*These items are considered dual purpose items. Prior to ordering these items, the enrollee must have an appropriate conversation
with the enrollee’s personal provider who orally recommends the OTC item for a specific diagnosable condition. OTC items may
only be purchased for the enrollee; it is prohibited to purchase supplies for family members, and friends. The following supplies
are not covered as they are non-eligible supplies: Alternative Medicines (Includes botanicals, herbals, probiotics, homeopathic, and
Item Brand
Generic Comparable
qty.
price
6I Chloraseptic
6J Chloraseptic Lozenges
Sore throat spray
Sore throat lozenges menthol
180ml
18
$5
$4
6K Sugar Free Cough Drops
Sugar Free Cough Drops
25
$4
6L Mucus Relief
6M Cepacol
30
16
$7
$5
7A Collyrium Eye Wash
Expectorant - Guaifenesin 400mg
Cepacol
(7) Eye Care
Eye Wash
118ml
$4
7B Visine
Eye Drops Irritation Relief
15ml
$3
15ml
15ml
5ml
$7
$4
$15
35g
$3
7C Moisture Eyes
7D Isopto Tears
7E Zaditor
8A Benadryl Cream
Artificial Tears
Liquid Tear Eye drops
Eye-Itch Relief Antihistamine
(8) First Aid Creams & Ointments & Antiseptics
Anti-Itch Cream
8B Bacitracin
Bacitracin
14g
$6
8C Lotrimin
Clotrimazole 1% Cream
28g
$7
8D Cortizone
8E Zinc Oxide
Hydrocortisone Cream
Zinc Oxide Ointment
28g
28g
$5
$8
8F Neosporin
Triple-Antibiotic Ointment
1oz
$6
8G Micatin
8H Debrox
28g
.5oz
$4
$7
1
10
100
1
3
113g
300
$4
$2
$3
$9
$3
$15
$5
100
60
119g
133ml
$5
$9
$11
$2
11A Sleep-Aid
11B Blood Pressure Kit*
11C Band Aid
Miconazole Nitrate 2% Cream
Ear wax removal
(9) First Aid Supplies
Elastic bandage w/clips 5yards
Butterfly Closures
Cotton Balls
Ice Bag 9” (1 quart capacity)
Gauze Rolls - Assorted sizes
Sun Screen Lotion SPF 30
Cotton Swabs
(10) Laxatives
Docusate Sodium 100mg
Fiber-Lax 500mg
Clear Lax Powder 4.1oz
Enema-Saline Laxative
(11) Miscellaneous Items
Sleep-tabs 25mg
Manual Self Taking Blood Pressure kit
Adhesive Bandages
24
1
50
$4
$19
$3
11D Digital Themometer
Digital Themometer
1
$5
9A Ace Bandage 3”
9B Butterfly Closure
9C Cotton Balls
9D Ice Bag
9E J&J Gauze
9F Sun Block 4oz
9G Q-Tips
10A Colace
10B Fibercon
10C Miralax
10D Fleet Enema
neutraceuticals), baby supplies, contraceptives, convenience & comfort supplies (insoles, gloves, etc.), cosmetics, food products or
supplements, replacement & attachments such as contact lens containers or batteries. To minimize mailing costs the plan may
impose a limited ordering quantity per purchase. This list is subject to change. This benefit is only available if your plan offers the
Item Brand
Generic Comparable
qty.
price
11E Dramamine
11F Pill Organizer
Motion Sickness Tablets
One Day At a time Medicine Organizer-Weekly
12
1
$4
$7
11G DEX4 Glucose Tablets
Glucose Chewable Tablets
50
$8
11H Melatonin-Sleep Aid
11I Eye Glass Wipes
Melatonin Tablet 3mg
Wipes and lens cleaner pack
60
1 box
$8
$3
(12) Topical Foot & Topical Oral
12A Callus Remover
Callus Remover
6
$4
12C Callus Cushion
Callus Pad
6
$3
12E Plackers Dental flossers
12F Pill Splitter
12G Polident
12H Toothpaste
Dental flossers
Pill Splitter
Denture Cleaners - 3 minutes
Toothpaste
36
1
40
2.7oz
$3
$5
$7
$4
12I Toothbrush
Toothbrush
1
$2
12J Fixodent
Denture Adhesives ADH CRM fresh
1.4 oz
$5
(13) Vitamins & Minerals*
13A Fish oil 1200mg
13B Prosight
13C Allbee With C
13D Vitamin B
13E Vitamin C
13F Centrum
13G Folic Acid
13H Glucosamine Chondroitin
13I Acidophilus
13J Vitamin E
13K Vitamin D
13L Antioxidant tablets
13M Selenium
13N Timed Release Niacin
13O Lactaid Tab
13P Ferrous Sulfate
13Q Calcium Citrate & Vitamin D*
13R One A Day Women’s*
Fish oil 1200mg
Supplement for eyes
B Complex with C
B Complex with B12
Vitamin C Chewable 500mg
Multivitamin & Mineral
Folic Acid 800mcg
Glucosamine Chondroitin
Acidophilus
Vitamin E 400 IU
Vitamin D 1000 IU
Antioxidant tablets
Selenium 200 mcg
Timed Release Niacin 500 mg
Dairy Digestive Supplement-Lactase Enzyme
Ferrous Sulfate 325mg
Calcium Citrate & Vitamin D
One A Day Women’s Multivitamin
90
60
100
100
100
60
100
60
100
100
100
50
60
60
60
100
60
60
$9
$6
$8
$6
$8
$6
$5
$15
$5
$8
$5
$7
$7
$10
$9
$3
$7
$10
13S Os-Cal*
Oyster Calcium + Vitamin D
100
$4
(14) Smoking Cessation
14A Nicorette 2mg
Stop Smoking Gum-Nicotine Polacrilex gum
50
$20
14B Nicorette 4mg
Stop Smoking Gum-Nicotine Polacrilex gum
50
$24
OTC service as a benefit. Orders will be shipped via UPS or USPS Please allow 7-10 business days to receive your order from the
time the order is placed. Please consult with your doctor before using any OTC products. All OTC Supplies are generic comparable
to the item brand and shipped based on manufacturer availability.
Hassle-Free and
as easy as 1... 2... 3...
1
Select items from
this brochure
2
Call 1-888-609-0692
to place your order
3
You receive your order
1-888-609-0692
TTY/TDD: 800-439-2370
Oct 1, 2013 to Feb 14, 2014 - 7 days a week, 8 am to 8 pm
Feb 15, 2014 to Sept 30, 2014 - Mon through Fri, 8 am to 8 pm
Oct 1, 2014 to Dec 31, 2014 - 7 days a week, 8 am to 8 pm
Harvard Pilgrim is an HMO plan with a Medicare contract. Enrollment in StrideSM (HMO) and StrideSM of NH
(HMO) depends on contract renewal.
The Hassle-Free and easy
way to get Over-the-Counter
health related supplies
Receive $25 every month
in Over-the-Counter Drugs & Supplies
That’s a savings of up to $300
over the course of a year!*
And Harvard Pilgrim takes the hassle out of ordering!
Check your Summary of Benefits for details.
Members must continue to pay their monthly plan premium. The benefit information provided is a brief summary,
not a complete description of benefits. For more information contact the plan. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on
January 1 of each year. *Based on a 12 month enrollment.