Over the Counter (OTC) Covered Items


1 EmblemHealth VIP Dual (HMO SNP) and EmblemHealth Affinity Medicare Ultimate (HMO SNP) Over-the-Counter (OTC) Covered Items As a member of EmblemHealth VIP Dual (HMO SNP) and EmblemHealth Affinity Medicare Ultimate (HMO SNP), you can use your Over-the-Counter (OTC) debit card to buy covered items from any participating OTC pharmacy. For more information about participating OTC pharmacies, please visit otcnetwork.com . Please note you can only use this card to buy items for yourself.

2 Over-the-Counter (OTC) Covered Drugs and Items Abdominal Supports & Rib Belts Acid Controllers Allergy Allergy Liquids, Tabs & Caps Allergy Nasal Sprays, Drops & Inhalers Anti-Diarrheals Anti-Diarrheal Tabs, Liquids & Caps Antifungal Treatments Antifungal Powders, Creams, Liquids & Sprays Nail Fungus Treatments Anti-Gas Mixed/Miscellaneous Anti-Gas Anti-Itch Treatments Anti-Itch Treatments (Excluding Hydrocortisone), Jock Itch & Insect Bite Remedies Hydrocortisone Products Antiparasitic Treatments Lice Treatments & Accessories Braces Ankle & Foot Elbow & Arm Hand & Wrist Joint Warmers & Arthritis Knee Thigh, Calf & Shin Contact Lens Care Gas Permeable & Hard Lens Care Soft Lens Cleaners Soft Lens Multi-Purpose & Saline Solutions Soft Lens Rewetting Drops Cough, Cold, Flu & Sinus Cold & Flu Preventatives/Symptom Reducers Cough, Cold, Flu & Sinus Liquids, Tabs & Caps Cough Drops, Sore Throat Relief Sore Throat Pain Relief Throat & Cough Drops

3 Over-the-Counter (OTC) Covered Drugs and Items Denture Care Alcohol Swabs and Wipes Denture Adhesives Denture Repair & Pain Relief Diabetes Health & Personal Care Diabetes Cough, Cold & Allergy Diabetes Skin Care & External Pain Relief Diabetes Supplements Digestive Aids Lactose Intolerance Prebiotics & Probiotics Diuretics & Weight Loss Cleansing & Detox Diuretics Weight Loss Cleansing & Detox Ear Care Ear Drops & Syringes Hearing Aids Lipoflavonoids Elastic Bandages & Athletic Treatments Athletic Treatments Elastic Bandages Protective Guards Electrical & Audio Hearing Aid Batteries (Standard & High Performance) External Pain Relief External Muscle/Joint Pain Relief Patches, Pads, Creams, Ointments, Gels, Lotions, Liquids, Roll-Ons & Sprays Eye Care Magnifying Glasses Reading Glasses Eye Preparations (Includes Sleep Masks) Dry Eye Relief Eye Relief Products Eye Wash Facial & Body Acne Medications Acne Creams, Gels, Lotions, Patches, Soaps, Cleansers, Astringents, Toners & Pads

4 Over-the-Counter (OTC) Covered Drugs and Items Feminine Antifungal First Aid Dressings Adhesive & Liquid Bandages Finger Cots & Splints First Aid Kits, Supplies & Tapes Gauze Pads, Dressings & Rolls Surgical Bandages & Dressings First Aid Treatments Antiseptics & Medicated Products (Includes Alcohol, Peroxide, Epsom Salt, Etc.) Skin Protectants (Includes Petroleum Jelly) Skin Treatments (Includes Burn & Scar) Topical Antibiotics Wound Cleansers Floss & Gum Care Dental Gum Floss & Flossers Gum Care Foot Cushioning & Treatments Corn, Callus & Bunion Pads Corn & Callus Removers Foot Pain Relief Athletic Support Socks General Compression Sleeves & Garments General Support - Low Compression (8-15 mmHg) & Medical Support High Compression (Over 8-15 mmHg) Lymphedema Treatments (Sleeves, Socks, Pumps, Etc.) Medical Compression Sleeves & Garments Mixed/Miscellaneous General Support - Low Compression (8-15mmHg) Medical Support & Accessories (Knee High, Thigh High & Waist High) Men’s Support Hose Women’s High Compression Support Hose - Full & Maternity Women’s Support Hose - Knee High, Thigh High, Full & Maternity Hemorrhoid Preparations Hemorrhoid Treatments, Wipes & Washes

5 Home Diagnostics and Aids for Daily Living Bathing & Oral Hygiene Aids Blood Pressure Kits & Accessories Drug & Alcohol Tests Electric Heating Pads Grooming & Dressing Aids Medical Alert IDs & Devices Medicine Dosers, Pillboxes, Organizers & Reminders Mobility Safety: Stair Rails, Stair Treads, Temporary Mobility Ramps Nightlights, Safety Lights, Pill Cutters Reachers, Grippers & Lifts Reading, Writing & Telephone Aids Stethoscopes & Accessories Thermometers, Fever Strips & Accessories Home Health Care Bathtub Safety & Accessories Bathtub & Toilet Rails & Frames Elevated Toilet Seats & Accessories Grab Bars & Handles Hand Held Showers Mixed/Miscellaneous Bathroom Safety Sitz Baths & Bidets Incontinence Personal Care Deodorizers Disposable Underwear, Briefs, Undergarments, Underpads, Pads, Shields, Guards & Drip Collectors Perineal - Only Antifungals Perineal - Only Cleansers & Washes Perineal - Only Moisturizers, Barriers & Protectants Perineal - Only Wipes & Novelettes Laxatives Enemas, Laxative Suppositories, Kits, Etc. Fiber Products Laxative Liquids & Combination Stool-Softener Products Non-Liquid Laxatives (Non-Fiber) & Combination Stool-Softener Products Stool Softeners

6 (Continued) Over-the-Counter (OTC) Covered Drugs and Items Lip Care Medicated Lip Treatments Nasal Decongestant Nasal Sprays, Drops & Inhalers Nasal Moisturizers, Washes, Strips & Snore Relief Oral Remedies (Includes Fluoride Treatments) Dry Mouth Oral Pain Relief & Mouth Sores Temporary Dental Repair Orthopedic & Surgical Support Arm Slings & Cervical Collars Hernia Supports & Suspensories Sacro & Back Braces Shoulder & Clavicle Braces Pain Relief Adult Acetaminophen Adult Aspirin & Combinations Adult Ibuprofen & Other Anti-Inflammatories Adult Nighttime Pain Relief Adult Specialty Pain Relief Feminine Pain Relief Patient Skin Support Antifungals Moisturizers, Barriers & Protectants Physical Fitness & Exercise Equipment Fitness Trackers & Pedometers Respiratory Treatments Asthma Preparations Humidifiers & Accessories Repository Treatments Vapor Products (Includes Waterless Vaporizers) Reusable Incontinence Reusable Garments & Underpads Sleep Aids, Stimulants & Motion Sickness Motion Sickness & Vertigo Sleep Aids, Sedatives & Stimulants Smoking Deterrents Nicotine Patches, Gums & Lozenges

7 (Continued) Over-the-Counter (OTC) Covered Drugs and Items Specialized Orthopedic Braces/Supports/ Splints Specialized Ankle & Foot Braces/Supports/Splints Specialized Elbow & Arm Braces/Supports/Splints Specialized Hinged Knee Braces/Supports/Splints Specialized Knee Immobilizer Braces/Supports/Splints Specialized Shoulder & Clavicle Braces/Supports/Splints Specialized Thigh & Calf Braces/Supports/Splints Specialized Wrist & Hand Braces/ Supports/Splints Specialized Wound Care Alginate Dressings Collagen Dressings Foam Dressings Gauze Dressings, Pads, Sponges & Packing Hydrocolloid/Hydrogel Dressings Tapes, Wraps & Compression Transparent Dressings Wound Cleansers, Treatments & Accessories Stomach Remedies Antacids Antacid Liquids, Tabs & Caps Effervescent Antacids & Combinations Multi-Symptom & Nausea Products Sun Protection Sport Sun Protection Sun Protection (< SPF 50) Sun Protection (SPF 50+) Supplements Enzymes, Amino Acids & Hormones Eye Health Vitamins General Health Prebiotics & Probiotics Menopause Support (Soy) Weight Management Tabs & Caps Toothbrushes Battery & Rechargeable Toothbrushes & Refills Manual Toothbrushes & Accessories

8 Over-the-Counter (OTC) Covered Drugs and Items (Continued) Toothpastes & Treatments Regular & Sensitive Toothpastes Tooth Powders & Treatments Whitening Toothpastes Urine Testing Urine Test Strips & Tabs Vitamins Calcium CoQ10 Only (UBIQUINOL) Eye Health Vitamins Heart Health & Essential Fatty Acids (Fish Oil, Flax, GLA, Etc.) Iron Joint Health (Including Glucosamine) Multi-Minerals Vitamin B & Vitamin B Complex Vitamin C Vitamin D Vitamin E Wart Removers Liquids & Pads HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. Group Health Incorporated (GHI), Health Insurance Plan of Greater New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. Y0026_127357_C NS 86-9378 1/19

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