1 Covered Items Counter Benefit | - the - Over - Counter (OTC) expenses include medicines or products that help treat Eligible Over - the injuries or illness. Members enrolled in the Fidelis Dual Advantage and Fidelis Dual fit through a debit card that can be used at Advantage Flex plans receive the OTC bene most chain pharmacies (for example, CVS, RiteAid, Duane Reade, Walgreens, etc.) The OTC benefit for each plan is: Fidelis Dual Advantage $25 per month Fidelis Dual Advantage Flex $70 per month eed to provide a statement from a medical provider or indicate a diagnosis in You do not n order to receive reimbursement. covered Items Covered and Non - included with this information If you are not A list of covered and non - covered items is . 247 - 800 1 covered, call Member Services at sure if an OTC item is - before you 1447 - 8544. From October 1 to February14, our - 695 - 800 - . TTY users should call 1 buy the item office hours are from 8:00 a.m. to 8:00 p.m., seven days a week. From February 15 to September 30, our office h ours are Monday to Friday, from 8:00 a.m. to 8:00 p.m. Your OTC Benefit is for You Alone Please remember that by law, you cannot buy OTC items for family members or friends. If it is discovered that you bought OTC items for family or friends, you could be required to reimburse Fidelis Care for the items you purchased, and you could face additional penalties, such as loss of your health insurance coverage and/or criminal prosecution. H3328_FC 17140 Accepted

2 Care OTC: Examples of Covered Items Fidelis l yleno ) Acetaminophen (T Acne m edication lign A - r Allergy medicine (a ntihistamines, S udafed , B enadryl , C laritin ) elief Analgesic o intment (D eep Heat ing rub, pain p atches) Antacids (Gas - X, Mylanta , P rilosec OTC) Antibiotics - t opical (N eosporin , B acitracin ) Aspirin Bandage s Blood - pressure monitor/cuff Bowel prep kit ChapStick m edicated - Cold - sore/blister m edications (A breva ) Colon c leanse Compression s tockings ) inus & S , A lu & F old C cough drops (Tylenol dvil Cold Cough/cold/flu m edicine / ) Dental care (toothbrushes, outhwash, P oligrip , O rajel toothpaste, m Dia betic supplies (test strips, i nsulin) Epsom - salt (anti itch, muscle - soothing s alt) Eye drops (allergy, l ubricants) Eyelid w ipes bunion, b reatments) t movers, orn c lister, and Foot c are ( call us re Hemorrhoid m reparation H ) edications (P , A Ibuprofen (Motrin dvil ) Incontinence supplies - a dult diapers (Depend, Poise ) intolerance - Lactose , L ) actrase actaid edications (L m , D Laxatives (Diocto ) ulcolax, Colace alcium C Oyster Rash ointments (A+D ointment, Desitin, ) Balmex azel) Rubbing alcohol (peroxide, witch h um) icorette g ids (N cessation a - Smoking Sunscreen amins (A, B, B5, C, D, E, Biotin Vit , Niacin) H3328_FC 17140 Accepted

3 Fidelis Care OTC: Additional Covered Items and Exceptions categories Sub Eligibility Type Category xceptions E Includes multivitamins, Minerals Eligible , individual vitamins and minerals Includes ultivitamins, m Vitamins Eligible , individual vitamins and minerals Equipment Thermometers are eligible blood diagnosing: items; sca - Diagnostic les are non pressure, cholesterol, Eligible e quipment is diagnos - eligible. Pregnancy , colorectal diabetes eligible - items are non screenings, HIV, etc. Phytohormone, Hormone Eligible replacement natural progesterone Any OTC foods, such as termine, Phen non Eligible protein shakes, are - loss items - Weight i, ll a , oodia h fücoTHIN eligible Fiber supplements are that upplements Eligible Fiber s primarily food with fiber eligible added are non - andages, dressings, B a - First Eligible Flashlights are non eligible - id supplies sport tapes - non Incontinence Eligible supplies H3328_FC 17140 Accepted

4 Fidelis Care OTC: Additional Covered Items and Exceptions Eligibility Type Exceptions Sub Category categories Medicines, Homeopathic and alternative ointments and medicines including , botan icals, herbals, sprays with active See footnote* below skin lotions, Eligible medical ingredients - probiotics, dry - and neutraceuticals are non , that cure, diminish eligible. For further or remove symptoms exceptions, see footnote** Sunscreen lotion Eligible Compression Arch and insoles are non hosiery, rib belts, - Eligible Support items eligible braces, orthopedic supports Toothbrushes, toothpaste, floss, Teeth - breath denture adhesives, Mout hwashes, bad related - whiteners items, dentures, Eligible items, and teeth and OTC items that outh care are non eligible - m treat gum problems, mouth or thru sh, sores medicine s *Items and services can be covered if they are one of these s, or spray s with an , ointment active medical ingredient: analgesics (which reduce pain, inflamma tion), anti - acid, anti - arthritics, inflammatory, antibiotics, anti - radicals, anti - diarrheas, anti - fungals, anti - gas, antihistamines, anti - anti - itch, anti - parasitic, antiseptics, anti , decongestants reducing), - pyretics (fever - insect, anti - - digestive aids , ea r drops, expector ants (mucus), eye drops, laxatives, lactose intolerance products sunscreen or steroids, (medicated) ; , , lip products (medicated) , pediculicide s with a condition Or, they treat one of the following ine, ointment, or spray with an active medic : acne, allergy, arthritis, asthma, blood clotting, bruises, burns, calluses, corns, medical ingredient colds, cold sores, cough, diabetes, flu, dermatitis, eczema, gastro intestinal, hay fever, headaches, hemorrhoidal, incontinence, influenza, usal, menstrual, sinus, motion sickness, nasal, lice, menopa ra osteoporosis, pain, psoriasis, rash, respi tory, scars, sleep, smoking, snoring, sore throat, stomach problems, travel sickness, thrush, wart, worms, wounds. H3328_FC 17140 Accepted

5 NON COVERED Item s Fidelis Care OTC: Examples of - erbal Remedies N utraceuticals H 5 HTP Alpha - - ipoic a cid l Acidophilus Altern No Calorie S weetener Agracejo (l t onic) Amino a cids iver Aloe v era AmLactin c ream Astra galus Anti - aging c ream Arginine onnieri Bacopa m Borage oil/starflower o The Cleaner W omen's F ormula il Brewer ’s y east Cod - l iver o il Butcher's b room Colostrum Plus Fish Cholest Off o il DHEA osamine & MSM Gluc Glucosamine c hondroitin Echinacea Flax s eed Glucosamine s ulfate Goldenseal Hyaluronic a cid Grape leaves/s eed Ionic Tonic/Gatorade Graviola il Krill o eed Lysine Horny goat w - L flex j - i oint Tyrosine Isotonix OPC Lutein 3 - Mag - G Kavinace magnesium gluconate - L - Theanin e Melatonin Mega - T MSM - alternative medicine scalp t Milk t Nioxin - histle reatment Move Free Polyglycol on essential synthetic n Osteo Bi - Flex Proline - - compound erbal la h Pimpinel p urner Recreate fat b lant Red yeast r ice Policosanol pine Pycnogenol - - b ark e xtract Rogaine SC4: Secretagogue HGH hormone Resveratrol Selenium upplements RNA/DNA s b e artilage Sambucol s yrup - Shark c lack lderberry Super DHA fish o il Spirulina Thyroid Complex TravaCor Ultra Sytrinol Uña de gato law Cat's c - Unda 1, 18, 243 Ultra Nattokinase Valerian Vibrant Health Green Vibrance p owder White chia s eed H3328_FC 17140 Accepted

6 Fidelis Care OTC: Examples of - COVERED Item s NON OTHER/MISC ELLANEOUS PROBIOTICS AmLactin Foot Cream Therapy Acidophilus Chap - non - m edicated Stick L. acidophilus Contact lens case/s olution Bifidobacteria (Bifidus) . L alls Cotton salivarius b L. rhamnosus Deodorants Ensure tarum L. pla n Lactobacil Exercising e nhancements lus Glucerna Primadophilus Hearing - aid b atteries Liquid Energy Lotion Pedialyte rinks d ars/ Protein b ips t - Q R eading g lasses OTC Shampoo Soap - Travel first its aid k NON Additional - COVERED Items and Exceptions categories Eligibility Type Exceptions Sub Category als, Includes botanic Vitamins and minerals Alternative herbals, probiotics, and Non - eligible medicines are dual eligible utraceuticals n Diapers, diaper bags, baby oil, shampoos, lotions, soaps, body wash, bottles, nipples, Non - Baby items eligible sterilizers, toys, monitors, strollers, crib, bedding, clothing y b and other ba , items are non - eligible Pregnancy kits and all - Non Contraceptives eligible forms of contraceptives - are non eligible Scales, fans, magnifying - Convenience (non eligible - Non glasses, ear plugs, foot items medical) insoles, gloves H3328_FC 17140 Accepted

7 Additional NON - COVERED Items and Exceptions Eligibility Type Exceptions categories Sub Category below Suntan lotions are eligible See footnote** Cosmetics Non - eligible Sugar/salt supplements, energy Vitamins and minerals are p dual eligible. Fiber products bars, , robiotics Non eligi ble Food supplements liquid energizers, are eligible unless they are - , power p rimarily foods with fiber protein bars drinks, Ensure, added Glucema Includes hearing - aid batteries, contact - items, Replacement , lens containers, etc. - eligible attachments, Non when not factory - peripherals packaged with original item - ** The following are Non - e ligible : Baby medicines , d ehydration drinks , dry skin lotions (for example, (it is non DairyCare it is food, Lactaid milk ( , medicated), - Eucerin, Aquaphor), not a ontraceptives c , smoking - cessation aides (although not covered by this OTC benefit, they ma y be medicine) ), d covered under Part B iabetic supplies (although not covered by this OTC benefit, they may be l ip balm, ), s h , hampoos to fight dandruff - loss products , covered under par t B or Part D air deodorants, facial cleansers, feminine products, grooming devices, hair conditioners, hair removal, perspirants, shampoos, shaving and men’s grooming, - ers, perfumes, anti hair bleaches, moisturiz . and soaps H3328_FC 17140 Accepted

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