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Some Drugs Are Excluded from Medicare Part D, but Are Covered by Your Medicaid Benefits Under the Healthpartners® MSHO Plan (HMO)

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Some Drugs Are Excluded from Medicare Part D, but Are Covered by Your Medicaid Benefits Under the Healthpartners® MSHO Plan (HMO) Some drugs are excluded from Medicare Part D, but are covered by your Medicaid benefits under the HealthPartners® MSHO Plan (HMO). These drugs include some over‐the‐counter (OTC) items, vitamins, and cough and cold medicines. If covered, these drugs will have no copay and will not count toward your total drug cost. For questions, please call Member Services at 952‐967‐7029 or 1‐888‐820‐4285. TTY members should call 952‐883‐6060 or 1‐800‐443‐0156. From October 1 through February 14, we take calls from 8 a.m. to 8 p.m., seven days a week. You’ll speak with a representative. From February 15 to September 30, call us 8 a.m. to 8 p.m. Monday through Friday to speak with a representative. On Saturdays, Sundays and holidays, you can leave a message and we’ll get back to you within one business day. Drug Description Strength 3 DAY VAGINAL 4% 5‐HYDROXYTRYPTOPHAN 50 MG ABSORBASE ACETAMINOPHEN 500 MG ACETAMINOPHEN 120MG ACETAMINOPHEN 325 MG ACETAMINOPHEN 650MG ACETAMINOPHEN 80 MG ACETAMINOPHEN 650 MG ACETAMINOPHEN 160 MG/5ML ACETAMINOPHEN 500 MG/5ML ACETAMINOPHEN 160 MG/5ML ACETAMINOPHEN 500MG/15ML ACETAMINOPHEN 100 MG/ML ACETAMINOPHEN 500 MG ACETAMINOPHEN 325 MG ACETAMINOPHEN 500 MG ACETAMINOPHEN 80 MG ACETAMINOPHEN 100.00% ACETAMINOPHEN 80 MG ACETAMINOPHEN 160 MG ACETAMINOPHEN 80MG/0.8ML ACETAMINOPHEN‐BUTALBITAL 50MG‐325MG ACNE CLEANSING PADS 2% ACNE TREATMENT,EXTRA STRENGTH 10% ACT ANTI‐CAVITY MOUTH RINSE 0.05% Updated 12/01/2012 ACTICAL ACTIDOSE‐AQUA 50G/240ML ACTIDOSE‐AQUA 15G/72ML ACTIDOSE‐AQUA 25G/120ML ACTIVATED CHARCOAL 25 G ADEKS 7.5 MG ADULT GLYCERIN ADULT ADULT WAL‐TUSSIN DM MAX 200‐10MG/5 AFRIN 0.05% AKWA TEARS RENEWED 0.1%‐0.3% ALAMAG 150‐300MG ALA‐SEB 2 %‐2 % ALCALAK 168(420)MG ALKA‐AID 180‐360MG ALL DAY ALLERGY 5 MG ALL DAY ALLERGY 10 MG ALLER‐CHLOR 2 MG/5 ML ALLERGY 25 MG ALLERGY 25 MG ALLERGY & CONGESTION 5 MG‐120MG ALLERGY COMPLETE‐D 5 MG‐120MG ALLERGY RELIEF 10 MG ALLERGY RELIEF 10 MG ALLERGY RELIEF‐NASAL DECONGEST 10MG‐240MG ALLFEN‐DM 1000‐55MG ALOE VESTA 2% ALOE VESTA ALOE VESTA SKIN CONDITIONER 2 3% ALTACHLORE 5% ALTALUBE ALTARUSSIN PE 100‐30MG/5 ALUMINUM HYDROXIDE 320MG/5ML ALUMINUM HYDROXIDE 600MG/5ML AMBI 60‐580 580MG‐60MG AMBI 80/780 780MG‐80MG AMERICIN AMERIGEL PREVENTIVE BARRIER AMERIGEL PREVENTIVE CARE AMITEX PSE 600‐120MG AMLACTIN 12% AMMONIUM LACTATE 5.00% Updated 12/1/2012 2 AMMONIUM LACTATE 12% AMMONIUM LACTATE 12%‐12% ANTACID 200(500)MG ANTACID 200‐200‐20 ANTACID PLUS EXTRA STRENGTH 450‐500‐40 ANTACID‐ANTIGAS 400‐400‐40 ANTI‐DIARRHEAL 1 MG/5 ML ANTI‐FUNGAL 2% ANTI‐ITCH 1% ANTIOXIDANT ANTIOXIDANT ANTIOXIDANT ULTRA FORMULA ANTISEPTIC BIO‐HAND 66.50% ANTISEPTIC GEL 62% ANUSERT HC‐1 1% AQUABASE AQUADEKS 0.1MG‐10MG AQUAPHILIC WITH CARBAMIDE AQUASOL E 50 UNIT/ML AQUATAB DM 835MG‐28MG AQUORAL ARTIFICIAL TEARS LUBRICATION G N/A ASCORBIC ACID 100% ASCORBIC ACID ASCORBIC ACID 100.00% ASCORBIC ACID 100MG ASCORBIC ACID 250 MG ASCORBIC ACID 500MG ASCRIPTIN 325 MG ASCRIPTIN MAXIMUM STRENGTH 500 MG ASPIRIN 81 MG ASPIRIN 600 MG ASPIRIN 300 MG ASPIRIN 325 MG ASPIRIN 500 MG ASPIRIN 81 MG ASPIRIN 500MG ASPIRIN BUFFERED 325 MG ASPIRIN EC 81 MG ASPIRIN EC 325 MG ASPIRIN/CALCIUM CARBONATE/MAG 500 MG Updated 12/1/2012 3 ATRAC‐TAIN 5% AYR AYR 2.65% AYR SALINE BABY AYR SALINE 0.65% BACITRACIN 500 UNIT/G BACITRACIN 500 UNIT/G BACITRACIN ZINC 500 UNIT/G BACITRACIN ZINC 500 UNIT/G BACMIN 27 MG‐1 MG BAYER WITH CALCIUM 81MG‐300MG BAZA PROTECT BENEFIBER 1 G BENZAC AC 5% BENZAC AC 10% BENZASHAVE 5% BENZONATATE 100 MG BENZOYL PEROXIDE 10% BENZOYL PEROXIDE 10% BENZOYL PEROXIDE 5% BETA‐CAROTENE 10000 UNIT BETA‐CAROTENE 25000 UNIT BETA‐CAROTENE(A) W‐C & E BETA‐CAROTENE(A) W‐C & E/ZN/CU 7160‐113 BETA‐CAROTENE(A) W‐C & E/ZN/SE BETADINE 7.50% BETADINE 5% BETADINE 7.50% BETADINE 5% BETAMIDE BIDEX‐A 600‐25MG BION TEARS 0.1%‐0.3% BIOSPEC DMX 25‐15MG/5 BIOTENE ORALBALANCE BIOTENE ORALBALANCE BISACODYL 10 MG BISACODYL 10MG/30ML BOUDREAUXS 25% BROFED 30‐4MG/5ML BROMHIST‐NR 12.5‐1MG/1 BROVEX SR 90 MG‐9 MG Updated 12/1/2012 4 BUFFERED SALT 287‐180‐15 BUTALBITAL COMPOUND 50‐325‐40 BUTALBITAL‐ACETAMINOPHEN‐CAFFE 50‐325‐40 CAL GLUCONATE/CAL LACTATE/GUM 300MG‐3G/7 CALAGESIC 1 %‐8 % CALAMINE CALAMINE 8 %‐8 % CALCET 200 MG‐250 CALCI‐MIX 500(1250) CALCIO DEL MAR 500 MG CALCIONATE 115MG/5ML CALCITRATE 200(950)MG CALCITRATE + VIT D 315 MG‐250 CALCIUM 600 MG CALCIUM 600 MG CALCIUM 300MG CALCIUM + VIT D 400‐133.3 CALCIUM 500 + VIT D 500 MG‐200 CALCIUM 500 + VIT D 500 MG‐400 CALCIUM 600 + VIT D 600 MG‐400 CALCIUM 600 + VIT D 600 MG‐400 CALCIUM CARBONATE 500(1250) CALCIUM CARBONATE 648 MG CALCIUM CARBONATE 500(1250) CALCIUM CARBONATE 500 MG/5ML CALCIUM CARBONATE/VITAMIN D3 600MG‐500 CALCIUM CARBONATE/VITAMIN D3 500 MG‐400 CALCIUM CARBONATE/VITAMIN D3 600MG‐125 CALCIUM CITRATE 1040MG CALCIUM CITRATE +VIT D3 200 MG‐250 CALCIUM CITRATE W/VIT D 600MG CALCIUM CITRATE‐VIT D 315MG‐200 CALCIUM CITRATE‐VITAMIN D 200MG‐125 CALCIUM CITRATE‐VITAMIN D 250MG‐200 CALCIUM GLUCONATE 61(648) MG CALCIUM GLUCONATE 60(648) MG CALCIUM GLUCONATE 61(648) MG CALCIUM LACTATE (blank) CALCIUM LACTATE 84 MG(648) CALCIUM WITH BORON 500‐1.5MG CALCIUM WITH VITAMIN D 600 MG‐200 Updated 12/1/2012 5 CALCIUM WITH VITAMIN D 600 MG‐200 CALCIUM WITH VITAMIN D 500 MG‐100 CALCIUM‐MAGNESIUM 300‐300MG CALDYPHEN 1 %‐8 % CALICYLIC 10% CALLUS REMOVER 40% CAPHOSOL CAPSAICIN CAPSAICIN 0.03% CAPSAICIN 0.03% CARMOL 10% CAVILON CECON 90 MG/ML CENTRAL VITE 18MG‐0.4MG CENTRAL‐VITE SELECT CENTRAVITES 0.4‐162‐18 CENTRAVITES 50 PLUS CENTURY .4‐300‐250 CERTA PLUS 0.4‐18‐250 CERTAVITE 9 MG/15 ML CETIRIZINE HCL 5 MG CHARCOAL, ACTIVATED CHARCOAL, ACTIVATED 260 MG CHARCOAL/SORBITOL SOLUTION 50G/240ML CHARCOAL/SORBITOL SOLUTION 25G/120ML CHEST CONGESTION RELIEF 400 MG CHEST CONGESTION RELIEF DM 400MG‐20MG CHEWABLE CALCIUM 500 MG CHILDREN'S ALLERGY 12.5MG/5ML CHILDREN'S CETIRIZINE HCL 1 MG/ML CHILDREN'S CHEST CONGESTION 100 MG/5ML CHILDREN'S CLARITIN 5 MG CHILDREN'S COLD & ALLERGY 15‐1MG/5ML CHILDREN'S COLD & COUGH 1‐2.5‐5/5 CHILDREN'S IBUPROFEN 100 MG/5ML CHILDREN'S LORATADINE 5 MG/5 ML CHILDREN'S MUCINEX 100‐5 MG/5 CHILDREN'S MULTIVITAMIN‐IRON CHILDREN'S PAIN RELIEF 160 MG/5ML CHILDREN'S PEPTO 400 MG CHILDREN'S WAL‐TAP 15‐1MG/5ML Updated 12/1/2012 6 CHLORHEXIDINE GLUCONATE 4% CHLORHEXIDINE GLUCONATE 2% CHLORHEXIDINE GLUCONATE 20% CHLORMATE SA 12MG CHLORPHENIRAMINE MALEATE 8MG CHLORPHENIRAMINE MALEATE 4 MG CHLOR‐TRIMETON ALLERGY 12 MG CHOLECALCIFEROL 1000 UNIT CHOLECALCIFEROL 400/ML CHOLECALCIFEROL 5000 UNIT CITRACAL CREAMY BITES 500 MG‐200 CITRACAL LIQUITAB 500MG CITRADERM CITRUS CALCIUM‐VITAMIN D 200 MG‐250 CLARITIN 10 MG CLEARLAX 17G/DOSE CLEMASTINE FUMARATE 1.34 MG CLOTRIMAZOLE 1% CLOTRIMAZOLE 1% CLOTRIMAZOLE 1% CLOTRIMAZOLE‐3 2% COAL TAR 2.00% COAL TAR COAL TAR 0.50% COAL TAR 2.00% COAL TAR 2.50% COLACE 200 MG/5ML COLD SORE 2% COMFORT SHIELD 3% COMPLETE 27MG‐0.4MG COMPOZ 50 MG CONGESTAC 400MG‐60MG CONPEC L.A. 500‐120MG CORAL CALCIUM 185 MG CORN‐CALLUS REMOVER COROMEGA 650MG‐1000 CORTAID 1% CREATINE MONOHYDRATE CRITIC‐AID 20%‐51% CRUEX 2% CYANOCOBALAMIN 1000MCG/ML Updated 12/1/2012 7 DAIRY DIGEST ULTRA 4500 UNIT DAIRY RELIEF 9000 UNIT DECUBITENE DELSYM 30 MG/5 ML DERMA CIDOL 2000 0.50% DERMADROX 0.45% DERMADROX DERMAFIX DESENEX 2% DESSICATED LIVER DEX4 GLUCOSE 4 G DEXTROMETHORPHAN HBR 15 MG/5 ML DEXTROMETHORPHAN HBR 5 MG/5 ML DEXTROMETHORPHAN HBR 7.5 MG/5ML DIARRHEA RELIEF 262MG/15ML DIASTAT ACUDIAL 5‐7.5‐10MG DIASTAT ACUDIAL 12.5‐15‐20 DIAZEPAM 5 MG/ML DIAZEPAM 5MG/5ML DIAZEPAM 2.5 MG DI‐GON II 600 MG DIMETHICONE 2% DIMETHICONE/ZINC OXIDE 5%‐5% DIOCTYL 60 MG/15ML DIPHENHIST 50 MG DIPHENHYDRAMINE HCL 12.5 MG DIPHENHYDRAMINE HCL 25 MG DIPHENHYDRAMINE HCL 12.5MG/5ML DOCUSATE SODIUM W/CASANTHRANOL 30‐100MG DOCUSIL 100 MG DUOFILM 17% DURADEX 1200‐20MG DURADEX FORTE 1200‐45MG DYNAHEX 4% DY‐O‐DERM E‐400 C‐500 & BETA CAROTENE EAR WAX REMOVAL 6.50% EASYGEL 0.40% EFFERVESCENT 325‐1916MG EFFERVESCENT PAIN RELIEF 324 MG ELDERCAPS 1 MG Updated 12/1/2012 8 ELDERTONIC ELEMENTAL ZINC 30 MG ENDIT ENEMA 19G‐7G/118 ENEMEEZ 283 MG/5ML ENTEX PSE 525MG‐50MG ENVIRO STRESS ERGOCALCIFEROL 8000/ML EUCERIN EUCERIN PLUS INTENSIVE REPAIR EYE ALLERGY RELIEF 0.025‐0.3% EYE CARE NUTRITIONAL SUPPLEMEN NA EYE HEALTH EYE ITCH RELIEF 0.03% FAMOTIDINE 10 MG FEOSTAT 300(100)/5 FERATAB 300(60)MG FERGON 240(27)MG FERREX 150 PLUS 150‐50‐50 FERRIMIN 150 456(150)MG FERRO‐PLEX HEMATINIC 115‐1MG FERROUS FUMARATE 90(29.5)MG FERROUS FUMARATE/FE PS CMPLX 106 MG FERROUS GLUCONATE 325 MG FERROUS SULFATE 220(44)/5 FERROUS SULFATE 300 MG/5ML FERROUS SULFATE 15MG/0.6ML FERROUS SULFATE 325(65) MG FERROUS SULFATE 325(65) MG FERROUS SULFATE 15MG/1.5ML FETRIN 200‐60MG‐5 FIBER FIBER‐LAX 625 MG FIRST‐HYDROCORTISONE 10% FLEET PREP KIT #2 FLETCHER'S CASTORIA 6.50% FLINTSTONES COMPLETE FLINTSTONES WITH EXTRA C FOAM INCONTINENCE KIT FOAMICON 237.5‐254 FOAMING ANTACID 358‐95/15 Updated 12/1/2012 9 FOLBEE 1‐2.5‐25MG FOLBEE PLUS 5 MG FOLGARD 115‐0.8‐10 FOLGARD RX 1‐2.2‐25MG FOLIC ACID 1 MG FOLIC ACID 0.4 MG FOLIC ACID 0.8 MG FOLIC ACID 100.00% FOLIC ACID/MULTIVITS‐MIN/LUT 500‐250MCG FOLIC ACID/MV,FE,OTHER MIN 0.4MG‐18MG FOLIC ACID/MV,FE,OTHER MIN .4‐18‐3500 FOLIC ACID/MV,FE,OTHER MIN 0.4MG‐18MG FOLTX 2‐2.5‐25MG FOSFREE 175.5‐14.5 FUNGOID TINCTURE 2% FUNGOID TINCTURE 2% GAS RELIEF 80 MG GAS RELIEF 125 MG GAS‐X 62.5 MG GAVISCON 14.2‐80MG GENTEAL 0.25%‐0.3% GENTEAL MILD 0.20% GENTEAL PM 15%‐85% GENTEAL SEVERE 0.30% GERI PROTECT GERITOL COMPLETE 16‐0.38 MG GFN 1200/DM 60 1200‐60MG GFN 550/PSE 60 550‐60MG GLUCOTEN 375‐300MG GLUTOSE 45 40% GLYCERIN 2.8G/2.7ML GLYCERIN/HYALURONATE SODIUM (blank) GORDO‐UREA 22% GORDO‐UREA 40% GRX DYNE 7.50% GUAI 800/DM 30 800MG‐30MG GUAIFENESIN 100
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