OTC) Items Are Covered When Written by a Prescription for Healthpartners Minnesota Health Care Programs

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The following over the counter (OTC) items are covered when written by a prescription for HealthPartners Minnesota Health Care Programs. This list is subject to change.

For questions, please call Member Services. Their phone number can be found on the back of your HealthPartners ID card. TTY members should call 952-883-6060 or 1-800- 443-0156. Medication Name Strength 5-HYDROXYTRYPTOPHAN 50 MG ACETAMINOPHEN 100MG/ML ACETAMINOPHEN 120 MG ACETAMINOPHEN 160 MG ACETAMINOPHEN 160MG/5ML ACETAMINOPHEN 167MG/5ML ACETAMINOPHEN 325 MG ACETAMINOPHEN 500 MG ACETAMINOPHEN 500 MG/5ML ACETAMINOPHEN 500MG/15ML ACETAMINOPHEN 650 MG ACETAMINOPHEN 80MG ACETAMINOPHEN 80MG/0.8ML ACTIVATED CHARCOAL 25 G ALUMINUM CHLORIDE ALUMINUM HYDROXIDE 320MG/5ML ALUMINUM HYDROXIDE 600MG/5ML AMMONIUM LACTATE 5% AMMONIUM LACTATE 12% AMMONIUM LACTATE 12%-12% ARGININE 500MG ASCORBIC ACID 1000 MG ASCORBIC ACID 250 MG ASCORBIC ACID 500 MG ASCORBIC ACID 500 MG/5ML ASCORBIC ACID/ZINC 30-15MG ASPIRIN 300 MG ASPIRIN 325MG ASPIRIN 500 MG ASPIRIN 600 MG ASPIRIN 81 MG ASPIRIN/ACETAMINOPHEN/CAFFEINE 250-250-65 ASPIRIN/CALCIUM CARBONATE/MAG 325 MG ASPIRIN/CALCIUM CARBONATE/MAG 500 MG BACITRACIN 500 UNIT/G BACITRACIN ZINC 500 UNIT/G BENZOYL PEROXIDE 5% BENZOYL PEROXIDE 10% BETA-CAROTENE 10000 UNIT BETA-CAROTENE 25000 UNIT BETA-CAROTENE(A) W-C & E BETA-CAROTENE(A) W-C & E/MIN BETA-CAROTENE(A) W-C & E/ZN/CU

1 Medication Name Strength BETA-CAROTENE(A) W-C & E/ZN/SE BISACODYL 10 MG BISACODYL 10MG/30ML BISACODYL 5MG BISACODYL/NAPH,MB-DB BISMUTH SUBSALICYLATE 262 MG BISMUTH SUBSALICYLATE 262MG/15ML BISMUTH SUBSALICYLATE 525MG/15ML CAL GLUCONATE/CAL LACTATE/GUM 300MG-3G/7 CALAMINE CALCIUM 300MG CALCIUM 500 MG CALCIUM CARBONATE 1.25G CALCIUM CARBONATE 1000 MG CALCIUM CARBONATE 300MG(750) CALCIUM CARBONATE 500 MG CALCIUM CARBONATE 500 MG/5ML CALCIUM CARBONATE 500(1250) CALCIUM CARBONATE 600 MG CALCIUM CARBONATE/MAG HYDROX 700-300MG CALCIUM CARBONATE/VITAMIN D2 250MG-125 CALCIUM CARBONATE/VITAMIN D2 500MG-125 CALCIUM CARBONATE/VITAMIN D3 250MG-125 CALCIUM CARBONATE/VITAMIN D3 500 MG-200 CALCIUM CARBONATE/VITAMIN D3 500 MG-400 CALCIUM CARBONATE/VITAMIN D3 500MG-100 CALCIUM CARBONATE/VITAMIN D3 600 MG-200 CALCIUM CARBONATE/VITAMIN D3 600MG-125 CALCIUM CARBONATE/VITAMIN D3 600MG-400 CALCIUM CARBONATE/VITAMIN D3 600MG-500 CALCIUM CITRATE 200(950)MG CALCIUM CITRATE/VITAMIN D3 315MG-200 CALCIUM LACTATE CALCIUM POLYCARBOPHIL 625 MG CAPSAICIN 0.025% CAPSAICIN 0.075% CARBAMIDE PEROXIDE 6.5% CARBOXYMETHYLCELL/GLYCERIN/PF 0.5%-0.9% CARBOXYMETHYLCELLULOS/GLYCERIN 0.5%-0.9% CARBOXYMETHYLCELLULOSE SODIUM 0.25% CARBOXYMETHYLCELLULOSE SODIUM 1% CASANTHRANOL/DOCUSATE SODIUM 30-100MG CELLULOSE CETIRIZINE HCL 1 MG/ML CETIRIZINE HCL 10 MG CETIRIZINE HCL 5 MG CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG CHARCOAL/SORBITOL SOLUTION 50G/240ML CHLORHEXIDINE GLUCONATE 4% CHLORPHENIRAMINE MALEATE 12 MG CHLORPHENIRAMINE MALEATE 2 MG/5 ML CHLORPHENIRAMINE MALEATE 4 MG CHOLECALCIFEROL 1000 UNIT CHOLECALCIFEROL 2000 UNIT

2 Medication Name Strength CHOLECALCIFEROL 400 UNIT CHOLECALCIFEROL 400/ML CHOLECALCIFEROL 5000 UNIT CLEMASTINE FUMARATE 1.34 MG CLOTRIMAZOLE 1% CLOTRIMAZOLE 2% CLOTRIMAZOLE 200MG-1% COAL TAR 0.5% COAL TAR 2.5% COAL TAR 20% COLLODION COLLOIDAL OATMEAL CONDOMS CREATINE MONOHYDRATE CROMOLYN SODIUM 40 MG/ML CYANOCOBALAMIN 100 MCG CYANOCOBALAMIN 1000 MCG CYANOCOBALAMIN 250 MCG CYANOCOBALAMIN 500 MCG DEXTRAN 70/HYPROMELLOSE DEXTRAN/HYPROMELLOSE/GLYCERIN 0.1-.3-.2% DEXTROMETHORPHAN HBR 10 MG/5 ML DEXTROMETHORPHAN HBR 15 MG/5 ML DEXTROMETHORPHAN HBR 5 MG/5 ML DEXTROMETHORPHAN HBR 7.5MG/5ML DEXTROMETHORPHAN POLISTIREX 30 MG/5 ML DEXTROMETHORPHAN POLISTIREX 30MG/5ML DEXTROSE 5% DEXTROSE 40% DEXTROSE 4 G DIMETHICONE 1% DIMETHICONE 2% DIMETHICONE DIMETHICONE/ZINC OXIDE 5%-5% DIPHENHYDRAMINE HCL 12.5 MG DIPHENHYDRAMINE HCL 12.5MG/5ML DIPHENHYDRAMINE HCL 25MG DIPHENHYDRAMINE HCL 50MG DOCOSAHEXANOIC ACID/EPA DOCUSATE SODIUM 100 MG DOCUSATE SODIUM 250 MG DOCUSATE SODIUM 283 MG DOCUSATE SODIUM 50 MG DOCUSATE SODIUM 50 MG/5 ML DOCUSATE SODIUM 60 MG/15ML DOCUSATE SODIUM/BENZOCAINE 283-20MG ELECTROLYTE,ORAL EMOLLIENT COMBINATION NO. 29 EMOLLIENT COMBINATION NO.37 ERGOCALCIFEROL 8000/ML ETHYL ALCOHOL ETHYL OLEATE FAMOTIDINE 20 MG FERROUS FUMARATE 324(106)MG

3 Medication Name Strength FERROUS FUMARATE 456(150)MG FERROUS FUMARATE 90(29.5)MG FERROUS FUMARATE/FE PS CMPLX 106 MG FERROUS GLUCONATE 240(27)MG FERROUS GLUCONATE 325 MG FERROUS SULFATE 15MG/0.6ML FERROUS SULFATE 15MG/1.5ML FERROUS SULFATE 300MG/5ML FERROUS SULFATE 325(65) MG FERROUS SULFATE/FOLIC ACID 160-0.4MG FOLIC ACID 0.4 MG FOLIC ACID 0.8MG FOLIC ACID/B COMPLEX & C NO.10 900MCG/5ML FOLIC ACID/MULTIVITS-MIN 0.4 MG FOLIC ACID/MULTIVITS-MIN/LUT 500-250MCG FOLIC ACID/MV,FE,OTHER MIN .4-18-3500 FOLIC ACID/MV,FE,OTHER MIN 0.4MG-18MG FOLIC ACID/MV,FE,OTHER MIN/LUT 0.4-18-250 GLYCERIN 35% GLYCERIN ADULT GLYCERIN PEDIATRIC GLYCERIN/HYALURONATE SODIUM GLYCOLIC ACID GUAIFENESIN 100 MG GUAIFENESIN 100 MG/5ML GUAIFENESIN 1200 MG GUAIFENESIN 400 MG GUAIFENESIN 50 MG GUAIFENESIN 600 MG GUAIFENESIN/CODEINE PHOS 100-10MG/5 GUAIFENESIN/DEXTRIMETHORPHAN 100-10/5ML GUAIFENESIN/DEXTRIMETHORPHAN 100-10MG/5 GUAIFENESIN/DEXTRIMETHORPHAN 100-5 MG/5 GUAIFENESIN/DEXTRIMETHORPHAN 100MG-5MG GUAIFENESIN/DEXTRIMETHORPHAN 400MG-20MG GUAIFENESIN/EPHEDRINE HCL 200-12.5MG GUAIFENESIN/PHENYLEPHRINE HCL 100-2.5/5 GUAIFENESIN/PHENYLEPHRINE HCL 100-5 MG/5 GUAIFENESIN/PHENYLEPHRINE HCL 380MG-10MG GUAIFENESIN/PHENYLEPHRINE HCL 400MG-10MG GUAIFENESIN/PHENYLEPHRINE HCL 50-2.5MG/5 GUAIFENESIN/PSEUDOEPHEDRINE 400MG-45MG HEXAVITAMINS HYDROCORTISONE 0.5% HYDROCORTISONE 1% HYDROCORTISONE ACETATE 1% HYDROGEN PEROXIDE 3% HYDROPHILIC OINTMENT HYDROXYPROPYL CELLULOSE HYPROMELLOSE 0.2% HYPROMELLOSE 0.3% IBUPROFEN 100 MG IBUPROFEN 100 MG/5ML IBUPROFEN 200MG

4 Medication Name Strength IBUPROFEN 50 MG/1.25 IRON ASPGLY&PS CMPLX/C/CA/SUC 150-50-50 IRON POLYSACCHARIDES COMPLEX 150 MG IRON POLYSACCHARIDES COMPLEX 180 MG IRON/LYSINE/VIT B COMP/FA 800-1MG/15 IRON/VITAMINS A, C, AND D3 10MG-400/2 IRON/VITAMINS A,C,AND D KETOTIFEN FUMARATE 0.025% LACTASE 250 MG LACTASE 3000 UNIT LACTASE 9000 UNIT LACTASE/RENNET 25-2MG LACTIC ACID LACTOSE LANOLIN/MIN OIL/PETROLAT,WHT LOPERAMIDE HCL 1 MG/5 ML LOPERAMIDE HCL 1MG/5ML LOPERAMIDE HCL 2 MG LORATADINE 10MG LORATADINE 5 MG LORATADINE 5 MG/5 ML LORATADINE/PSEUDOEPHEDRINE SUL 10MG-240MG LORATADINE/PSEUDOEPHEDRINE SUL 5 MG-120MG MAG HYDROX/AL HYDROX/SIMETH 200-200-20 MAG HYDROX/AL HYDROX/SIMETH 200-200-25 MAG HYDROX/AL HYDROX/SIMETH 400-400-40 MAG HYDROX/AL HYDROX/SIMETH 450-500-40 MAGNESIUM 250 MG MAGNESIUM CARBONATE/AL HYDROX 105-160MG MAGNESIUM CHLORIDE 64 MG MAGNESIUM CITRATE MAGNESIUM GLUCONATE 54 MG/5 ML MAGNESIUM HYDROXIDE 400 MG/5ML MAGNESIUM HYDROXIDE 80MEQ/30ML MAGNESIUM HYDROXIDE 80MEQ/30ML MAGNESIUM HYDROXIDE/AL HYDROX 500-500/5 MAGNESIUM OXIDE 400 MG MAGNESIUM OXIDE 500 MG MECLIZINE HCL 12.5 MG MECLIZINE HCL 25 MG MENTHOL METHYLCELLULOSE METHYLCELLULOSE 500 MG MICONAZOLE NITRATE 2% MICONAZOLE NITRATE 4% MICONAZOLE NITRATE 100 MG MICONAZOLE NITRATE 100MG MICONAZOLE NITRATE 100MG-2% MICONAZOLE NITRATE 200 MG-2 % MICONAZOLE NITRATE 200MG-2% MICONAZOLE NITRATE 200MG-2% MINERAL OIL MINERAL OIL/PEGS MINERAL OIL/PETROLATUM,WHITE 15%-85%

5 Medication Name Strength MULTIVITAMIN MULTIVITAMINS MULTIVITAMINS W-IRON MULTIVITAMINS W-MINERALS MULTIVITAMINS W-MINERALS/LUT MULTIVITAMINS,THER W-MINERALS MULTIVITAMINS,THERAPEUTIC MULTIVITAMINS/IRON/FOLIC ACID 18MG-0.4MG MULTIVITS & MINS/COENZYME Q10 2 MG/ML MULTIVITS W-FE,OTHER MIN MULTIVITS W-FE,OTHER MIN/LUT MULTIVITS W-IRON,HEMATINIC MULTIVITS W-IRON,HEMATINIC 27MG-0.4MG MULTIVITS&MINS/FA/COENZYME Q10 0.2MG-10MG MULTIVITS,STRESS FORMULA MULTIVITS,STRESS FORMULA/ZINC MULTIVITS,THERAP W-FE,HEMATIN 30-0.8MG MULTIVITS-MIN/FA/LUT/ZEAXANTH 1.66-0.83 NA PHOS,M-B/NA PHOS,DI-BA 19G-7G/118 NA PHOS,M-B/NA PHOS,DI-BA 7.2-2.7/15 NACL/NA PHOS,DI-BA/K PHOS NAPH,MB-DB/K PH,MBDB 280-250MG NAPHAZOLINE HCL/PHENIR MAL 0.025-0.3% NAPROXEN SODIUM 220 MG NAPROXEN SODIUM 220MG NEOMY SULF/BACITRAC ZN/POLY 3.5-400-5K NIACIN 100 MG NIACIN 1000 MG NIACIN 250 MG NIACIN 50 MG NIACIN 500 MG NIACIN 750 MG NIACINAMIDE 100 MG NICOTINE 14MG/24HR NICOTINE 21 MG/24HR NICOTINE 21MG/24HR NICOTINE 7MG/24HR NICOTINE POLACRILEX 2 MG NICOTINE POLACRILEX 4 MG OMEGA-3 FATTY ACIDS/FISH OIL 340-1000MG OXYMETAZOLINE HCL 0.05% OXYMETAZOLINE HCL/MENTHOL 0.05% PERMETHRIN 1% PETROLAT,WHT/MIN OIL/SOD CHL PETROLATUM,WH/CARBOXYMETHYL PETROLATUM,WHITE PETROLATUM,WHITE/LANOLIN PHENYLEPHRINE HCL/CHLOR-MAL 10MG-4MG PHENYLEPHRINE HCL/CHLOR-MAL 2.5-1MG/5 PHENYLEPHRINE/BROMPHENIRAMINE 2.5-1MG/5 PHENYLEPHRINE/DIPHENHYDRAMINE 2.5-6.25/5 PHENYLEPHRINE/DIPHENHYDRAMINE 5MG-12.5MG PIP BUTOX/PYRETHRINS/PERMETH 4-.33-.5% PIPERONYL BUTOXIDE/PYRETHRINS 3-0.3%

6 Medication Name Strength PIPERONYL BUTOXIDE/PYRETHRINS 4%-0.33% POLOXAMER/GLYCERIN/DIMETH/H2O POLYETHYLENE GLYCOL POLYETHYLENE GLYCOL 1000 POLYETHYLENE GLYCOL 3350 POLYETHYLENE GLYCOL 400 POLYVINYL ALCOHOL 1.4% POLYVINYL ALCOHOL/POVIDONE 0.5%-0.6% POTASSIUM BROMIDE POTASSIUM IODIDE 325MG/5ML POVIDONE-IODINE 10% PRENATAL VIT/FE FUMARATE/FA 27-0.8MG PRENATAL VIT/FE FUMARATE/FA 28-0.8MG PRENATAL VIT/FE GLUCONATE/FA 30-0.4MG PRENATAL VIT/FE GLUCONATE/FA 30-0.8MG PRENATAL VITS W-CA,FE,FA(<1MG) PROPYLENE GLYCOL PROPYLENE GLYCOL/CARBOMER 940 PROPYLENE GLYCOL/PEG 400 0.3%-0.4% PROPYLENE GLYCOL/PEGS 20-15% PROPYLENE GLYCOL/PEGS 5-15% PSEUDOEPHEDRINE HCL 120 MG PSEUDOEPHEDRINE HCL 30 MG/5 ML PSEUDOEPHEDRINE HCL 30MG PSEUDOEPHEDRINE HCL 60 MG PSEUDOEPHEDRINE HCL/BROMPHENIRAMINE 15-1MG/5ML PSEUDOEPHEDRINE/LORATADINE 120-5MG PSEUDOEPHEDRINE/LORATADINE 240-10MG PSYLLIUM PSYLLIUM HUSK 0.52G PSYLLIUM HUSK/ASPARTAME 3.4G/5.8G PSYLLIUM HUSK/ASPARTAME 3.5G PSYLLIUM HUSK/SUCROSE 3.4G/11G PSYLLIUM HUSK/SUCROSE 3.4G/7G PSYLLIUM SEED 3.4G/5.8G PSYLLIUM SEED/ASPARTAME PSYLLIUM SEED/DEXTROSE PSYLLIUM SEED/SUCROSE PV W-O CAL/FE GLUCONATE/FA 30-0.8MG PYRIDOXINE HCL 100 MG PYRIDOXINE HCL 25 MG PYRIDOXINE HCL 50 MG RACEPINEPHRINE HCL 0.0225 RANITIDINE HCL 150 MG RASPBERRY FLAVOR SACCHARIN SALICYLIC ACID 3% SALICYLIC ACID 15% SALICYLIC ACID 17% SALICYLIC ACID 40% SALT IRRIGATION SOLUTION NO.1 SENNOSIDES 8.6 MG SENNOSIDES 8.8MG/5ML SENNOSIDES/DOCUSATE SODIUM 8.6MG-50MG

7 Medication Name Strength SENNOSIDES/PSYLLIUM 9MG-500MG SILICA,COLLOIDAL SIMETHICONE 125 MG SIMETHICONE 40MG/0.6ML SIMETHICONE 80 MG SIMPLE SYRUP SOD BORATE/BORIC AC/H2O/NACL SODIUM BICARBONATE 325 MG SODIUM BICARBONATE 650 MG SODIUM BORATE SODIUM BROMIDE SODIUM CHLORIDE 0.65% SODIUM CHLORIDE 2% SODIUM CHLORIDE 2.65% SODIUM CHLORIDE 5% SODIUM CHLORIDE/SOD BICARB SODIUM CL FOR INHALATION 0.9% SODIUM FLUORIDE 0.02% SODIUM FLUORIDE 0.1% SORBITOL SOLUTION 70% STANNOUS FLUORIDE 0.4% SUCROSE TERBINAFINE HCL 1% TETRAHYDRZ/DEXT 70/PEG 400/PVP 0.05-.1-1% THIAMINE HCL 100 MG THIAMINE HCL 50 MG THICKENING AGENT, TOPICAL NO.1 TIOCONAZOLE 6.5% TOLNAFTATE 1% UBIDECARENONE 100 MG UBIDECARENONE 200 MG UBIDECARENONE 30 MG UBIDECARENONE 30 MG/5 ML UBIDECARENONE 400 MG UBIDECARENONE 50 MG UBIDECARENONE/VITAMIN E 100MG-1/5 VIT A,C & E/LUTEIN/MINERALS 1000-60-2 VIT C/DL-E AC/LUT/COPPER/ZNOX 226-200-5 VIT C/VIT E AC/LUT/MINERAL 1 60-30-6 VIT C/VIT E ACETATE/LUTEIN/MIN VITAMIN A 10000 UNIT VITAMIN A 8000 UNIT VITAMIN B COMP W-C VITAMIN E 100 UNIT VITAMIN E 1000 UNIT VITAMIN E 200 UNIT VITAMIN E 50 UNIT/ML VITAMIN E 600 UNIT VITAMIN E (DL, ACETATE) 400 UNIT VITAMIN E MIXED 200 UNIT VITAMINS A AND D WATER WHEAT DEXTRIN 1 G WHEAT DEXTRIN 3G/3.5G

8 Medication Name Strength ZINC 23MG ZINC GLUCONATE 50 MG ZINC OXIDE 10% ZINC OXIDE 25% ZINC OXIDE/PETROLATUM,WHITE 15%-49% ZINC SULFATE 220 MG