MSHO Plan Drug Wrap List Some drugs are excluded from Medicare Part D, but are covered by your Medicaid benefits under the HealthPartners® MSHO Plan (HMO SNP). 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 952-8836060 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 Federal holidays, you can leave a message and we’ll get back to you within one business day.

Analgesics Analgesics, Miscellaneous acetaminophen (bulk) powder 100 % acetaminophen oral drops 100 mg/ml acetaminophen oral elixir 160 mg/5 ml acetaminophen oral liquid 160 mg/5 ml, 500 mg/5 ml acetaminophen oral solution 160 mg/5 ml (5 ml) acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 325 mg acetaminophen oral tablet,disintegrating 160 mg, 80 mg acetaminophen rectal suppository 120 mg, 650 mg arthritis pain relief (acetam) oral tablet extended release 650 mg capsaicin topical cream 0.025 % children's pain reliever oral tablet,chewable 80 mg extra strength muscle rub topical cream 15-10 % feverall rectal suppository 325 mg, 80 mg mapap (acetaminophen) oral capsule 500 mg mapap (acetaminophen) oral liquid 500 mg/15 ml muscle relief topical cream 0.075 % non-aspirin infants oral drops,suspension 100 mg/ml Last Updated: October 1, 2015

pain relief extra strength oral tablet 250-250-65 mg pain reliever extra strength oral tablet 500 mg sarna anti-itch topical lotion 0.5-0.5 % Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet 325 mg aspirin oral tablet,chewable 81 mg aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg aspirin rectal suppository 300 mg bufferin oral tablet 325 mg ibuprofen oral capsule 200 mg ibuprofen oral tablet 200 mg ibuprofen oral tablet,chewable 100 mg infant's ibuprofen oral drops,suspension 50 mg/1.25 ml naproxen sodium oral tablet 220 mg Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents nicotine (polacrilex) buccal gum 2 mg, 4 mg nicotine (polacrilex) buccal lozenge 2 mg, 4 mg nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr Antifungals Antifungals antifungal (tolnaftate) topical aerosol,spray 1 % clotrimazole 3 day vaginal cream 2 % clotrimazole topical cream 1 % clotrimazole topical solution 1 % fungoid tincture topical tincture 2 % gyne-lotrimin vaginal cream 1 % lamisil (aerosol) topical aerosol,spray 1 % lamisil af topical powder 1 % micatin topical cream 2 % miconazole-3 vaginal suppository 200 mg mitrazol topical powder 2 % monistat 3 vaginal kit 200 mg- 2 % (9 gram) monistat 7 vaginal cream 2 % monistat 7 vaginal suppository 100 mg terbinafine hcl topical cream 1 % tolnaftate topical aerosol powder 1 % tolnaftate topical cream 1 % tolnaftate topical solution 1 % Last Updated: October 1, 2015

triple paste af topical ointment 2 % vagistat-1 vaginal ointment 6.5 % Antihistamines Antihistamines allergy & congestion relief oral tablet extended release 12 hr 5-120 mg allergy relief(chlorpheniramn) oral tablet 4 mg cetirizine oral tablet 10 mg, 5 mg cetirizine oral tablet,chewable 10 mg, 5 mg cetirizine-pseudoephedrine oral tablet extended release 12 hr 5-120 mg children's allergy (diphenhyd) oral tablet,disintegrating 12.5 mg children's claritin oral tablet,chewable 5 mg children's cold & allergy oral liquid 1-15 mg/5 ml cold & allergy oral tablet 4-10 mg dimetapp cold-allergy (pe) oral solution 1-2.5 mg/5 ml diphenhydramine hcl oral capsule 25 mg, 50 mg diphenhydramine hcl oral elixir 12.5 mg/5 ml diphenhydramine hcl oral liquid 12.5 mg/5 ml diphenhydramine hcl oral tablet 25 mg loratadine oral solution 5 mg/5 ml loratadine oral tablet 10 mg loratadine oral tablet,disintegrating 10 mg loratadine-d oral tablet extended release 12 hr 5-120 mg loratadine-d oral tablet extended release 24 hr 10-240 mg Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) bacitracin topical ointment 500 unit/gram bacitracin zinc topical ointment 500 unit/gram betadine topical solution 10 % hibiclens topical liquid 4 % neosporin (neo-bac-polym) topical ointment 3.5mg-400 unit- 5,000 unit/gram povidone-iodine topical ointment 10 % Antinausea Agents Antinausea Agents meclizine oral tablet 12.5 mg motion sickness relief(mecliz) oral tablet,chewable 25 mg promethazine vc-codeine oral syrup 6.25-5-10 mg/5 ml promethazine-codeine oral syrup 6.25-10 mg/5 ml promethazine-dm oral syrup 6.25-15 mg/5 ml Last Updated: October 1, 2015

Cardiovascular Agents Dyslipidemics niacin oral capsule, extended release 250 mg, 500 mg niacin oral tablet 100 mg, 50 mg, 500 mg niacin oral tablet extended release 1,000 mg niacin oral tablet extended release 500 mg niacor oral tablet 500 mg slo-niacin oral tablet extended release 250 mg, 750 mg Contraceptives Contraceptives condoms-prem lubricated device Dental And Oral Agents Dental And Oral Agents Dermatological Agents Dermatological Agents, Other amlactin topical lotion 12 % aqua glycolic face topical cream aquabase topical ointment baza protect topical cream benzoyl peroxide topical cleanser 10 %, 5 % benzoyl peroxide topical gel 10 %, 5 % benzoyl peroxide topical lotion 10 %, 5 % bp wash acne treatment topical kit 8-5 % calamine-zinc oxide topical lotion 8-8 % coal tar (bulk) topical solution 20 % dhs sal topical shampoo 3 % dhs tar topical shampoo 0.5 % eucerin topical cream geri-hydrolac topical cream 12 % hydrating healing topical ointment hydrocerin topical lotion lac-hydrin five topical lotion 5 % lantiseptic skin protectant topical cream 50 % pacnex mx topical cleanser 4.25 % proshield plus skin protectant topical cream 1 % salacyn topical cream 6 % salicylic acid topical gel 6 % salicylic acid topical lotion 6 % salicylic acid topical shampoo 6 % sebex topical shampoo 2-2 % Last Updated: October 1, 2015

urea topical cream 40 % urea topical gel 40 % urea topical lotion 40 % zinc oxide topical paste 25 % Dermatological Anti-Inflammatory Agents anti-itch (hc) topical cream 1 % aquanil hc topical lotion 1 % hydrocortisone acetate topical cream 1 % hydrocortisone acetate topical ointment 1 % hydrocortisone topical cream 0.5 % hydrocortisone topical ointment 0.5 %, 1 % Scabicides And Pediculicides complete lice treatment topical kit 4-0.33-0.5 % lice killing topical shampoo 0.33-4 % lice treatment topical liquid 1 % pyrethrin lice treatment m topical liquid 0.33-4 % Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous 12 hour nasal relief spray nasal spray,non-aerosol 0.05 % artificial tears (pf) ophthalmic dropperette ayr allergy & sinus nasal aerosol,spray 2.65 % ayr saline nasal drops 0.65 % biotene moisturizing mouth mucous membrane spray,non-aerosol biotene oralbalance mucous membrane gel ear wax removal drops otic drops 6.5 % eye drops (with povidone) ophthalmic drops 0.05-0.1-1-1 % eye itch relief ophthalmic drops 0.025 % (0.035 %) for sty relief ophthalmic ointment genteal mild to moderate ophthalmic drops 0.3 % genteal gel ophthalmic drops, liquid gel 0.25-0.3 % genteal severe ophthalmic gel 0.3 % hydrogen peroxide solution 3 % hypotears ophthalmic drops 1-1 % mouth kote mucous membrane aerosol,spray muro 128 ophthalmic drops 2 % naphcon-a ophthalmic drops 0.025-0.3 % nasal moisturizing nasal aerosol,spray 0.65 % nasalcrom nasal spray,non-aerosol 5.2 mg/spray (4 %) natural balance ophthalmic drops 0.4 % ocean complete nasal aerosol Last Updated: October 1, 2015

polyvinyl alcohol ophthalmic drops 1.4 % refresh celluvisc ophthalmic dropperette,gel 1 % refresh classic (pf) ophthalmic dropperette 1.4-0.6 % refresh liquigel ophthalmic drops, liquid gel 1 % refresh optive ophthalmic drops 0.5-0.9 % refresh optive sensitive (pf) ophthalmic dropperette 0.5-0.9 % refresh p.m. ophthalmic ointment 57.3-42.5 % refresh plus ophthalmic dropperette 0.5 % refresh tears ophthalmic drops 0.5 % sodium chloride ophthalmic drops 5 % sodium chloride ophthalmic ointment 5 % systane ophthalmic drops 0.4-0.3 % tears again ophthalmic ointment tears naturale forte ophthalmic drops 0.1-0.3-0.2 % tears naturale ii ophthalmic drops theratears ophthalmic dropperette 0.25 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants acid control (ranitidine) oral tablet 150 mg acid reducer (famotidine) oral tablet 10 mg aluminum hydroxide gel oral suspension 320 mg/5 ml antacid anti-gas oral suspension 200-200-20 mg/5 ml antacid exst (ca carb-mag hyd) oral tablet,chewable 675-135 mg antacid extra-strength oral suspension 200-200-20 mg/5 ml calcium antacid oral tablet,chewable 300 mg (750 mg) calcium carbonate oral suspension 500 mg/5 ml (1,250 mg/5 ml) calcium carbonate oral tablet 260 mg calcium (648 mg) calcium carbonate oral tablet 500 mg calcium (1,250 mg) calcium carbonate oral tablet,chewable 400 mg (1,000 mg) calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -400 unit, 600 mg(1,500mg) -400 unit calcium carbonate-vitamin d3 oral tablet,chewable 500 mg(1,250mg) -400 unit calcium carbonate-vitamin d3 oral tablet,chewable 500-100 mg-unit ez char oral suspension for reconstitution 25 gram gaviscon extra strength oral tablet,chewable 160-105 mg insta-char-sorbitol oral suspension 50 gram/240 ml kaopectate (bismuth subsalicy) oral suspension 262 mg/15 ml maalox maximum strength oral suspension 400-400-40 mg/5 ml magox oral tablet 400 mg Last Updated: October 1, 2015

mi-acid oral tablet,chewable 700-300 mg mintox plus oral tablet,chewable 200-200-25 mg pink bismuth oral suspension 525 mg/15 ml sodium bicarbonate oral tablet 325 mg, 650 mg stomach relief oral tablet,chewable 262 mg Gastrointestinal Agents, Other antacid extra-strength oral tablet,chewable 200 mg calcium (500 mg) gas-x extra strength oral capsule 125 mg gas-x extra strength oral tablet,chewable 125 mg gas-x oral tablet,chewable 80 mg imodium a-d oral tablet 2 mg lactaid fast act oral tablet 9,000 unit lactaid fast act oral tablet,chewable 9,000 unit lactase oral tablet 3,000 unit lactrase oral capsule 250 mg loperamide oral liquid 1 mg/5 ml milk digestant oral tablet 25-2 mg simethicone oral capsule 180 mg simethicone oral drops,suspension 40 mg/0.6 ml Laxatives citrucel sugar free oral powder col-rite oral capsule 50 mg docusate sodium oral capsule 100 mg, 250 mg docusate sodium oral liquid 50 mg/5 ml docusate sodium oral syrup 60 mg/15 ml docusol rectal enema 283 mg fiber therapy oral tablet 500 mg fibercon oral tablet 625 mg fleet bisacodyl rectal enema 10 mg/30 ml fleet enema rectal enema 19-7 gram/118 ml fleet glycerin (adult) rectal suppository fleet glycerin (child) rectal suppository fleet mineral oil rectal enema gentle laxative rectal suppository 10 mg konsyl (sugar) oral powder 3.4 gram/12 gram konsyl sugar-free (aspartame) oral powder in packet 3.5 gram konsyl sugar-free oral powder 6 gram/6 gram laxative oral tablet 5 mg laxative oral tablet,delayed release (dr/ec) 5 mg magnesium citrate oral solution Last Updated: October 1, 2015

metamucil fiber singles oral powder in packet 3.4 gram metamucil smooth (with sugar) oral powder in packet 3.4 gram metamucil sugar free oral powder metamucil sugar-free (aspart) oral powder 3.4 gram/5.8 gram milk of magnesia oral suspension 400 mg/5 ml mineral oil oral oil natural fiber laxative (sugar) oral powder , 3.4 gram/11 gram natural fiber laxative oral capsule 0.52 gram natural fiber laxative s/f oral powder 3.4 gram/5.8 gram natural fiber laxative(aspart) oral powder natural veg laxative(dextrose) oral powder natural vegetable (psyllium) oral powder pedia-lax rectal solution 2.8 gram/2.7 ml phosphate laxative oral solution senna laxative oral tablet 25 mg senna oral syrup 8.8 mg/5 ml senna-gen oral tablet 8.6 mg senna-s oral tablet 8.6-50 mg sorbitol solution 70 % Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents alcohol prep pads topical pads, medicated compound w topical adhesive patch,medicated 40 % dextrose oral gel 40 % glucose oral tablet,chewable , 4 gram glycerin (bulk) liquid 100 % thiamine hcl (bulk) powder wart remover topical liquid , 17 % Respiratory Tract Agents Respiratory Tract Agents, Other adult nasal decongestant oral liquid 15 mg/5 ml adult robitussin peak cold dm oral liquid 10-100 mg/5 ml benzonatate oral capsule 100 mg codeine-guaifenesin oral liquid 10-100 mg/5 ml day-time cough oral syrup 5 mg/5 ml delsym 12 hour oral suspension,extended rel 12 hr 30 mg/5 ml dextromethorphan-guaifenesin oral syrup 10-100 mg/5 ml guaifenesin oral liquid 100 mg/5 ml guaifenesin oral tablet 200 mg guaifenesin oral tablet extended release 12hr 600 mg Last Updated: October 1, 2015

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml mucinex cough mini-melts oral granules in packet 5-100 mg mucinex d oral tablet extended release 12 hr 60-600 mg mucinex fast-max dm max oral liquid 5-100 mg/5 ml mucinex mini-melts oral granules in packet 100 mg mucinex oral tablet extended release 12hr 1,200 mg mucus relief dm oral tablet 20-400 mg mucus relief oral tablet 400 mg pro-clear caps oral capsule 9-200 mg pseudoephedrine hcl oral liquid 30 mg/5 ml pseudoephedrine hcl oral tablet 30 mg, 60 mg robitussin pediatric oral syrup 7.5 mg/5 ml sodium chloride inhalation solution for nebulization 0.9 % sudafed 12 hour oral tablet extended release 120 mg tussin cough (dm only) oral liquid 15 mg/5 ml Sleep Disorder Agents Sleep Disorder Agents sleep aid (diphenhydramine) oral capsule 50 mg sleep aid (diphenhydramine) oral tablet 25 mg temazepam oral capsule 15 mg, 30 mg, 7.5 mg Vitamins And Minerals Vitamins And Minerals anticavity fluoride rinse dental solution 0.05 % antioxidant with zn & selenium oral tablet aquadeks oral capsule 100-10 mcg-mg aquadeks oral tablet,chewable 100-5 mcg-mg aquadeks pediatric oral drops 400 mcg/ml ascorbic acid oral tablet extended release 1,000 mg b complete oral tablet b-complex with vitamin c oral tablet beta carotene oral capsule 25,000 unit calci-chew oral tablet,chewable 500 mg calcium (1,250 mg) calcitrate-vitamin d oral tablet 315-250 mg-unit calcium 600 + d(3) oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit calcium 600 oral tablet 600 mg (1,500 mg) calcium 600 with vitamin d3 oral tablet 600 mg(1,500mg) -200 unit calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -200 unit calcium citrate oral tablet 200 mg (950 mg) calcium citrate-vitamin d3 oral tablet 200-125 mg-unit Last Updated: October 1, 2015

calcium citrate-vitamin d3 oral tablet 250 mg calcium- 200 unit, 315-200 mg-unit calcium magnesium oral tablet 500 mg calcium -250 mg caltrate-600 + d vit d3 (800) oral tablet 600 mg(1,500mg) -800 unit centavite a-z complete-mineral oral tablet 27-0.4 mg centrum complete oral tablet 18-400 mg-mcg centrum kids oral tablet,chewable 18 mg iron centrum oral liquid 9 mg iron/15 ml centrum oral tablet,chewable 3,500-18-0.4 unit-mg-mg centrum silver oral tablet 0.4-300-250 mg-mcg-mcg cerovite jr oral tablet,chewable certa plus oral tablet 18-0.4-250 mg-mg-mcg certavite-antioxidant oral tablet 18-400 mg-mcg children's chewable vitamin oral tablet,chewable children's complete vitamin oral tablet,chewable 18 mg iron cholecalciferol (vitamin d3) oral capsule 5,000 unit cholecalciferol (vitamin d3) oral tablet 1,000 unit, 2,000 unit coenzyme q10 oral capsule 100 mg, 200 mg, 30 mg compete oral tablet complete senior oral tablet cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml cyanocobalamin (vitamin b-12) oral tablet 100 mcg, 250 mcg cyanocobalamin (vitamin b-12) oral tablet extended release 1,000 mcg daily multi-vitamin oral tablet daily multi-vitamins/iron oral tablet daily vitamin with iron and ca oral tablet drisdol oral drops 8,000 unit/ml d-vi-sol oral drops 400 unit/ml ellis tonic oral elixir ergocalciferol (vitamin d2) oral capsule 50,000 unit ergocalciferol (vitamin d2) oral tablet 400 unit fergon oral tablet 240 mg (27 mg iron) ferrex 150 plus oral capsule 150-50-50 mg ferrous fumarate oral tablet 324 mg (106 mg iron) ferrous gluconate oral tablet 324 mg (38 mg iron) ferrous sulfate oral drops 15 mg iron (75 mg)/ml ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml ferrous sulfate oral tablet 325 mg (65 mg iron) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) Last Updated: October 1, 2015

fish oil oral capsule 340-1,000 mg folbee oral tablet 2.5-25-1 mg folbee plus oral tablet 5 mg folgard rx oral tablet 2.2-25-1 mg folic acid (bulk) powder 100 % folic acid oral tablet 1 mg, 400 mcg, 800 mcg folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg foltabs 800 oral tablet 0.8-10-115 mg-mg-mcg icaps areds oral tablet,delayed release (dr/ec) 7,160-113-100 unit-mg-unit icaps plus oral tablet mag-delay oral tablet extended release 64 mg magnesium gluconate oral tablet 27 mg (500 mg) magnesium oral tablet 250 mg mephyton oral tablet 5 mg multi-delyn oral liquid multiple vitamins with iron oral tablet,chewable mykidz iron oral suspension 10-1,500-400 mg -unit-unit/2 ml natrol 5-htp oral capsule 50 mg nephrocaps oral capsule 1 mg niacinamide oral tablet 100 mg nu-iron oral capsule 150 mg iron oncovite oral tablet one daily for women oral tablet 18-0.4 mg opti-vitamins oral tablet 1,000 unit-200 mg-60 unit-2 mg oyst-cal-d 500 oral tablet 500 mg(1,250mg) -200 unit oyster shell + d3 oral tablet 250-125 mg-unit oyster shell calcium with d oral tablet 250 (625)-125 mg-unit pedialyte oral solution phos-nak oral powder in packet 280-160-250 mg poly-vi-sol oral drops 750-35-400 unit-mg-unit/ml poly-vitamin with iron oral drops prenatal 19 oral tablet,chewable 29 mg iron- 1 mg prenatal vitamin oral tablet , 27-0.8 mg prenatal vitamin with minerals oral tablet 28-0.8 mg preservision areds oral tablet 7,160-113-100 unit-mg-unit preservision lutein oral capsule 226-200-5-0.8 mg-unit-mg-mg pyridoxine oral tablet 25 mg riboflavin (vitamin b2) oral tablet 100 mg sodium chloride oral tablet 1 gram Last Updated: October 1, 2015

sodium chloride tablet,soluble 1,000 mg stress formula oral tablet stress formula with zinc oral tablet therapeutic liquid oral liquid therapeutic-m vitamin/minerals oral tablet 27-0.4 mg therems-m oral tablet 27-0.4 mg thermotabs oral tablet 287-180-15 mg thiamine hcl oral tablet 50 mg tri-vi-sol oral drops 750 unit-35 mg -400 unit/ml tri-vi-sol with iron oral drops 1,500 unit- 10 mg iron/ml tri-vita oral drops 1,500-35-400 unit-mg-unit/ml v-c forte oral capsule 1 mg vision oral tablet vision plus lutein oral tablet vitamin a oral capsule 10,000 unit, 8,000 unit vitamin b-1 oral tablet 100 mg vitamin b-12 oral tablet 1,000 mcg, 500 mcg vitamin b-6 oral tablet 100 mg, 50 mg vitamin c oral capsule, extended release 500 mg vitamin c oral syrup 500 mg/5 ml vitamin c oral tablet 1,000 mg, 250 mg, 500 mg vitamin c oral tablet extended release 500 mg vitamin c oral tablet,chewable 250 mg, 500 mg vitamin d3 oral capsule 1,000 unit, 2,000 unit vitamin d3 oral tablet 400 unit vitamin e (dl, acetate) oral capsule 400 unit vitamin e oral capsule 1,000 unit, 100 unit, 200 unit, 400 unit vitamin e oral drops 50 unit/ml vitamins & minerals oral tablet women's daily formula oral tablet 27-0.4 mg zinc gluconate oral tablet 50 mg zinc sulfate oral capsule 220 (50) mg zinc sulfate oral tablet 220 mg zinc sulfate-vitamin c oral lozenge 15-30 mg

Last Updated: October 1, 2015