Covered OTC List - OptumRx

1 TennCare Covered OTC List - Effective 8/1/2022 NDCL abel NameGen NamePackage SizeCovered- KidsPA only- KidsCovered- AdultsPA only- AdultsNot Covered -AdultsANTIHELMENTICP lease refer to TennCare's PDL for coverage of the following:PYRANTEL PAMOATEEMERGENCY CONTRACEPTIVESP lease refer to TennCare's PDL for coverage of the following:AFTERA OTCPLAN B ONE-STEP OTCTAKE ACTION OTCCOVID TEST KITSQ uantity Covered per member per month = 8 tests08337000158 INTELISWAB KIT COVID-19 COVID-19 AT HOME ANTIGEN TEST KIT2xx11877001140 BINAXNOW COV KIT HOME TESCOVID-19 AT HOME ANTIGEN TEST KIT2xx14613033972 QUICKVUE HOM KIT COVID-19 COVID-19 AT HOME ANTIGEN TEST KIT2xx50021086001 ELLUME COV19 KIT HOME TESCOVID-19 AT HOME ANTIGEN TEST KIT1xx56964000000 ELLUME COV19 KIT HOME TESCOVID-19 AT HOME ANTIGEN TEST KIT1xx60006019166ON/GO COVID KIT ANTIGENCOVID-19 AT HOME ANTIGEN TEST KIT2xx82607066026 FLOWFLEX KIT TESTCOVID-19 AT HOME ANTIGEN TEST KIT1xx82607066027 FLOWFLEX KIT TESTCOVID-19 AT HOME ANTIGEN TEST KIT2xxDIABETES

2 INSULIN PRODUCTSP lease refer to TennCare's PDL for coverage of the following:HUMULIN 70/30 KWIKPENHUMULIN 70-30 VIALHUMULIN N VIALHUMULIN R VIALNOVOLIN R VIALNOVOLIN 70-30 VIALNOVOLIN N VIAL00169183702 RELION NOVOLIN 70-30 VIALINSULIN NPH HUM/REG INSULIN HM 70-30/ML10xx00169183402 RELION NOVOLIN N 100 UNIT/MLINSULIN NPH HUMAN ISOPHANE 100/ML10xx00169183302 RELION NOVOLIN R 100 UNIT/MLINSULIN REGULAR, HUMAN 100/ML10xxGLUCOSE 38396061375 CVS GLUCOSE CHW FRUITGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG100xx50428001769 CVS GLUCOSE CHW ORANGEGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG50xxProprietary Confidential 2022, OptumRx . All Rights Covered OTC List - Effective 8/1/2022 NDCL abel NameGen NamePackage SizeCovered- KidsPA only- KidsCovered- AdultsPA only- AdultsNot Covered -Adults50428235154 CVS GLUCOSE CHW RASPBERYGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG10xx38396055675 CVS GLUCOSE CHW TROP BLSGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG50xx38396054363 DEX4 CHW GRAPEGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG50xx83744025204 GLUCO BURST GEL 40%DEXTROSE 40 % CHW 4 GMDEXTROSE 4 GM10xx11917006844 GLUCOSE CHW 4 GMDEXTROSE 4 GM10xx11917016741 GLUCOSE CHW 4 GMDEXTROSE 4 GM50xx80681010000 GLUCOSE CHW 4 GMDEXTROSE 4 GM10xx11917004681 GLUCOSE CHW ORANGEDEXTROSE 4 GM50xx11917013294 GLUCOSE CHW ORANGEGLUCOSE-VITAMIN C CHEW TAB 4-6

3 GM-MG50xx11917016740 GLUCOSE CHW ORANGEGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG50xx38396054132 GLUCOSE CHW ORANGEGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG50xx11917016744 GLUCOSE CHW RASPBRRYGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG10xx11917013315 GLUCOSE CHW TROP FRTGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG10xx11917016944 GLUCOSE GEL 15GM/33 GGLUCOSE GEL 15 GM/33GM33xx38396055025 GLUCOSE GEL 40%DEXTROSE 40 %38xx00574007030 GLUTOSE 15 GEL 40%DEXTROSE 40 % 15 GELDEXTROSE 40 % GLUCOSE CHW SOUR APPDEXTROSE 4 GM10xx38396051691 TGT GLUCOSE CHW GRAPEGLUCOSE-VITAMIN C CHEW TAB 4-6 GM-MG10xx56151162501 TRUEPLS GLUC GEL 15/32 MLGLUCOSE GEL 15 GM/32ML32xxSYRINGES/NEEDLES8622704812510 ML SYRINGE MIS LUER LOKSYRINGE, DISPOSABLE, 10 ML100xx082903096261ML TB SYRNG MIS 25GX5/8"TUBERCULIN/ALLERGY SYRINGES,1 ML 25GX5/8"100xx082903059451ML TB SYRNG MIS 27GX1/2"TUBERCULIN/ALLERGY SYRINGES,1 ML 27GX1/2"100xx082903096231ML TB SYRNG MIS 27GX1/2"TUBERCULIN/ALLERGY SYRINGES,1 ML 27GX1/2"100xx082903095803ML LL SYRNG MIS "SYRINGE/NEEDLE (DISP)

4 3 ML 100xx94046000164 ADVOCATE INS ML 30GX5/16"SYRINGE-NEEDLE,INSULIN, ML 30G X5/16"100xx94046000168 ADVOCATE INS 1 ML 31GX5/16"SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"100xx08290301604BD 10 ML SYRINGESYRINGE, DISPOSABLE, 10 ML100xx08290309581BD 3 ML SYRINGE 25GX1"SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX1"100xx08290309582BD 3 ML SYRINGE 25GX1-1/2"SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX1 1/2"100xx08290309598BD 3 ML SYRINGE WITH NEEDLESYRINGE W-NEEDLE,DISPOSAB,3 ML 21 G X 1"100xx08290309577BD 3 ML SYRINGE WITH NEEDLESYRINGE W-NEEDLE,DISPOSAB,3 ML 21GX1 1/2"100xx08290309572BD 3 ML SYRINGE WITH NEEDLESYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX1"100xx08290309574BD 3 ML SYRINGE WITH NEEDLESYRINGE W-NEEDLE,DISPOSAB,3 ML 22GX1 1/2"100xx08290309571BD 3 ML SYRINGE WITH NEEDLESYRINGE W-NEEDLE,DISPOSAB,3 ML 23GX1"100xx08290309588BD 3 ML SYRINGE WITH NEEDLESYRINGE W-NEEDLE,DISPOSAB,3 ML 23GX1"100xx08290324909BD INSULIN SYR ML 6 MMX31 GSYRING-NEEDL,DISP,INSUL, ML 31GX15/64"100xxProprietary Confidential 2022, OptumRx .

5 All Rights Covered OTC List - Effective 8/1/2022 NDCL abel NameGen NamePackage SizeCovered- KidsPA only- KidsCovered- AdultsPA only- AdultsNot Covered -Adults08290328438BD INSULIN SYR ML 8 MMX31 GSYRING-NEEDL,DISP,INSUL, ML 31 GX5/16"100xx08290329461BD INSULIN SYR ML 28GX1/2"SYRINGE-NEEDLE,INSULIN, ML 28GX1/2"100xx08290329465BD INSULIN SYR ML 28GX1/2"SYRINGE-NEEDLE,INSULIN, ML 28GX1/2"100xx08290328468BD INSULIN SYR ML 8 MMX31 GSYRINGE-NEEDLE,INSULIN, ML 31 GX5/16"100xx08290329651BD INSULIN SYR 1 ML 25GX5/8"SYRINGE AND NEEDLE,INSULIN,1ML 25GX5/8"100xx08290329412BD INSULIN SYR 1 ML 27GX5/8"SYRINGE AND NEEDLE,INSULIN,1ML 27GX5/8"100xx08290329410BD INSULIN SYR 1 ML 28GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2"100xx08290329420BD INSULIN SYR 1 ML 28GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2"100xx08290329424BD INSULIN SYR 1 ML 28GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2"100xx08290305930BD INSULIN SYR 1 ML 29GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2"100xx08290329464BD INSULIN SYR 1 ML 29GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2"100xx08290329416BD INSULIN SYR 1 ML 31GX5/16"SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"100xx08290309570BD LUER-LOK SYR 3 ML 25GX5/8"SYRINGE W-NEEDLE,DISPOSAB,3 ML 25GX5/8"100xx08290305937BD SAFTGLD INS ML 31GX5/16 SYRING-NEEDL,DISP,INSUL.

6 ML 31 GX5/16"100xx08290305934BD SAFTGLD INS SYR ML 30 GSYRINGE-NEEDLE,INSULIN, ML 30G X5/16"100xx08290324910BD SYR ML 6 MMX31G (1/2)SYRING-NEEDL,DISP,INSUL, ML 31GX15/64"100xx08290328440BD SYR ML 8 MMX31G (1/2)SYRGE-NDL,INS ML HALF MARK 31 GX5/16"100xx08290328431BD SYRINGE ML ,DISP,INSUL, ML 30GX1/2"100xx08396801900CA INS SYR ML 31GX5/16"SYRINGE-NEEDLE,INSULIN, ML 31 GX5/16"100xx08396802000CA INSULIN SYR 1 ML 31GX5/16"SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"100xx98302013931 COMFORT EZ INS 30GX5/16"SYRING-NEEDL,DISP,INSUL, ML 30G X5/16"100xx98302013930 COMFORT EZ INSULIN SYR MLSYRINGE-NEEDLE,INSULIN, ML 31 GX5/16"100xx98302013932 COMFORT EZ INSULIN SYR MLSYRINGE-NEEDLE,INSULIN, ML 30G X5/16"100xx98302013938 COMFORT EZ SYR 1 ML 29GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2"100xx98302013933 COMFORT EZ SYR 1 ML 30GX5/16"SYRINGE AND NEEDLE,INSULIN.

7 1ML 30G X5/16"100xx98302013919 COMFORT EZ SYR 1 ML 31GX5/16"SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"100xx91237000188 EASY COMFORT ML 31GX5/16"SYRINGE-NEEDLE,INSULIN, ML 31 GX5/16"100xx91237000189 EASY COMFORT 1 ML 31GX5/16"SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"100xx91237000108 EASY COMFORT INSULIN 1 ML SYRSYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16"100xx08496271501 EASY TOUCH 1 ML SYR 27GX1/2"SYRINGE AND NEEDLE,INSULIN,1ML 27GX1/2"100xx08496303601 EASY TOUCH INSULIN SYR MLSYRING-NEEDL,DISP,INSUL, ML 30G X5/16"100xx08496313601 EASY TOUCH INSULIN SYR MLSYRING-NEEDL,DISP,INSUL, ML 31 GX5/16"100xx08496315601 EASY TOUCH INSULIN SYR MLSYRINGE-NEEDLE,INSULIN, ML 31 GX5/16"100xx08496285501 EASY TOUCH INSULIN SYR MLSYRINGE-NEEDLE,INSULIN, ML 28GX1/2"100xx08496295501 EASY TOUCH INSULIN SYR MLSYRINGE-NEEDLE,INSULIN, ML 29 G X1/2"100xx08496305601 EASY TOUCH INSULIN SYR MLSYRINGE-NEEDLE,INSULIN, ML 30G X5/16"100xx08496281501 EASY TOUCH INSULIN SYR 1 MLSYRINGE AND NEEDLE,INSULIN,1ML 28GX1/2"100xx08496291501 EASY TOUCH INSULIN SYR 1 MLSYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2"100xx08496301601 EASY TOUCH INSULIN SYR 1 MLSYRINGE AND NEEDLE,INSULIN,1ML 30G X5/16"100xx08496311611 EASY TOUCH INSULIN SYR 1 MLSYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"10xxProprietary Confidential 2022, OptumRx .

8 All Rights Covered OTC List - Effective 8/1/2022 NDCL abel NameGen NamePackage SizeCovered- KidsPA only- KidsCovered- AdultsPA only- AdultsNot Covered -Adults08496311601 EASY-TOUCH INS 1 ML 31GX5/16"SYRINGE AND NEEDLE,INSULIN,1ML 31 GX5/16"100xx38396044964 GNP INSUL SYR ML 31GX5/16"SYRING-NEEDL,DISP,INSUL, ML 31 GX5/16"100xx38396044364 GNP ULTRA COMFORT ML SYRSYRINGE-NEEDLE,INSULIN, ML 29 GAUGE100xx38396044764 GNP ULTRA COMFORT 1 ML SYRINGESYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE100xx11917002529 INSULIN 1 ML SYRINGESYRINGE AND NEEDLE,INSULIN,1ML 30 GAUGE100xx11917001489 INSULIN 1/2 ML SYRINGESYRINGE-NEEDLE,INSULIN, ML 29 GAUGE100xx11917002528 INSULIN 1/2 ML SYRINGESYRINGE-NEEDLE,INSULIN, ML 30 GAUGE100xx11917001492 INSULIN 3/10 ML SYRINGESYRING-NEEDL,DISP,INSUL, ML 29 GAUGE100xx11917002527 INSULIN 3/10 ML SYRINGESYRING-NEEDL,DISP,INSUL, ML 30 GAUGE100xx90166005635 INSULIN SYRG MIS ,DISP,INSUL, ML 30G X5/16"100xx90166045035 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 30 X 1/2"100xx08396801800 INSULIN SYRG MIS ,INS ML HALF MARK 31 GX5/16"100xx08290490901 INSULIN SYRG MIS ,DISP,INSUL, ML 31GX15/64"10xx81131013839 INSULIN SYRG MIS ,DISP,INSUL, ML 31GX15/64"10xx90166025635 INSULIN SYRG MIS ,DISP,INSUL, ML 31 GX5/16"100xx98302013920 INSULIN SYRG MIS ,DISP,INSUL.

9 ML 31 GX5/16"100xx81131031165 INSULIN SYRG MIS ,INSULIN, ML 29 G X1/2"10xx08290305932 INSULIN SYRG MIS ,INSULIN, ML 29 G X1/2"100xx89134052802 INSULIN SYRG MIS ,INSULIN, ML 29 G X1/2"200xx08396800700 INSULIN SYRG MIS ,INSULIN, ML 30G X5/16"100xx08290328279 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 30 X 1/2"90xx08222093554 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 30 X 1/2"100xx08290328466 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 30 X 1/2"100xx38396040725 INSULIN SYRG MIS , DISPOSABLE, 10 ML100xx89134074202 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 31 X 5/16"200xx08290324911 INSULIN SYRG MIS SYRINGE/NEEDLE,1/2 ML 31 X 15/64"100xx08290491101 INSULIN SYRG MIS SYRINGE/NEEDLE,1/2 ML 31 X 15/64"10xx08484990435 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 31 X 5/16"100xx11917004814 INSULIN SYRG MIS SYRINGE/NEEDLE, ML 31 X 5/16"100xx81131013836 INSULIN SYRG MIS SYRINGE/NEEDLE,1/2 ML 31 X 15/64"100xx81131013837 INSULIN SYRG MIS SYRINGE/NEEDLE,1/2 ML 31 X 15/64"10xx08290329622 INSULIN SYRG MIS 1ML/25 GSYRING-NEEDL,DISP,INSUL,1 ML 25 G X1"100xx11917001487 INSULIN SYRG MIS 1ML/29 GSYRINGE AND NEEDLE,INSULIN,1ML 29 G X1/2"100xx08222093158 INSULIN SYRG MIS 1ML/30 GINSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2"100xx08290328411 INSULIN SYRG MIS 1ML/30 GINSULIN SYRINGE/NEEDLE,1 ML, 30G X 1/2"100xx0849630150