Items and Their OTC Status

40.4 – Items and Their OTC Status (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) Table IV below displays examples of categories of OTC items that MA plans may cover as supplemental benefits, and also provides guidance to help plans distinguish between items that would be eligible for coverage and those that would not. Those items shown as “eligible” OTC items may be purchased by the enrollee without restriction. Those items shown as “dual purpose” may be purchased only after the enrollee discusses the purchase with their personal provider (or satisfies other requirements the plan may specify, to ensure that the covered item or service is health-related and appropriate for the enrollee). The plan may require a written note from, or a verbal discussion with, the enrollee’s personal health care provider as a condition for purchase of eligible or dual purpose items. Table V displays examples of categories of items that are not eligible as OTC supplemental benefits because they are not “health benefits” within the meaning of the statute. Note: Tables IV and V display categories of items rather than listing individual items. For example, a plan that chooses to offer cough medicines as a Part C OTC supplemental benefit must cover all items and brands and may not choose to cover only specified items or brands, in order to meet access requirements for the benefit. The plan must clearly indicate in its OTC listing the items and drugs that, under certain circumstances, may be covered under either Part B or Part D. When an item is covered by Part B or Part D due to particular circumstances, the enrollee would not use his or her OTC benefit to obtain the item because it is Medicare-covered in those circumstances, and not part of the supplemental OTC benefit. For example, gauze may be covered under Part B when it is being used as prescribed, to perform surgical wound dressing changes. Table IV: Eligibility Status of OTC Items Eligible? Category Examples of items and drugs included in this category Dual Purpose Minerals and vitamins Dual Purpose In home testing and monitoring Equipment to monitor blood pressure, cholesterol, blood sugar, to test for pregnancy, HIV, fecal occult blood. Bathroom scales may be covered for enrollees with CHF or liver disease to monitor fluid retention Dual Purpose Hormone replacement Phytohormone, natural progesterone, DHEA Dual Purpose Weight loss items Appetite suppressants, fat absorption inhibitors, food scales Eligible Fiber supplements Pills, powders and non-food liquids that supplement fiber in the diet Eligible First Aid supplies Adhesive bandages, gauze and other dressings, antibacterial ointment, peroxide, thermometers, non-sport tapes Eligible Incontinence supplies Diapers, pads Eligible Medicines, ointments and sprays with active medical ingredients that alleviate symptoms Antacids, analgesics, anti-bacterials, anti-histamines, anti-inflammatories, antiseptics, decongestants, sleep aids Eligible Topical Sunscreen Eligible Supportive items for comfort Compression hosiery, rib belts, elastic knee support Eligible Mouth care Toothbrushes, toothpaste, floss, denture adhesives, denture cleaners and gum stimulators Table V: OTC Items Not Eligible as a Supplemental Benefit