HMO - Simply Healthcare Plans

CTLFLH-1NAME (NOMBRE)_______________________________________________________________ADDRESS (DIRECCIÓN) _____________________________________________________________________________________________________________________________________MEMBER ID ( NUMERO DE MEMBRESIA) _________________ PHONE (TELEFONO)__________________ItemAntacids / Digestion / Laxatives(Antiácidos / Digestión / Laxantes)QTY PriceCantidad PrecioA1 EFFERVESCENT PAIN RELIEF 36 ct 4.69A4 CALCIUM ANTACID ES TABLETS (MIXED FRUIT) 96 ct 4.29A7 RANITIDINE 75MG 30 ct 9.19A8 ANTIACID TABS 100 ct 6.39D7 BILIARY SALTS 30 6.99L1 BISACODYL TABS 100 ct 8.89L2 STOOL SOFTENER 60 ct 6.69L11 COLON CLEANSER 120 ct 7.99L4 NATURAL VEGETABLE LAXATIVE 100 ct 11.99L5 CASCARA SAGRADA 90 ct 5.99L6 GLYCERIN SUPPOSITORIES ADULT 25 ct 3.69L7 FIBER CAPSULES 160 ct 11.49L13 ENEMA SINGLE 1 ct 1.99D1 ANTI-DIARRHEAL TABLETS 18 ct 5.59D3 PINK BISMUTH TABLETS CHEWABLE 30 ct 4.39D4 GAS RELIEF E/S 30 ct 5.59Pain Relief (Analgésicos)P1 IBUPROFEN TABS 200MG 50 ct 4.19P11 NON-ASPIRIN CHEW 80MG 30 ct 4.99P13 NON-ASPIRIN SUSPENSION CHERRY 4 oz 3.29P14 HOT AND COLD PATCHES 5 ct 7.99P17 MIGRAINE RELIEF CAPLETS 100 ct 6.69P19 NAPROXEN 220MG 10 ct 7.89P20 GLUCOSE CHEWABLE TABS ORANGE 10 ct 2.29P2 ASPIRIN 325MG 100 ct 2.79P9 ASPIRIN COATED 100 ct 1.99P3 ENTERIC ASPIRIN 325MG 100 ct 5.39P4 LOW-DOSE ASPIRIN ENTERIC COATED 120 ct 5.49P44 THERAPEUTIC BLUE GEL 4 oz 4.19P6 ACETAMINOPHEN 500MG TABLETS 100 ct 6.99P8 CHEWABLE ASPIRIN 81MG 36 ct 5.39Cough / Cold / Allergy (Tos / Catarros / Alergia)C1 NASAL SPRAY REGULAR 1 oz 4.39C10 LORATIDINE 10MG 10 ct 8.89C11 SORE THROAT LOZENGES 18 ct 3.29C12 TUSSIN EXPECTORANT 4 oz 4.39C13 TUSSIN DM 4 oz 4.39C20 CH.ALLERGY ELIXIR NON PSEUDO 4OZ 4.59C14 MAPAP COLD MULTI SYMPTOM MAJOR 24 ct 4.29C16 NASAL DECONGESTANT PSEUDO FREE 18 ct 4.39C19 CHEST CONGESTANT RELIEF 400MG 50 ct 8.49C2 ALLERGY CAPSULES 24 ct 3.29C24 DAYTIME PE SOFTGELS 12 ct 4.39C30 SINUS AND ALLERGY TABS PSEUDO FREE 24 ct 5.59C35 TUSSIN SUGAR FREE 4 oz 4.39C52 SALINE NASAL SPRAY 1.5 oz 3.69C53 CETIRIZINE 10MG TABLETS 14 ct 10.99C54 SINUS CONGESTION & PAIN NIGHTTIME (PSE) 12 ct 4.19C7 MEDICATED CHEST RUB 4 oz 4.99H5471_OTC 005ItemFirst Aid QTY PricePrimeros Auxilios Cantidad PrecioC8 THERMOMETER DIGITAL 1 ct 5.39F1 BANDAGE SELF-ADHERANT 3" 3.29F11 ANTI-ITCH CREAM 1 oz 3.29F2 MUSCLE RUB 4 oz 5.29F21 PV IODINE 1 oz 2.19F22 PV MERCUROCHROME 1 oz 1.99F24 PV FIRST-AID KIT Each 6.69F29 ANTI-ITCH GEL 4 oz 4.69F34 HOT/COLD THERAPY 1 ct 5.39F35 MEDICATED CALLOUS REMOVER 6 ct 3.19F4 CALAMINE LOTION 6 oz 2.19F5 HYDROCORTISONE CREAM 1% 1 oz 4.99F61 TRIPLE ANTIBIOTIC OINTMENT PLUS 1 oz 6.69F62 FIRST AID TAPE .5"X5 yd 1.99F7 TRIPLE ANTIBIOTIC OINTMENT .5 oz 4.39F9 CLEAR PLASTIC BANDAGES 30 ct 2.49Dental Teeth Related (Dental)B2 DENTURE TABS 40 ct 5.39B6 DENTURE ADHESIVE REGULAR 2.5 oz 4.69M2 TOOTHBRUSH 1ea .99M35 DENTAL FLOSS WAXED 100 yd 1.99Anti-Hemorroidals (Contra Hemorroides)H3 HEMORROIDAL OINTMENT 2 oz 6.69Anti-Fungals (Antimicóticos)O1 CLOTRIMAZOLE 1 oz 9.99O2 TOLNAFTATE 1 oz 5.59M25 CLOTRIMAZOLE VAG. 30 gr 6.39Ear and Eye Care (Cuidado de la Vista y Oido)E1 ARTIFICIAL TEARS .5 oz 4.29E2 EYE DROPS .5 ml 3.69E3 EARACHE DROPS .4 oz 7.99B16 EAR WAX DROP .5 oz 3.99MiscellaneousB18 VITAMIN E CREAM 4 oz 4.29M1 SUNBLOCK SPF 30 4 oz 4.29M3 LIP BALM .5 oz 1.19M6 SLEEP AID 16 ct 4.99M50 LUBRICATING JELLY 4 oz 3.69

Vitamins / Minerals (Vitamins / Minerales) • Dual Purpose Items* (Producto de doble propósito*)V1 B-COMPLEX VITAMIN 100% RDA* 100 ct 4.29 V26 VITAMIN D 400 IU* 100 ct 3.19V10 GLUCOSAMIN/CHONDROITIN* 50 ct 10.69 V22 COLLAGEN 500MG* 100 ct 8.79V11 CALCIUM 500 MG +D* 75 ct 5.39 V3 CALCIUM CARBONATE + D* 60 ct 4.29V14 A 10,000 IU NATURAL* 100 ct 3.69 V5 COENZYME Q-10 10MG* 30 ct 5.39V15 CHEWABLE MULTIVITAMINS* 100 ct 6.19 V6 DAILY MULTI VITAMIN* 100 ct 4.59V16 VITAMIN E 400 IU* 100 ct 9.99 V7 COMPLETE SENIOR VITAMINS* 100 ct 8.39V17 FOLIC ACID 800MCG* 100 ct 3.19 V32 VITAMIN D 1,000 IU* 100 CT 3.49V18 IRON SUPPLEMENT* 100 ct 5.39 V33 VITAMIN B-12 1000 MCG* 100 CT 7.99V19 OMEGA-3 FISH OIL 1000MG* 100 ct 7.49 V34 RESVERATOL XTRA FORMULA 30 CAPS* 30 CT 4.99V2 VITAMIN C 500MG* 100 ct 5.89 V35 MAGNESIUM 500 MG* 100 CT 3.99V20 SOYA LECITHIN 1200* 100 ct 6.99 V36 ZINC GLUCONATE 50 MG* 100 CT 4.69V21 URINOZINC CAPSULES* 60 ct 14.99 V38 CO-Q10 30MG* 90 CT 9.99B72 BLOOD PRESSURE MONITOR* Each 15.99*Must consult with Primary Care Physician prior to ordering a dual-purpose item. *Consulte su Médico Primario antes de ordenar un producto de doble propósito.A Simply Healthcare Plans is a Coordinated Care plan with a Medicare contract.Simply Healthcare Plans es un plan de Atención Médica Coordinada con un contrato Medicare.YOU WILL RECEIVE THE GENERIC EQUIVALENT OF ALL ITEMS.USTEDUSTEDRECIBIRARECIBIRAELELGENERICOGENERICODE TODOSDE TODOSLOS PRODUCTOS.LOS PRODUCTOS.2013 OVER-THE-COUNTER (OTC) ORDER FORM$15 each monthSimply More (HMO) - Hillsborough, Hernando, Pasco, PinellasORDER BY MAIL:1. Clearly write your name, address, telephone numberthe and space member at the top ID of the in form. the space Your shipping at the address top of must the be form. the sameYour shipping address must be the same as theaddress in your member record. We cannot fill yourorder if your address is not the same.2. Check (√) items you want on the order form thatadd up to your benefit amount or less.3. Fold this form and put in an envelope. Place a first classpostage stamp on the envelope and send it to:OTC Health Solutions9400 NW 104 StreetMedley, FL 33178ORDER BY PHONE:To place your order by phone, call 1-877-577-0115,TTY 711 from 8 a.m. to 8 p.m. E.S.T. Monday throughFriday.ORDER BY FAX:Fax the completed order form to 1-877-577-0114 any time.PICK UP AT ANY OF THE NAVARRO DISCOUNTPHARMACIES STORESEligible Items: Each eligible OTC item is either a medicine, ointment or spray, or used for treatment of a condition whichis addressed by a medicine, ointment or spray, which has active medical ingredients. First aid supplies includingbandages, dressings, and non-sport tapes are also eligible. Non-eligible items will not be covered.*Dual-Purpose items: Prior to order/purchase (1) the member must have appropriate conversations with the member’spersonal provider, and (2) the member’s personal provider orally recommends the OTC item for a specific diagnosablecondition. Other items on this order form are classified as eligible. These eligible items may be ordered/purchased bythe member without further action.Orders will be shipped to your home at no extra charge. Please allow 2 - 3 weeks for delivery. This product list issubject to change. This benefit is only available if your plan offers the OTC service as a benefit. Please review yourEvidence of Coverage document for more information.This information is available for free in other languages. Please contact our Member Services Department at 1-877-577-0115TTY: 711 for more information. From October 1, 2012 until February 14, 2013 our hours of operation are from 8 a.m. to8 p.m., 7 days a week. From February 15, 2013 until September 30, 2013 our hours of operation is Monday thru Fridayfrom 8 a.m. to 8 p.m. After hours, on weekends and holidays you can leave us a voice mail message and we will returnyour call the next business day.Esta información esta disponible de gratis en otros idiomas. Por favor póngase en contacto con nuestro Departamentode Servicios para Afiliados llamando al 1-877-577-0115, TTY 711 para obtener información adicional. Desde Octubre 1,2012 hasta Febrero 14, 2013 el horario de atención es de 8 a.m. a 8 p.m. los siete días a la semana. A partir de Febrero15, 2013 hasta Septiembre 30, 2013 el horario de atención es de Lunes a Viernes de 8 a.m. a 8 p.m. Después del horariode trabajo y los sábados, domingos y dias festivos puede dejarnos un mensaje de voz y nosotros le devolveremos lallamada el siguiente día laboral.