Over-the-Counter Pharmacy Order Form

Transcription

1 Over-the-Counter Pharmacy Order Form If you have chosen the Over-the-Counter Merchandise option from PHP (HMO SNP) s Health and Wellness Benefit, you may order up to $200 worth of over-the-counter (OTC) pharmacy items for the plan year. You may order items in whatever increment you d like up to $200 total for the plan year. A plan year is January 1 through December 31. OTC items are fulfilled by AHF Pharmacy. All available OTC items are listed on this form. There is no cost to you for your order or its delivery. The price shown for each item on this form is approximate and is subject to change. The price listed should be used as a guide in helping you select the items you want and figuring the approximate cost of your order. The actual price of your order will likely differ and will be shown on the receipt you get with your items. AHF Pharmacy reserves the right to substitute brand name items with like items when necessary. This OTC item list is effect July 1, The list of available OTC items and/or pricing may change during the year. To see the most current list of OTC items available and pricing, go to the plan s website at To place your order, complete Part I and Part II of the form, then go to Part III and select the items and quantities you want. In Part IV, compute the total value of the order. Please allow seven (7) days for delivery of your order. You may place your order through any AHF Pharmacy in person or by mail, phone or fax. See the insert page for the directory of AHF Pharmacies in Los Angeles County. If you need help finding an AHF Pharmacy, please call Member Services at (800) (TTY 711), 8:00 a.m. to 8:00 p.m., seven days a week. If you run out of order forms or need help, please call Member Services at (800) (TTY 711), 8:00 a.m. to 8:00 p.m., seven days a week, to request more forms. You can also download and print forms from the plan s website at Part I Your Information. Please print legibly. Orders cannot be delivered to post office boxes. Date of Birth (MM/DD/YY) Home Phone Alternate Phone Date of Order Signature Part II Indicate how you want to receive your order. Orders cannot be delivered to post office boxes. Pick up at pharmacy. Specify which pharmacy. Refer to the insert page for pharmacy locations: Deliver to: Street Address (No PO Boxes) Apt. City State Zip Effective July 1, 2017 Page 1 of 4 H5852_

2 Part II Select the items you want to order by placing a quantity number desired in the Qty. Ordered column. Multiply Qty. Ordered by Item to get the of the item(s) you want and fill in the column. Remember, you can order up to $200 worth of items for the plan year. Effective July 1, 2017 Page 2 of 4 H5852_ Qty./ Size Item Qty. Ordered Allergy Prevention and Treatment/Antihistamines Claritin Loratadine 10 mg Tablets 30 $1.89 X = Benadryl Tablets Diphenhydramine 25 mg Caplets 24 $0.97 X = Benadryl Elixir Diphenhydramine Liquid -- Alcohol Free 4 oz $0.99 X = Sudafed PE Phenylephrine HCL 10mg Tablets 18 $0.72 X = Analgesics/Antipyretics/NSAIDS Bayer Aspirin Aspirin 325 mg Tablets 100 $0.99 X = Bayer EC Aspirin (Adult Regimen) Aspirin EC 81 mg Tablets 120 $1.97 X = Bengay Muscle Rub 3 oz $1.92 X = Capsaicin Capsaicin 0.025% cream 60 g $7.63 X = Tylenol Extra Strength Caplets Acetaminophen Extra Strength 500 mg Caplets 50 $2.25 X = Advil Tablets Ibuprofen 200 mg FC Tablets 50 $1.14 X = Aleve Caplets Naproxen Sodium 220 mg Caplets 50 $2.48 X = Excedrin Acetaminophen, Aspirin, Caffeine 250 mg/250 mg/65 mg Tablet 100 $2.15 X = Antacids and Acid Reducers Mylicon Simethicone 80 mg 100 $1.64 X = Prilosec (Limit two per month) Omeprazole 20 mg 14 $8.25 X = Tums Tablets Antacid Chewable Tablets 150 $2.74 X = Zantac Tablets Ranitidine HCL 75 mg Tablets 30 $2.33 X = Anti-Arthritis Glucosamine/ Chondroitin Glucosamine/Chondroitin 100 mg Tablets 60 $8.53 X = Antibiotics (Topical) Neosporin Ointment Triple Antibiotic Ointment 1 oz $2.91 X = Anticandidals (Yeast) / Antifungals Clotrimazole Vaginal 1% Cream Gyne-Lotrimin Cream Application 45 g $2.60 X = Tinactin Cream Tolnaftate 1% Cream 1 oz $4.45 X = Antidiarrheals and Laxatives Colace Softgels Doc-Q-Lace 100 mg Softgels 100 $2.14 X = Dulcolax Suppositories Bisac-Evac 10 mg Rectal Suppositories 12 $0.99 X = Dulcolax Tablets Bisacodyl EC 5 mg 100 $1.73 X = Imodium Caplets Anti-Diarrheal 2 mg Caplets 12 $2.18 X = Pepto-Bismol Liquid Bismatrol Suspension 8 oz $1.47 X =

3 Qty./ Item Qty. Size Ordered Miralax Polyethylene Glycol 3350, 17 g/capful 238 g $7.54 X = Anti-Itch Lotions and Cream Calamine Lotion Calamine Lotion 6 oz $1.38 X = Aveeno Anti-Itch Lotion Colloidal Oatmeal Lotion 7.5 oz $3.75 X = Cold Remedies Mucinex Guaifenesin 600 mg Tablets 14 $10.95 X = Afrin Nasal Spray Nasal Decongestant Spray 30 ml $1.02 X = Chloraseptic Throat Lozenges Cherry 18 $2.68 X = Robitussin Syrup Guaifenesin 100 mg/tsp 4 oz $0.93 X = Camphor 4.8%, Eucalyptus Oil 1.2%, Vicks Menthol, 2.6% Ointment 50 g $2.56 X = Dental Care Anbesol Anbesol 0.3 oz $5.04 X = Mouthwash Mouthwash 500 ml $2.05 X = Toothbrush Toothbrush 1 $0.36 X = Toothpaste Toothpaste 113 g $1.71 X = Waxed Dental Floss Waxed Dental Floss 55 yd $1.14 X = Ear Care Ear Syringe Ear Syringe 1 $2.48 X = Debrox Ear Wax Removal Drops Carbamide Peroxide 0.5 oz $1.19 X = Eye Care Dry Eye Drops Artificial Tears 0.5 oz $1.77 X = Visine Drops Sterile Eye Drops Irritation Relief 0.5 oz $1.72 X = Fiber Supplements Metamucil Fiber Capsules 100 $5.99 X = First Aid/Medical Supplies Ace Bandage Athletic Bandage 1 $3.52 X = Adhesive Tape Adhesive Tape 1 Inch x 2 Yards 1 $1.57 X = Alcohol Swabs * Alcohol Swabs 100 $1.28 X = Band-Aids Adhesive Bandage 60 $2.21 X = Cotton Balls Cotton Balls 100 $1.17 X = Cotton Swabs Cotton Swabs 170 $0.93 X = Ice Bag Ice Bag 1 $3.97 X = J & J Gauze * Stretch Gauze Bandage 2 In x 5 Yd 1 $1.16 X = Oral Thermometer Oral Thermometer 1 $1.84 X = Healing Ointments Aquaphor Skin Healing Ointment Aquaphor ointment 50 g $4.05 X = Eucerin Moisturizing Lotion 4 oz $5.96 X = Hemorrhoidal Preparations Preparation H Prompt Relief Hemorrhoid Ointment 57 g $2.18 X = Effective July 1, 2017 Page 3 of 4 H5852_

4 Qty./ Size Item Qty. Ordered Incontinence Supplies Leader Fitted Briefs Small/Medium case 4x20 ct $50.33 X = Leader Fitted Briefs Large case 4x16 ct $50.33 X = Insect Repellent OFF! Deep Woods 25% DEET; Aerosol Spray 6 oz $5.31 X = OFF! Active 15% DEET; Sweat-Resistant; Spray 6 oz $4.79 X = Lactose Intolerance Lactaid Dairy Relief Capsule 60 $4.66 X = Pediculosis RID Extra Strength Shampoo Lice Treatment Maximum Strength Cream 4 oz $4.63 X = Sun Protection Coppertone Sport Sunblock Lotion SPF 30 Sunblock SPF 30 8 oz $4.95 X = Topical Steroids Cortaid Cream Hydrocortisone 1% Maximum Strength Cream 28 g $1.52 X = Vitamins and Minerals (If pregnant or in reproductive years, check with your PCP before using any supplements) B-Complex with B-12 Tablets B-Complex/B-12 Tablets 100 $3.59 X = Centrum Tablets Multivitamin Tables 200 $11.99 X = Stuart Prenatal Tablets Prenatal -S Tablets 100 $6.89 X = Magnesium Magnesium 400mg 120 $3.09 X = Vitamin C Tablets C Chewable 500 mg Tablets 100 $2.98 X = Vitamin E Softgels E DL Alpha 400 IU SG Caplets 100 $4.38 X = Vitamin A 10,000 IU Vitamin A 10,000 IU 100 $2.20 X = Caltrate 600 Calcium 600 D Tablets 60 $1.15 X = Therapeutic M. High Potency Multivitamin w/minerals 100 $1.15 X = * These items are covered under your Part D benefit if you are insulin-dependent (diabetic). Part III Add the price from each item together to total your order. Remember you may order up to $200 worth of items per year in as many increments as you like. Order Total $ PHP is an HMO plan with a Medicare contract. Enrollment in PHP depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of every year. Effective July 1, 2017 Page 4 of 4 H5852_

5 You may place and pick up your order at any of the Los Angeles County AHF Pharmacies listed below. To place your order, take your completed order form to the pharmacy of your choice. You can also call your order into the pharmacy of your choice, or mail or fax it. AHF Pharmacy - Downtown Los Angeles 1400 S. Grand Ave., Ste. 801 Los Angeles, CA Phone: (213) Fax: (213) AHF Pharmacy East Los Angeles 5356 Whittier Blvd. Los Angeles, CA Phone: (323) Fax: (323) AHF Pharmacy - West Hollywood 8212 Santa Monica Blvd. West Hollywood, CA Phone: (323) Fax: (323) AHF Pharmacy - Westside 99 N. La Cienega Blvd., Ste. 200 Beverly Hills, CA Phone: (310) Fax: (310) AHF Pharmacy - Hollywood 1300 N. Vermont Ave., Ste. 407 Los Angeles, CA Phone: (323) Fax: (323) AHF Pharmacy - Long Beach 3500 Pacific Coast Hwy Long Beach, CA Phone: (562) Fax: (562) AHF Pharmacy - San Fernando Valley 4940 Van Nuys Blvd., Ste. 200 Sherman Oaks, CA Phone: (818) Fax: (818) AHF Pharmacy - Sunset 6210 W. Sunset Blvd. Los Angeles, CA Phone: (323) Fax: (323) OTC Order Form Insert H5852_