Over-the-Counter (OTC) Benefit Catalog

Transcription

1 Over-the-Counter (OTC) Benefit Catalog As a member of AmeriHealth Caritas VIP Care, you have a quarterly over-the-counter (OTC) benefit which allows you to order OTC products such as bandages, cold and allergy medicines, pain relievers, and vitamins, at no cost to you. Please check your Summary of Benefits or Evidence of Coverage to see what your quarterly benefit amount is. Benefit amounts do not roll over, so be sure to use them before the end of every quarter. Ordering is easy. Just call the toll-free number or fill out and mail the order form provided. Your order will be shipped directly to your door. You can order OTC products without having to talk with your doctor, but we always recommend that you talk with your doctor before starting a new product regimen. AmeriHealth Caritas VIP Care is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the state and Medicare. This information is not a complete description of benefits. Call Member Services at (TTY 711), 8 a.m. 8 p.m., seven days a week, for more information. Y0093_CAT_2442_NM

2 HELPFUL INFORMATION You can place your order by mail or phone. To place an order by mail, please mail your order form to OTC Servicing Center, P.O. Box , Weston, FL To place your order over the phone, OTC advocates are available Monday Friday, 8 a.m. to 11 p.m. ET, at (TTY 711). After your order is placed, please allow seven to 10 business days for delivery. Returns are not accepted. OTC items are available through mail order only. Products may not be purchased at a local retail pharmacy or through any source other than the AmeriHealth Caritas VIP Care OTC Benefit Catalog. If you disenroll from AmeriHealth Caritas VIP Care, your OTC benefit will automatically terminate. Orders may only be placed by a member, a member s authorized representative who has been verbally approved by the member at the time of the order, or a member s power of attorney representative whose name is on file. OTC products are intended for members use only. AmeriHealth Caritas VIP Care prohibits the purchase of OTC items for family members and friends. We encourage you to use your full quarterly benefit amount in one order. This benefit amount does not roll over from quarter to quarter. If you place your order using an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29, but we receive it on July 1, your order total will be applied to your July (or third-quarter) benefit, not your June (or second-quarter) benefit. If you re getting close to the end of the quarter and you do not think your order form will be received in time, please call in your order. Our OTC advocates are available to take your order Monday Friday, from 8 a.m. 11 p.m. ET, at (TTY 711). Your quarterly order total may not exceed the quarterly benefit amount. You may not use cash, checks, money orders, or any other form of personal payment to purchase items under this OTC benefit. Items in the OTC Benefit Catalog may change throughout the year. A copy of this catalog is also available on the AmeriHealth Caritas VIP Care website at For up-to-date information, please call our OTC advocates Monday Friday, from 8 a.m. 11 p.m. ET, at (TTY 711). H4227_002-CAT

3 OTC ALLERGY, COLD, FLU DECONGESTANT, AND SINUS TREATMENTS Allergy relief nasal spray, 24 hour, fluticasone spray 50 mcg $25.00 propionate All-night cold and flu oz 12.5 mg, 30 mg, $ mg Cetirizine HCL allergy relief* count 10 mg $8.00 Chlorpheniramine maleate antihistamine count 4 mg $9.00 Cough and cold for high blood pressure count $10.00 Cough drops, cherry count 5.8 mg $5.00 Cough drops, sugar free, cherry count 5.8 mg $5.00 Cough syrup, expectorant oz 200 mg, 10 ml $7.00 Cromolyn sodium allergy nasal spray ml $18.00 Diabetic Tussin DM oz $10.00 Diphenhydramine antihistamine count 25 mg $10.00 Diphenhydramine antihistamine count 25 mg $5.00 Guaifenesin cough expectorant count 200 mg $11.00 Loratadine allergy relief count 10 mg $15.00 Mucus relief DM expectorant and count 400 mg, 20 mg $11.00 cough suppressant Mucus relief DM expectorant and cough suppressant, extended release count 1200 mg, 60 mg $16.00 Multi-symptom cold formula count 5 mg, 10 mg, 325 mg $10.00 Nasal decongestant spray, 12 hour oz.05% $9.00 Nasal spray, saline oz.65% $8.00 Personal steam inhaler count $50.00 Sore throat lozenges, cherry count $8.00 Sore throat spray, cherry oz $7.50 Sudogest PE nasal and sinus decongestant count 10 mg $9.00 Vapor rub oz 4.7%, 1% $8.00 ANTACIDS AND ACID REDUCERS Antacid/anti-gas liquid oz $7.50 Antacid chewables count 500 mg $8.00 Effervescent pain reliever count $8.00 Esomeprazole magnesium, 24-hour delayedrelease count 20 mg $23.00 acid reducer* Famotidine acid reducer* count 10 mg $10.00 Omeprazole acid reducer* count 20 mg $26.00 Omeprazole acid reducer, delayed release, count 20 mg $26.00 dissolvable* Ranitidine acid reducer count 75 mg $9.00 Simethicone anti-gas chewables count 80 mg $8.00 ANTICANDIDAL (YEAST) S Clotrimazole seven-day treatment vaginal cream gm 1% $11.00 (with applicator) Micanozole three-day treatment vaginal cream (with applicator) kit 2% $17.00 ANTIDIARRHEAL, LAXATIVE, AND DIGESTIVE HEALTH S Bisacodyl enteric coated laxative count 5 mg $7.00 Bismatrol chewable tablets count 262 mg $9.00 Docusate sodium stool softener count 100 mg $7.00 Glycerin suppository count 2 gm $8.00 Lactase capsules count 9000 FCC units $14.00 Loperamide HCL anti-diarrheal* count 2 mg $7.00 Milk of magnesia oz 400 mg $8.00 Natural vegetable laxative oz $14.00 Pink bismuth oz 525 mg, 30 ml $8.00 Polycarbophil (fiber tablets) count 625 mg $14.00 Senna plus stool softener plus laxative count 8.6 mg, 50 mg $10.00

4 OTC ANTIFUNGAL AND ANTI-ITCH S Clotrimazole antifungal athlete s foot cream oz 1% $9.00 Diphenhydramine HCL/zinc acetate oz $7.00 anti-itch cream Hydrocortisone 1% cream oz 1% $6.00 Medicated antifungal foot powder spray oz $10.50 Miconazole nitrate 2% antifungal cream oz 2% $10.00 Terbinafine HCL antifungal cream oz 1% $12.00 Tolnaftate antifungal cream oz 1% $10.00 COLD SORE AND OTHER MEDICATED LIP S Abreva gm 10% $28.00 Blistex lip ointment gm $6.00 Herpecin L lip balm oz 1% $11.00 DENTAL OR DENTURE CARE S Denture brush count $6.00 Denture cleaning tablets count $7.00 Efferdent Plus mint tablets count $8.00 Effergrip denture cream adhesive oz $9.50 Fixodent oz $6.50 Interdental Flossups count $6.00 Oral pain relief oz 20% $8.00 Polident denture cream oz $9.00 Polident overnight count $12.50 Tongue cleaner count $6.00 Toothbrush, Colgate, adult soft count $3.00 Toothbrush, rechargeable count $37.00 Toothbrush, soft count $6.00 Toothbrush, Tek Pro, angled soft count $3.00 Toothpaste, Colgate oz $6.00 Toothpaste, Crest Sensi-Relief oz $9.50 Toothpaste, Pepsodent oz $4.00 Toothpaste, Ultrabrite Advanced Whitening oz $6.00 Water jet count $39.00 Water jet replacement tips count $18.00 Reach waxed dental floss mint yd $4.00 DIABETES SUPPLIES Diabetic socks, black, medium pair $9.00 Diabetic socks, black, large pair $9.00 Diabetic socks, black, X-large pair $9.00 Diabetic socks, white, medium pair $9.00 Diabetic socks, white, large pair $9.00 Diabetic socks, white, X-large pair $9.00 Ultra soft padded diabetic sock, black, medium pair $11.00 Ultra soft padded diabetic sock, black, large pair $11.00 Ultra soft padded diabetic sock, black, X-large pair $11.00 Ultra soft padded diabetic sock, white, medium pair $11.00 Ultra soft padded diabetic sock, white, large pair $11.00 Ultra soft padded diabetic sock, white, X-large pair $11.00 EAR CARE S Cotton-tipped swabs count $7.00 Ear wax removal drops ml 6.5% $7.50 Ear wax removal system with rubber bulb ml $10.00 EYE CARE S Artificial tears drops oz $7.00 Artificial tears ointment gm $9.00 Clear eyes eye drops oz $6.00 Multipurpose contact lens solution oz $8.00 Redness relief eye drops ml 0.05% $5.00

5 OTC FIRST AID AND MEDICAL SUPPLIES Adhesive bandages* count $6.00 Alcohol pads* 1200 Box/100 70% $6.00 Antiseptic skin cleanser oz $11.00 Antiseptic towelettes count $7.50 Bacitracin ointment oz 500 U/gm $7.00 Bath bench with back count $50.00 Bath bench without back count $45.00 Bath mat, non-skid count $20.00 Bathtub safety rail count $38.00 Conforming gauze sterile pads (3 x 4.1 yd) count $8.50 Cotton balls count $4.50 Cushion, foam ring count $20.00 Cushion, gel/foam seat count $30.00 Cushion, lumbar count $25.00 Elastic bandage (2 x 4.5 yd) *B count $6.00 Elastic bandage (3 x 5 yd) *B count $6.00 Elastic bandage (4 x 5 yd) *B count $6.00 Elastic bandage (6 x 5 yd) *B count $6.00 First aid kit pieces $7.00 First aid kit pieces $13.00 First aid kit pieces $17.00 Folding cane with ergonomic handle* count $21.00 Hot or cold pack small pack $10.00 and 1 large pack Hydrogen peroxide oz 3% $5.00 Humidifier, ultra-sonic cool mist count $65.00 Ice bag, count $9.00 Insect repellent spray (DEET) oz 30% $13.00 Isopropyl alcohol, wintergreen oz 70% $7.50 Knurled chrome grab bar, count $20.00 Knurled chrome grab bar, count $25.00 Neosporin Plus oz $12.00 Pain relief mask count $9.00 Povidone iodine solution antiseptic oz $9.00 Raised toilet seat count $36.00 Raised toilet seat with arms count $65.00 Shower mat, non-skid count $17.00 Tape, paper surgical (1 x 10 yd)* count $6.00 Tape, silk surgical (1 x 10 yd)* count $6.00 Tape, transparent surgical (1 x 10 yd)* count $6.00 Thermometer, digital 60 seconds count $8.00 Thermometer, digital ear count $25.00 Thermometer, flexible tip, digital 10 seconds count $11.00 Thermometer, talking ear and forehead count $50.00 Toilet safety rails set $42.00 Triple antibiotic ointment oz $6.00 FOOT CARE Callus remover pads count $7.00 Corn remover pads count $7.00 HEMORRHOID PREPARATIONS Hemorrhoid ointment oz $10.00 Hemorrhoidal suppository count $7.00 Pre-moistened hemorrhoid pads count $10.00 HORMONE REPLACEMENT S DHEA count 50 mg $12.00 INCONTINENCE SUPPLIES A + D ointment oz $7.00 Adult briefs, medium (32 to 44 )* count $15.00 Adult briefs, large (45 to 58 )* count $15.00 Adult briefs, x-large (59 to 64 )* count $15.00

6 OTC Attends discreet men s guard count $14.00 Attends discreet men s shield count $15.00 Attends discreet women s maximum bladder count $20.00 control pad Attends discreet women s moderate bladder count $18.00 control pad Attends discreet women s panty liner count $14.00 Attends discreet women s ultimate bladder count $20.00 control pad Attends discreet women s ultrathin pad count $14.00 Barrier cream oz $9.00 Bladder control shaped pad, moderate count $16.00 absorbency* Bladder control shaped pad, heavy absorbency* count $16.00 Bladder control shaped pad, maximum count $16.00 absorbency* Disposable underwear, medium (34 to 44 )* count $16.00 Disposable underwear, large (44 to 58 )* count $16.00 Disposable underwear, x-large (58 to 68 )* count $16.00 Enema oz $6.00 Flushable wipes count $8.00 Natural vegetable laxative oz $18.00 Natural vegetable laxative, sugar free oz $15.00 Underpad, disposable (23 x 24 )* count $15.00 Underpad, disposable (23 x 36 )* count $12.00 Underpad, disposable (30 x 30 )* count $9.00 Washcloth with lanolin count $9.00 IN-HOME DIAGNOSTIC SUPPLIES Bathroom scale count $40.00 Desktop automatic blood pressure monitor count $35.00 Desktop talking blood pressure monitor count $40.00 Desktop blood pressure monitor count $19.00 replacement cuff Finger pulse oximeter count $40.00 Heart rate monitor watch count $40.00 Wrist blood pressure monitor count $30.00 Wrist talking blood pressure monitor count $35.00 MOTION SICKNESS TREATMENTS Driminate antiemetic count 50 mg $9.00 Meclizine HCL antiemetic count 12.5 mg $8.50 PAIN RELIEVERS AND FEVER REDUCERS Acetaminophen count 325 mg $8.00 Acetaminophen count 500 mg $7.00 Acetaminophen count 500 mg $9.00 Arthritis pain reliever count 650 mg $14.00 Aspirin count 325 mg $5.50 Aspirin, enteric-coated count 325 mg $7.00 Aspirin, enteric coated, low dose count 81 mg $6.00 Aspirin, low dose, chewables ct 81 mg $6.00 Capsaicin external analgesic oz 0.025% $11.00 Cold/hot menthol medicated patch count 5% $10.00 Heating pad (12 x 15 )* count $25.00 Heating pad, X-large (12 x 24 )* count $35.00 Heating pad wrap for shoulder, neck, and back count $55.00 (25 x 26 )* Ibuprofen count 200 mg $6.00 Lidocaine patch count 4% $13.00 Migraine relief count 250 mg, 65 mg $11.00 Naproxen count 220 mg $9.00 Naproxen count 220 mg $12.00 Pain reliever, p.m., extra strength count 25 mg, 500 mg $11.00 Pain-relieving muscle rub oz 2.5% $7.50

7 OTC Salonpas pain relief patches /box 25 mg $13.00 ThermaCare HeatWraps, back and hip count $12.00 ThermaCare HeatWraps, neck, shoulder, and wrist count $12.00 PEDICULICIDE Lice elimination kit kit $27.00 Lice treatment shampoo oz $10.00 PERSONAL CARE S Acne gel 10% benzoyl peroxide oz 10% $10.00 Ammonium lactate moisturizing lotion oz 12% $14.00 Hand sanitizer oz $6.00 SLEEP AIDS Nasal strips, large count $14.00 Nasal strips, medium count $14.00 Sleep tablets count 25 mg $10.00 SMOKING CESSATION S Nicorelief gum count 4 mg $23.00 Nicotine lozenges count 4 mg $43.00 Nicotine patch, step count 21 mg/24 hr $37.00 Nicotine patch, step count 14 mg/24 hr $37.00 Nicotine patch, step count 7 mg/24 hr $37.00 SUPPORTIVE ITEMS Ankle support count $13.00 Arthritis gloves, small pair $25.00 Arthritis gloves, medium pair $25.00 Arthritis gloves, large pair $25.00 Back support elastic (24 to 46 ) count $25.00 Back support elastic with lumbar count $30.00 Carpal tunnel brace, small count $25.00 Carpal tunnel brace, medium count $25.00 Carpal tunnel brace, large count $25.00 Compression knee high socks, men s black, pair mmhg $20.00 medium (shoe size 8 10) Compression knee high socks, men s black, large pair mmhg $20.00 (shoe size ) Compression knee high socks, men s white, pair mmhg $20.00 medium (shoe size 8 10) Compression knee high socks, men s white, large pair mmhg $20.00 (shoe size ) Compression knee high socks, women s black, pair 8 15 mmhg $15.00 small (shoe size 4 5) Compression knee high socks, women s black, pair 8 15 mmhg $15.00 medium (shoe size ) Compression knee high socks, women s black, pair 8 15 mmhg $15.00 large (shoe size ) Compression knee high socks, women s nude, pair 8 15 mmhg $15.00 small (shoe size 4 5) Compression knee high socks, women s nude, pair 8 15 mmhg $15.00 medium (shoe size ) Compression knee high socks, women s nude, pair 8 15 mmhg $15.00 large (shoe size ) Knee support, elastic, small count $11.00 Knee support, elastic, medium count $11.00 Knee support, elastic, large count $11.00 Night wrist support smart glove count $30.00 THERAPEUTIC SKIN AND SUN CARE Aloe vera cream oz $7.00 Moisturizing body lotion with aloe oz $9.00 Sunscreen lotion oz SPF 30 $9.00 VITAMINS AND MINERALS Biotin gummy count 5,000 mcg $13.00 Calcium and vitamin D count 600 mg/400 u $7.00

8 OTC Calcium and vitamin D gummy count 500 mg, 1,000 IU $13.00 Calcium carbonate supplement tablets count 600 mg $9.00 Calcium chew, chocolate count 500 mg, 1,000 IU $11.00 Centrum Silver chewables count $17.50 Coenzyme Q count 50 mg $12.00 Daily multivitamin count $9.00 Daily mulitivitamin gummy count $13.00 Daily multivitamin tablets with minerals count $8.00 Ferrous gluconate iron supplement count 240 mg $7.50 Ferrous sulfate iron supplement count 325 mg $9.00 Fish oil, soft gels count 1,000 mg $12.00 Fiber tablets count 500 mg $10.00 Flaxseed count 1,000 mg $12.00 Folic acid count 800 mcg $7.00 Glucosamine and chondroitin count 250 mg, 200 mg $14.00 Glucosamine joint/muscle count 500 mg $10.00 Iron count 27 mg $8.00 Immune support chewables count $12.00 Magnesium oxide count 250 mg $9.00 Melatonin count 5 mg $12.00 Niacin count 100 mg $6.50 Niacin, no flush count 500 mg $12.00 One Daily men s multivitamin count $11.00 One Daily women s multivitamin count $11.00 Senior multivitamin count $11.00 Vitamin A count 10,000 iu $7.50 Vitamin B count 100 mg $9.00 Vitamin B count 1,000 mcg $11.00 Vitamin B count 500 mcg $10.00 Vitamin B count 50 mg $8.00 Vitamin B complex count $8.00 Vitamin B complex gummy count $13.00 Vitamin C count 500 mg $8.00 Vitamin C gummy count 250 mg $11.00 Vitamin D count 1,000 iu $9.00 Vitamin D count 400 iu $8.00 Vitamin E, soft gels count 400 iu $11.00 Vitamin E, soft gels count 100 iu $8.00 Zinc, chelated count 50 mg $8.00 WART REMOVERS Wart remover (liquid) ml 17% $11.00 WEIGHT LOSS AIDS Vitafusion fiber weight management count $17.50 *These items may also be covered by the plan, or Medicare if you are not enrolled in the plan, if your health care provider determines them to be medically necessary. Dual-purpose items are medicines and products that can be used for either a medical condition or for general health and well-being. In certain circumstances, some items in this catalog may also be covered under your Medicare Part B (medical) benefit or Part D (pharmacy) benefit. These items have a *B or a *D after their names. For example, alcohol pads are covered under Part D if they are used for administering insulin. For all other purposes, this item is covered under your OTC benefit.

9 See the other side of this panel for your AmeriHealth Caritas VIP Care Over-the-Counter (OTC) Benefit Order Form. Information on how to place your OTC order can be found on the back cover.

10 Over-the-Counter (OTC) Benefit Order Form If you have questions or would like to place an order over the phone, OTC advocates are available Monday Friday, from 8 a.m. to 11 p.m. ET, at (TTY 711). To place an order by mail, please mail your order form to OTC Servicing Center, P.O. Box , Weston, FL COMPLETE YOUR INFORMATION BELOW Member ID number (found on health ID card) Date of birth First name Last name MI Street number Street name Apartment or suite number City State ZIP code Please check this box if this is a new address: Daytime phone SELECTION Your quarterly order total may not exceed the quarterly benefit amount. Cash, checks, money orders, or any other form of personal payment to purchase items are not accepted under this OTC benefit. ITEM NUMBER NAME QUANTITY PRICE TOTAL ORDER $ If you use an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29, but we receive it on July 1, your order total will be applied to your July (or third-quarter) benefit, not your June (or second-quarter) benefit.