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 1-866-533-5490 (TTY 711), 8 a.m. 8 p.m., seven days a week, for more information. Y0093_CAT_2442_NM
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 267067, Weston, FL 33326. To place your order over the phone, OTC advocates are available Monday Friday, 8 a.m. to 11 p.m. ET, at 1-800-580-7813 (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 1-800-580-7813 (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 www.amerihealthcaritasvipcare.com. For up-to-date information, please call our OTC advocates Monday Friday, from 8 a.m. 11 p.m. ET, at 1-800-580-7813 (TTY 711). H4227_002-CAT-113051
OTC ALLERGY, COLD, FLU DECONGESTANT, AND SINUS TREATMENTS Allergy relief nasal spray, 24 hour, fluticasone 1946 120 spray 50 mcg $25.00 propionate All-night cold and flu 1361 4 oz 12.5 mg, 30 mg, $8.00 650 mg Cetirizine HCL allergy relief* 1090 14 count 10 mg $8.00 Chlorpheniramine maleate antihistamine 1008 100 count 4 mg $9.00 Cough and cold for high blood pressure 1166 16 count $10.00 Cough drops, cherry 1056 30 count 5.8 mg $5.00 Cough drops, sugar free, cherry 1182 25 count 5.8 mg $5.00 Cough syrup, expectorant 1054 4 oz 200 mg, 10 ml $7.00 Cromolyn sodium allergy nasal spray 1356 26 ml $18.00 Diabetic Tussin DM 1323 4 oz $10.00 Diphenhydramine antihistamine 1308 100 count 25 mg $10.00 Diphenhydramine antihistamine 1009 24 count 25 mg $5.00 Guaifenesin cough expectorant 1180 60 count 200 mg $11.00 Loratadine allergy relief 1611 100 count 10 mg $15.00 Mucus relief DM expectorant and 1178 30 count 400 mg, 20 mg $11.00 cough suppressant Mucus relief DM expectorant and cough suppressant, extended release 1965 14 count 1200 mg, 60 mg $16.00 Multi-symptom cold formula 1357 24 count 5 mg, 10 mg, 325 mg $10.00 Nasal decongestant spray, 12 hour 1091 1 oz.05% $9.00 Nasal spray, saline 1052 1.5 oz.65% $8.00 Personal steam inhaler 1792 1 count $50.00 Sore throat lozenges, cherry 1176 18 count $8.00 Sore throat spray, cherry 1904 6 oz $7.50 Sudogest PE nasal and sinus decongestant 1352 36 count 10 mg $9.00 Vapor rub 1164 3.5 oz 4.7%, 1% $8.00 ANTACIDS AND ACID REDUCERS Antacid/anti-gas liquid 1006 12 oz $7.50 Antacid chewables 1346 150 count 500 mg $8.00 Effervescent pain reliever 1314 36 count $8.00 Esomeprazole magnesium, 24-hour delayedrelease 1949 42 count 20 mg $23.00 acid reducer* Famotidine acid reducer* 1108 30 count 10 mg $10.00 Omeprazole acid reducer* 1970 42 count 20 mg $26.00 Omeprazole acid reducer, delayed release, 1966 42 count 20 mg $26.00 dissolvable* Ranitidine acid reducer 1900 30 count 75 mg $9.00 Simethicone anti-gas chewables 1800 100 count 80 mg $8.00 ANTICANDIDAL (YEAST) S Clotrimazole seven-day treatment vaginal cream 1115 45 gm 1% $11.00 (with applicator) Micanozole three-day treatment vaginal cream (with applicator) 1117 1 kit 2% $17.00 ANTIDIARRHEAL, LAXATIVE, AND DIGESTIVE HEALTH S Bisacodyl enteric coated laxative 1128 100 count 5 mg $7.00 Bismatrol chewable tablets 1045 30 count 262 mg $9.00 Docusate sodium stool softener 1126 100 count 100 mg $7.00 Glycerin suppository 1125 25 count 2 gm $8.00 Lactase capsules 1067 60 count 9000 FCC units $14.00 Loperamide HCL anti-diarrheal* 1133 12 count 2 mg $7.00 Milk of magnesia 1011 12 oz 400 mg $8.00 Natural vegetable laxative 1340 13 oz $14.00 Pink bismuth 1318 8 oz 525 mg, 30 ml $8.00 Polycarbophil (fiber tablets) 1012 90 count 625 mg $14.00 Senna plus stool softener plus laxative 1130 60 count 8.6 mg, 50 mg $10.00
OTC ANTIFUNGAL AND ANTI-ITCH S Clotrimazole antifungal athlete s foot cream 1047 1.5 oz 1% $9.00 Diphenhydramine HCL/zinc acetate 1140 1 oz $7.00 anti-itch cream Hydrocortisone 1% cream 1074 1 oz 1% $6.00 Medicated antifungal foot powder spray 1874 4.6 oz $10.50 Miconazole nitrate 2% antifungal cream 1135 1 oz 2% $10.00 Terbinafine HCL antifungal cream 1046 0.5 oz 1% $12.00 Tolnaftate antifungal cream 1064 1.25 oz 1% $10.00 COLD SORE AND OTHER MEDICATED LIP S Abreva 1152 2 gm 10% $28.00 Blistex lip ointment 1256 6 gm $6.00 Herpecin L lip balm 1153 0.1 oz 1% $11.00 DENTAL OR DENTURE CARE S Denture brush 1747 1 count $6.00 Denture cleaning tablets 1032 40 count $7.00 Efferdent Plus mint tablets 1653 36 count $8.00 Effergrip denture cream adhesive 1843 2.5 oz $9.50 Fixodent 1187 0.75 oz $6.50 Interdental Flossups 1751 90 count $6.00 Oral pain relief 1286 0.5 oz 20% $8.00 Polident denture cream 1324 3.9 oz $9.00 Polident overnight 1892 84 count $12.50 Tongue cleaner 1746 1 count $6.00 Toothbrush, Colgate, adult soft 1413 1 count $3.00 Toothbrush, rechargeable 1450 1 count $37.00 Toothbrush, soft 1948 2 count $6.00 Toothbrush, Tek Pro, angled soft 1412 1 count $3.00 Toothpaste, Colgate 1831 4 oz $6.00 Toothpaste, Crest Sensi-Relief 1838 4.1 oz $9.50 Toothpaste, Pepsodent 1414 5.5 oz $4.00 Toothpaste, Ultrabrite Advanced Whitening 1716 6 oz $6.00 Water jet 1744 1 count $39.00 Water jet replacement tips 1743 5 count $18.00 Reach waxed dental floss mint 1455 55 yd $4.00 DIABETES SUPPLIES Diabetic socks, black, medium 1956 3 pair $9.00 Diabetic socks, black, large 1957 3 pair $9.00 Diabetic socks, black, X-large 1958 3 pair $9.00 Diabetic socks, white, medium 1953 3 pair $9.00 Diabetic socks, white, large 1954 3 pair $9.00 Diabetic socks, white, X-large 1955 3 pair $9.00 Ultra soft padded diabetic sock, black, medium 1959 2 pair $11.00 Ultra soft padded diabetic sock, black, large 1960 2 pair $11.00 Ultra soft padded diabetic sock, black, X-large 1961 2 pair $11.00 Ultra soft padded diabetic sock, white, medium 1962 2 pair $11.00 Ultra soft padded diabetic sock, white, large 1963 2 pair $11.00 Ultra soft padded diabetic sock, white, X-large 1964 2 pair $11.00 EAR CARE S Cotton-tipped swabs 1742 300 count $7.00 Ear wax removal drops 1190 15 ml 6.5% $7.50 Ear wax removal system with rubber bulb 1363 15 ml $10.00 EYE CARE S Artificial tears drops 1192 0.5 oz $7.00 Artificial tears ointment 1194 3.5 gm $9.00 Clear eyes eye drops 1199 0.2 oz $6.00 Multipurpose contact lens solution 1468 4 oz $8.00 Redness relief eye drops 1061 15 ml 0.05% $5.00
OTC FIRST AID AND MEDICAL SUPPLIES Adhesive bandages* 1344 60 count $6.00 Alcohol pads* 1200 Box/100 70% $6.00 Antiseptic skin cleanser 1808 8 oz $11.00 Antiseptic towelettes 1201 100 count $7.50 Bacitracin ointment 1020 1 oz 500 U/gm $7.00 Bath bench with back 1728 1 count $50.00 Bath bench without back 1727 1 count $45.00 Bath mat, non-skid 1459 1 count $20.00 Bathtub safety rail 1730 1 count $38.00 Conforming gauze sterile pads (3 x 4.1 yd) 1223 12 count $8.50 Cotton balls 1763 200 count $4.50 Cushion, foam ring 1732 1 count $20.00 Cushion, gel/foam seat 1466 1 count $30.00 Cushion, lumbar 1731 1 count $25.00 Elastic bandage (2 x 4.5 yd) *B 1207 1 count $6.00 Elastic bandage (3 x 5 yd) *B 1209 1 count $6.00 Elastic bandage (4 x 5 yd) *B 1211 1 count $6.00 Elastic bandage (6 x 5 yd) *B 1213 1 count $6.00 First aid kit 1947 20 pieces $7.00 First aid kit 1215 75 pieces $13.00 First aid kit 1738 175 pieces $17.00 Folding cane with ergonomic handle* 1726 1 count $21.00 Hot or cold pack 1062 1 small pack $10.00 and 1 large pack Hydrogen peroxide 1228 16 oz 3% $5.00 Humidifier, ultra-sonic cool mist 1795 1 count $65.00 Ice bag, 9 1761 1 count $9.00 Insect repellent spray (DEET) 1796 4 oz 30% $13.00 Isopropyl alcohol, wintergreen 1229 16 oz 70% $7.50 Knurled chrome grab bar, 12 1798 1 count $20.00 Knurled chrome grab bar, 24 1797 1 count $25.00 Neosporin Plus 1326 0.5 oz $12.00 Pain relief mask 1762 1 count $9.00 Povidone iodine solution antiseptic 1203 4 oz $9.00 Raised toilet seat 1729 1 count $36.00 Raised toilet seat with arms 1950 1 count $65.00 Shower mat, non-skid 1460 1 count $17.00 Tape, paper surgical (1 x 10 yd)* 1217 1 count $6.00 Tape, silk surgical (1 x 10 yd)* 1219 1 count $6.00 Tape, transparent surgical (1 x 10 yd)* 1221 1 count $6.00 Thermometer, digital 60 seconds 1063 1 count $8.00 Thermometer, digital ear 1285 1 count $25.00 Thermometer, flexible tip, digital 10 seconds 1697 1 count $11.00 Thermometer, talking ear and forehead 1925 1 count $50.00 Toilet safety rails 1779 1 set $42.00 Triple antibiotic ointment 1014 1 oz $6.00 FOOT CARE Callus remover pads 1238 6 count $7.00 Corn remover pads 1236 9 count $7.00 HEMORRHOID PREPARATIONS Hemorrhoid ointment 1066 2 oz $10.00 Hemorrhoidal suppository 1247 12 count $7.00 Pre-moistened hemorrhoid pads 1364 100 count $10.00 HORMONE REPLACEMENT S DHEA 1737 50 count 50 mg $12.00 INCONTINENCE SUPPLIES A + D ointment 1300 2 oz $7.00 Adult briefs, medium (32 to 44 )* 1303 12 count $15.00 Adult briefs, large (45 to 58 )* 1304 12 count $15.00 Adult briefs, x-large (59 to 64 )* 1305 15 count $15.00
OTC Attends discreet men s guard 1811 20 count $14.00 Attends discreet men s shield 1810 20 count $15.00 Attends discreet women s maximum bladder 1812 20 count $20.00 control pad Attends discreet women s moderate bladder 1813 20 count $18.00 control pad Attends discreet women s panty liner 1815 28 count $14.00 Attends discreet women s ultimate bladder 1814 20 count $20.00 control pad Attends discreet women s ultrathin pad 1816 20 count $14.00 Barrier cream 1302 4 oz $9.00 Bladder control shaped pad, moderate 1478 24 count $16.00 absorbency* Bladder control shaped pad, heavy absorbency* 1479 24 count $16.00 Bladder control shaped pad, maximum 1480 18 count $16.00 absorbency* Disposable underwear, medium (34 to 44 )* 1021 20 count $16.00 Disposable underwear, large (44 to 58 )* 1026 18 count $16.00 Disposable underwear, x-large (58 to 68 )* 1027 14 count $16.00 Enema 1733 4.5 oz $6.00 Flushable wipes 1928 24 count $8.00 Natural vegetable laxative 1967 30.4 oz $18.00 Natural vegetable laxative, sugar free 1968 15 oz $15.00 Underpad, disposable (23 x 24 )* 1476 50 count $15.00 Underpad, disposable (23 x 36 )* 1299 25 count $12.00 Underpad, disposable (30 x 30 )* 1477 10 count $9.00 Washcloth with lanolin 1348 64 count $9.00 IN-HOME DIAGNOSTIC SUPPLIES Bathroom scale 1935 1 count $40.00 Desktop automatic blood pressure monitor 1253 1 count $35.00 Desktop talking blood pressure monitor 1503 1 count $40.00 Desktop blood pressure monitor 1504 1 count $19.00 replacement cuff Finger pulse oximeter 1505 1 count $40.00 Heart rate monitor watch 1771 1 count $40.00 Wrist blood pressure monitor 1501 1 count $30.00 Wrist talking blood pressure monitor 1502 1 count $35.00 MOTION SICKNESS TREATMENTS Driminate antiemetic 1263 12 count 50 mg $9.00 Meclizine HCL antiemetic 1366 100 count 12.5 mg $8.50 PAIN RELIEVERS AND FEVER REDUCERS Acetaminophen 1001 100 count 325 mg $8.00 Acetaminophen 1105 50 count 500 mg $7.00 Acetaminophen 1600 100 count 500 mg $9.00 Arthritis pain reliever 1311 100 count 650 mg $14.00 Aspirin 1095 100 count 325 mg $5.50 Aspirin, enteric-coated 1096 100 count 325 mg $7.00 Aspirin, enteric coated, low dose 1002 120 count 81 mg $6.00 Aspirin, low dose, chewables 1802 36 ct 81 mg $6.00 Capsaicin external analgesic 1367 2 oz 0.025% $11.00 Cold/hot menthol medicated patch 1944 5 count 5% $10.00 Heating pad (12 x 15 )* 1861 1 count $25.00 Heating pad, X-large (12 x 24 )* 1942 1 count $35.00 Heating pad wrap for shoulder, neck, and back 1943 1 count $55.00 (25 x 26 )* Ibuprofen 1004 100 count 200 mg $6.00 Lidocaine patch 1871 5 count 4% $13.00 Migraine relief 1365 100 count 250 mg, 65 mg $11.00 Naproxen 1041 50 count 220 mg $9.00 Naproxen 1097 100 count 220 mg $12.00 Pain reliever, p.m., extra strength 1332 100 count 25 mg, 500 mg $11.00 Pain-relieving muscle rub 1475 2 oz 2.5% $7.50
OTC Salonpas pain relief patches 1739 5/box 25 mg $13.00 ThermaCare HeatWraps, back and hip 1859 2 count $12.00 ThermaCare HeatWraps, neck, shoulder, and wrist 1860 3 count $12.00 PEDICULICIDE Lice elimination kit 1929 1 kit $27.00 Lice treatment shampoo 1271 4 oz $10.00 PERSONAL CARE S Acne gel 10% benzoyl peroxide 1076 1.5 oz 10% $10.00 Ammonium lactate moisturizing lotion 1368 8 oz 12% $14.00 Hand sanitizer 1065 8 oz $6.00 SLEEP AIDS Nasal strips, large 1725 30 count $14.00 Nasal strips, medium 1724 30 count $14.00 Sleep tablets 1276 50 count 25 mg $10.00 SMOKING CESSATION S Nicorelief gum 1372 50 count 4 mg $23.00 Nicotine lozenges 1281 72 count 4 mg $43.00 Nicotine patch, step 1 1369 14 count 21 mg/24 hr $37.00 Nicotine patch, step 2 1370 14 count 14 mg/24 hr $37.00 Nicotine patch, step 3 1371 14 count 7 mg/24 hr $37.00 SUPPORTIVE ITEMS Ankle support 1225 1 count $13.00 Arthritis gloves, small 1767 1 pair $25.00 Arthritis gloves, medium 1766 1 pair $25.00 Arthritis gloves, large 1765 1 pair $25.00 Back support elastic (24 to 46 ) 1487 1 count $25.00 Back support elastic with lumbar 1488 1 count $30.00 Carpal tunnel brace, small 1770 1 count $25.00 Carpal tunnel brace, medium 1769 1 count $25.00 Carpal tunnel brace, large 1768 1 count $25.00 Compression knee high socks, men s black, 1398 1 pair 15 20 mmhg $20.00 medium (shoe size 8 10) Compression knee high socks, men s black, large 1399 1 pair 15 20 mmhg $20.00 (shoe size 10.5 12) Compression knee high socks, men s white, 1400 1 pair 15 20 mmhg $20.00 medium (shoe size 8 10) Compression knee high socks, men s white, large 1401 1 pair 15 20 mmhg $20.00 (shoe size 10.5 12) Compression knee high socks, women s black, 1409 1 pair 8 15 mmhg $15.00 small (shoe size 4 5) Compression knee high socks, women s black, 1410 1 pair 8 15 mmhg $15.00 medium (shoe size 5.5 7.5) Compression knee high socks, women s black, 1411 1 pair 8 15 mmhg $15.00 large (shoe size 8 10.5) Compression knee high socks, women s nude, 1406 1 pair 8 15 mmhg $15.00 small (shoe size 4 5) Compression knee high socks, women s nude, 1407 1 pair 8 15 mmhg $15.00 medium (shoe size 5.5 7.5) Compression knee high socks, women s nude, 1408 1 pair 8 15 mmhg $15.00 large (shoe size 8 10.5) Knee support, elastic, small 1481 1 count $11.00 Knee support, elastic, medium 1482 1 count $11.00 Knee support, elastic, large 1483 1 count $11.00 Night wrist support smart glove 1463 1 count $30.00 THERAPEUTIC SKIN AND SUN CARE Aloe vera cream 1070 8 oz $7.00 Moisturizing body lotion with aloe 1893 8 oz $9.00 Sunscreen lotion 1284 3.5 oz SPF 30 $9.00 VITAMINS AND MINERALS Biotin gummy 1820 60 count 5,000 mcg $13.00 Calcium and vitamin D 1373 60 count 600 mg/400 u $7.00
OTC Calcium and vitamin D gummy 1823 60 count 500 mg, 1,000 IU $13.00 Calcium carbonate supplement tablets 1291 60 count 600 mg $9.00 Calcium chew, chocolate 1945 60 count 500 mg, 1,000 IU $11.00 Centrum Silver chewables 1420 60 count $17.50 Coenzyme Q-10 1829 30 count 50 mg $12.00 Daily multivitamin 1393 100 count $9.00 Daily mulitivitamin gummy 1972 120 count $13.00 Daily multivitamin tablets with minerals 1385 100 count $8.00 Ferrous gluconate iron supplement 1375 100 count 240 mg $7.50 Ferrous sulfate iron supplement 1376 100 count 325 mg $9.00 Fish oil, soft gels 1741 60 count 1,000 mg $12.00 Fiber tablets 1155 60 count 500 mg $10.00 Flaxseed 1849 100 count 1,000 mg $12.00 Folic acid 1850 100 count 800 mcg $7.00 Glucosamine and chondroitin 1003 60 count 250 mg, 200 mg $14.00 Glucosamine joint/muscle 1114 60 count 500 mg $10.00 Iron 1417 110 count 27 mg $8.00 Immune support chewables 1866 50 count $12.00 Magnesium oxide 1377 100 count 250 mg $9.00 Melatonin 1879 100 count 5 mg $12.00 Niacin 1378 100 count 100 mg $6.50 Niacin, no flush 1930 60 count 500 mg $12.00 One Daily men s multivitamin 1886 100 count $11.00 One Daily women s multivitamin 1887 100 count $11.00 Senior multivitamin 1392 90 count $11.00 Vitamin A 1379 100 count 10,000 iu $7.50 Vitamin B-1 1016 100 count 100 mg $9.00 Vitamin B-12 1381 100 count 1,000 mcg $11.00 Vitamin B-12 1389 100 count 500 mcg $10.00 Vitamin B-6 1380 100 count 50 mg $8.00 Vitamin B complex 1382 100 count $8.00 Vitamin B complex gummy 1915 70 count $13.00 Vitamin C 1017 100 count 500 mg $8.00 Vitamin C gummy 1916 60 count 250 mg $11.00 Vitamin D 1390 100 count 1,000 iu $9.00 Vitamin D 1383 100 count 400 iu $8.00 Vitamin E, soft gels 1384 100 count 400 iu $11.00 Vitamin E, soft gels 1391 100 count 100 iu $8.00 Zinc, chelated 1419 100 count 50 mg $8.00 WART REMOVERS Wart remover (liquid) 1075 9 ml 17% $11.00 WEIGHT LOSS AIDS Vitafusion fiber weight management 1735 90 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.
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.
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 1-800-580-7813 (TTY 711). To place an order by mail, please mail your order form to OTC Servicing Center, P.O. Box 267067, Weston, FL 33326. 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 Email 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.