1. No category

Aetna_2016_20_OH_Layout 1 9/25/15 10:22 AM Page 1
NAME (NOMBRE) ______________________________________________________________________
ADDRESS (DIRECCIÓN) ________________________________________________________________
___________________________________________________________________________________
MEMBER ID ( NÚMERO DE MEMBRESÍA) ______________ PHONE (TELÉFONO) ______________________
/ Digestion / Laxatives
Item Antacids
(Antiácidos / Digestión / Laxantes)
Qty
Brand
Marca
Price
Precio
First Aid / Personal Care
Item Primeros
Auxilios / Cuidado Personal Qty
A1 EFFERVESCENT PAIN RELIEF 36CT ALKA-SELTZER 4.49
F1
ELASTIC BANDAGE
A2 DAIRY RELIEF FAST ACTING CHEWABLE 60CT
F2
MUSCLE RUB
A7
RANITIDINE 75MG
30CT
12.49
ZANTAC
L6 GLYCERIN SUPPOSITORIES ADULT 25CT
L11
COLON CLEANSER
120CT
7.99
3.49
FDC
7.99
Q3 PINK BISMUTH CHEWABLE TABS 30CT PEPTO-BISMOL 3.99
Q9
GRIPE WATER COLIC
4OZ
8.49
Pain Relievers (Analgésicos)
Brand
Price
Marca
Precio
1CT
3.99
3OZ BEN-GAY 5.99
F3 ANTIBAC HEAVY DUTY FABRIC BANDAGE 20CT
3.49
F4
CALAMINE LOTION
6OZ CALADRYL 2.99
F9
CLEAR BANDAGES
45CT
3.99
F10 DIAPER RASH OINTMENT
2OZ
DESITIN 3.99
F12
SHEER BANDAGES
40CT
2.49
P6 ACETAMINOPHEN 500MG TABS 100CT
6.99
F21
IODINE
1OZ
2.49
P9 HEADACHE RELIEF COATED TABLETS 24CT
1.99
F22
MERTHIOLATE
2OZ
3.99
ICY HOT 6.99
F24
FIRST-AID KIT
EACH
6.99
7.49
F29 ITCH RELIEF GEL MAX STRENGTH 4OZ
4.99
7.49
F34 HOT/COLD MULTI-COMPRESS 1CT
8.49
24ct TYLENOL PM 3.99
F61
BACITRACIN OINTMENT
1OZ
5.99
Miscellaneous / Sunscreen Lotion (Misceláneo / Loción Protectora Del Sol)
F62
FIRST AID TAPE
EACH
1.99
4.99
P14
HOT / COLD PATCHES
5CT
P17 HEADACHE RELIEF COATED TABLETS 100CT
EXCEDRIN
P44 MUSCLE THERAPEUTIC BLUE GEL 8OZ
P45
ACETAMINOPHEN NIGHTTIME PAIN RELIEF
F35 LIQUID CORN & CALLUS REMOVER
.5OZ
3.99
F66
LIQUID BANDAGE
.3OZ
M1
SUNBLOCK SPF 45
3OZ
NEUTROGENA 6.99
M52
BENZOCAINE TOPICAL
.33OZ
M3
LIP BALM
.15OZ
1.99
M53
GAUZE
1CT
1.99
M9 COTTON SWABS DOUBLE TIPPED PLASTIC STICK 375CT
2.49
M56
GENTLE TAPE 2 PK
EACH
5.99
EACH
17.99
1CT
0.99
M4 SENSATIVE TOOTHPASTE EXTRA WHITENING 4OZ
4.49
M35 DENTAL FLOSS WAXED
100YD
2.49
M11
BABY POWDER WITH CORN STARCH
4OZ
M12
BABY WIPES
20CT
1.99
M23
HAND SANITIZER
2OZ
.99
M39
UNISEX FOAM INSOLES
EACH
2.49
M43
TWEEZERS
EACH
1.99
M44
NAIL CLIPPER
EACH
2.49
M46
AZO URINARY RELIEF
M48
OIL OF BEAUTY
6OZ
M51
7 DAY WEEKLY PILL PLANNER
J&J
1.99
12CT AZO STANDARD 4.99
X72 *BLOOD PRESSURE MONITOR MANUAL
ANBESOL
5.99
Dental (Dental)
M2
TOOTHBRUSH
6.99
X2
DENTURE TABS
84CT
5.49
EACH
2.49
X5
DENTURE CLEANSER TABLETS
40CT
2.99
M55 HEARING AID BATTERIES 312
8CT
6.99
M57 VINYL DISPOSABLE GLOVES
50CT
7.49
X18
VITAMIN E CREAM
4OZ
4.99
X74
BLADDER CONTROL PADS*
20CT
X75
WOMEN S/M UNDERWEAR XTRA
20ct
12.99
X76
MEN L/XL UNDERWEAR MAX
16ct
12.99
X77
MEN S/M UNDERWEAR MAX
18ct
12.99
X80
MAXI PADS REGULAR
48ct
STAYFREE 5.49
X82
TAMPON PLASTIC
20ct
TAMPAX
OLAY
POISE
X6 DENTURE ADHESIVE REGULAR
Cough / Cold / Allergy
2.4OZ FIXODENT 3.99
(Tos / Catarros / Alergia)
5.99
4.49
C7
MEDICATED CHEST RUB 3.53OZ VICK'S VAPORUB 5.99
C8
THERMOMETER DIGITAL
EACH
4.99
C11 SORE THROAT LOZENGES 18CT
3.99
C57
SORE THROAT SPRAY
6OZ CHLORASEPTIC 4.49
Aetna Better Health of Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. Limitations,
copays, and restrictions may apply. For more information, call Aetna Better Health of Ohio Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week
or read the Aetna Better Health of Ohio Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks may change from time to time
throughout the year and on January 1 of each year.”
YOU WILL RECEIVE THE GENERIC EQUIVALENT OF ALL ITEMS.
USTED RECIBIRÁ EL GENÉRICO EQUIVALENTE DE TODOS LOS PRODUCTOS.
FOR QUESTIONS, CALL AETNA BETTER HEALTH OF OHIO AT 1-855-364-0974 (TTY: 711) 24 HOURS A DAY, 7 DAYS A WEEK.
YOU CAN GET THIS INFORMATION FOR FREE IN OTHER LANGUAGES. CALL 1-855-364-0974 AND TTY: 711; 24 HOURS A DAY, 7 DAYS A WEEK. THE CALL IS FREE.
Puede obtener esta información en otros idiomas de manera gratuita. Llame al 1-855-364-0974 (TTY: 711), 24 horas al dia, siete dias de la semana. Esta llamada es gratuita.
This information is available for free in other languages and formats like Braille or audio CD.
*LIMIT (1) PER ORDER • *LÍMITE DE (1) POR ORDER
CMS APPROVED
H7172_16_038
Aetna_2016_20_OH_Layout 1 9/25/15 10:22 AM Page 2
Vitamins / Minerals (Vitaminas / Minerales)
V10 GLUCOSAMIN/CHONDROITIN 50 CT
NATURE'S BOUNTY
10.99
V45
15CT
13.49
V14
A 10,000 IU NATURAL
NATURE'S BOUNTY
4.99
V49 MELATONIN GUMMIES 5MG 60CT
9.49
V22
COLLAGEN 500MG
100 CT BOTANIC CHOICE 8.49
V50 L-LYSINE 500MG VITAMIN
100CT
5.49
V33
B-12 1000 MCG
100CT
V51
1O0CT
10.49
100 CT
8.99
PROBIOTIC ADULT 20 BILLION
TURMERIC 400MG
Participant must consult with Primary Care Physician prior to ordering a dual-purpose item.
Debe consultar con su médico de cabecera antes de ordenar un producto de doble propósito.
Over-the-Counter Drug Catalog Program
Programa de Catálogo de Medicamentos sin Receta
$20 Monthly Benefit
Beneficio de $20 Mensual
Aetna Better Health Ohio
Aetna Better Health Ohio
Aetna Better Health Ohio is pleased to provide its members with the Over-the-Counter (OTC)
Drug Catalog. This is a convenient way to get OTC drugs and supplies by mail through your
Aetna Better Health Ohio OTC benefit.
Aetna Better Health Ohio se complace en proveer a sus miembros el Catálogo de
Medicamentos Sin Receta. Esta es una forma conveniente de recibir por correo sus
medicamentos y suministros sin receta medica a través de su beneficio de Aetna Better
Health Ohio.
HOW TO ORDER BY MAIL:
COMO ORDENAR POR CORREO:
1. Clearly write your name, address, telephone number and member ID in the space at
the top of the form. Your shipping address must be the same as the address in your
member record. We cannot fill your order if your address is not the same.
1.
2. Check (√) items you want on the order form that add up to $20 or less. Your benefit
limit is $20 every month. If you order more than $20, you will receive the first $20 of
items on your order.
Escriba claramente su nombre, dirección, numero de teléfono y numero de socio en
el espacio indicado. Su dirección de envio debe coincidir con la dirección que
tenemos en su archivo de afiliación. No se completarán las solicitudes en los
casos en que no coincidan las direcciónes.
2.
3. Fold and insert completed form in envelope, place first class postage and mail to:
OTC Health Solutions
Seleccione artículos que sumen hasta $20 o menos. Su beneficio tiene un limite de
$20 cada mes. Si excede este limite, recibirá automáticamente sólo los primeros
artículos que sumen un total de $20.
3.
Coloque este formulario dentro de un sobre con una estampilla de Primera Clase
y envienosla a:
OTC Health Solutions
9400 NW 104 Street • Medley, FL 33178
ORDER BY PHONE:
To place your order by phone, call 1-888-628-2770 from 9 a.m. to 5 p.m. E.S.T. Monday
through Friday.
ORDER BY FAX:
Fax the completed order form to 1-866-682-6733 any time.
ORDER ONLINE: aetnaoh.otchs.com
9400 NW 104 Street • Medley, FL 33178
POR TELEFONO:
Para colocar su orden llame al 1-888-628-2770 de 9 a.m. a 5 p.m., Hora del Este Lunes a
Viernes.
POR FAX:
Envie su forma por fax al 1-866-682-6733 a cualquier hora.
Por internet: aetnaoh.otchs.com
Name: _______________________________________________
Address: _____________________________________________
City: _____________________ State: __________ Zip: ________
OTC Health Solutions
9400 NW 104 Street
Medley, FL 33178
Place
Stamp
Here