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
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