1. Healthcare

2014 Over-the-Counter (OTC) Order Form
2014 Formulario de Productos de Venta Libre (OTC)
YOU WILL RECEIVE THE GENERIC EQUIVALENT OF ALL ITEMS.
USTED RECIBIRA EL GENERICO DE TODOS LOS PRODUCTOS.
Plan Name
Simply Complete (HMO SNP)
Simply More (HMO)
Simply Options (HMO-POS)
Simply Care (HMO SNP)
Simply Comfort (HMO SNP)
Simply Level (HMO SNP)
Simply Clear (HMO SNP)
Simply Complete (HMO SNP)
Simply More (HMO)
Simply Options (HMO-POS)
Simply Care (HMO SNP)
Simply Comfort (HMO SNP)
Simply Level (HMO SNP)
Simply Complete (HMO SNP)
Simply More (HMO)
Simply Level (HMO SNP)
Simply Complete (HMO SNP)
Simply More (HMO)
Simply More (HMO)
Simply Care (HMO SNP)
Simply Comfort (HMO SNP)
Simply Level (HMO SNP)
Simply Complete (HMO SNP)
Simply More (HMO)
Simply More (HMO)
Simply Extra (HMO)
Simply Level (HMO SNP)
Simply Level (HMO-POS SNP)
County
Broward
Broward
Broward
Broward
Broward
Broward
Broward, Miami-Dade
Miami-Dade
Miami-Dade
Miami-Dade
Miami-Dade
Miami-Dade
Miami-Dade
Palm Beach
Palm Beach
Palm Beach
Hernando, Hillsborough, Pasco, Pinellas, Polk
Hernando, Hillsborough, Pasco, Pinellas
Polk
Hernando, Hillsborough, Pasco, Pinellas, Polk
Hernando, Hillsborough, Pasco, Pinellas, Polk
Hernando, Hillsborough, Pasco, Pinellas, Polk
Brevard, Orange, Osceola, Seminole
Orange, Osceola, Seminole
Brevard
Brevard
Brevard, Orange, Osceola, Seminole
Clay, Duval
OTC
$40 Monthly
$30 Monthly
$25 Monthly
$30 Monthly
$27.50 Monthly
$20 Monthly
$50 Monthly
$50 Monthly
$40 Monthly
$15 Monthly
$50 Monthly
$55 Monthly
$30 Monthly
$25 Monthly
$10 Monthly
$10 Monthly
$16 Monthly
$15 Monthly
$10 Monthly
$35 Monthly
$31 Monthly
$10 Monthly
$20 Monthly
$10 Monthly
$10 Monthly
$15 Monthly
$10 Monthly
$15 Monthly
Simply Healthcare Plans, Inc., a Medicare-contracted coordinated care plan that has a Medicaid contract
with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to
be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal.
Simply Healthcare Plans, Inc. es un plan de atención médica coordinada con un contrato Medicare y un
contrato Medicaid con la Agencia de Administración de Cuidado de la Salud (AHCA) del estado de la Florida para proveer o coordinar los beneficios a ser proporcionados a los afiliados. La inscripción en Simply
Healthcare Plans, Inc. depende de la renovación del contrato.
H5471_SHPPDOTC_2014 Accepted
ORDER BY MAIL:
1. Clearly write your name, address, telephone number and member ID number 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.
2. Check (√) items you want on the order form that add up to your benefit amount or less.
3. Fold this form and put in an envelope. Place a first class postage stamp on the envelope and send it to:
OTC Health Solutions, 9400 NW 104 Street, Medley, FL 33178
ORDER BY PHONE:
To place your order by phone, call 1-877-577-0115, TTY 711, from 8 a.m. to 8 p.m., Eastern, Monday through Friday.
ORDER BY FAX:
Fax the completed order form to 1-866-682-6733 at any time.
PICK UP AT ANY OF THE NAVARRO DISCOUNT PHARMACIES STORES
Eligible Items: Each eligible OTC item is either a medicine, ointment or spray, or used for treatment of a condition which is addressed by a medicine, ointment or spray, which has active medical ingredients. First aid supplies including bandages, dressings,
and non-sport tapes are also eligible. Non-eligible items will not be covered.
*Dual-Purpose items: Prior to order/purchase (1) the member must have appropriate conversations with the member’s personal
provider, and (2) the member’s personal provider orally recommends the OTC item for a specific diagnosable condition. Other items
on this order form are classified as eligible. These eligible items may be ordered/purchased by the member without further action.
Orders will be shipped to your home at no extra charge. Please allow 2 - 3 weeks for delivery. This product list is subject to change.
This benefit is only available if your plan offers the OTC service as a benefit. Please review your Evidence of Coverage document
for more information.
This information is available for free in other languages. Please call Member Services toll-free at 1-877-577-0115 (TTY 711). From
October 1 to February 14, we are open 7 days a week, from 8 a.m. – 8 p.m., Eastern. From February 15, we are open Monday
through Friday, 8 a.m. – 8 p.m.
PEDIDO POR CORREO:
1. Escriba claramente su nombre, dirección, número de teléfono y su número de afiliado en el espacio indicado. Su dirección debe
coincidir con la dirección que tenemos en su archivo de afiliado. No se completaran aquellas solicitudes en que no coincidan las
direcciones.
2. Marque (√) los artículos que desee y sumen hasta la cantidad establecida de su beneficio o menos.
3. Coloque este formulario dentro de un sobre con una estampilla de Primera Clase y envíenosla a:
OTC Health Solutions, 9400 NW 104 Street, Medley, FL 33178
PEDIDO POR TELEFONO:
Para realizar su pedido por teléfono, llame al 1-877-577-0115, TTY 711 de 8 am a 8 pm, hora del este, de lunes a viernes.
PEDIDO POR FAX:
Envíe por fax el formulario completado a 1-866-682-6733 en cualquier momento.
RECOGER EN CUALQUIER FARMACIA NAVARRO
Artículos Elegibles: Cada producto OTC elegible es, o un medicina, o una pomada, o un aerosol, o se usa para tratar una enfermedad que se trata con un medicamento, una pomada o un aerosol que tienen ingredientes medicinales activos. Los suministros
de primeros auxilios, incluyendo los vendajes, los esparadrapos (no de deportes) también son elegibles. Los productos que no son
elegibles no estarán cubiertos.
*Productos de Doble Propósito: Antes de hacer el pedido/compra (1) el afiliado debe tener las conversaciones apropiadas con su
proveedor personal, y (2) el proveedor personal debe recomendar verbalmente el producto OTC para una condición diagnosticable
específica. Otros productos en este formulario están clasificados como elegibles. Estos pueden ser ordenados o comprados sin
ninguna otra acción adicional.
Los pedidos serán enviados a su domicilio sin cargo adicional. Por favor permita 2-3 semanas para la entrega. Esta lista de productos está sujeta a cambios. Este beneficio sólo está disponible si su plan ofrece el servicio de venta libre como beneficio. Por favor
revise su Evidencia de Cobertura para obtener más información.
Esta información esta disponible de gratis en otros idiomas. Por favor llame a Servicios al Afiliado sin cargo al 1-877-577-0115 (TTY
711). Desde el 1 de octubre al 14 de febrero, los 7 días a la semana de 8 a.m. a 8 p.m, hora del este. A partir del 15 de febrero de
lunes a viernes de 8 a.m. a 8 p.m.
2014 Over-the-Counter (OTC) Order Form
2014 Formulario de Productos de Venta Libre (OTC)
YOU WILL RECEIVE THE GENERIC EQUIVALENT OF ALL ITEMS.
USTED RECIBIRA EL GENERICO DE TODOS LOS PRODUCTOS.
Name:
(Nombre):
Address:
(Dirección):
Member Id:
(Numero De Membresia):
Item
C1
C10
C11
C12
C13
C20
C14
C16
C19
C2
C24
C35
C52
C53
C54
C7
Item
E1
E2
E3
B16
Item
B2
B6
M2
M35
Cough / Cold / Allergy
QTY
Price
(Tos / Catarros / Alergia)
Cantidad Precio
Nasal Spray Regular
1 oz 4.39
Loratidine 10mg
10 ct 8.89
Sore Throat Lozenges
18 ct 3.29
Tussin Expectorant
4 oz 4.39
Tussin DM
4 oz 4.39
Ch. Allergy Elixir Non Pseudo
4 oz 4.59
MAPAP Cold Multi Symptom Major
24 ct 4.29
Nasal Decongestant Pseudo Free
18 ct 4.39
Chest Congestant Relief 400mg
50 ct 8.49
Allergy Capsules
24 ct 3.29
Daytime PE Softgels
12 ct 4.39
Tussin Sugar Free
4 oz 4.39
Saline Nasal Spray
1.5 oz 3.69
Cetirizine 10mg Tablets
14 ct 10.99
Sinus Congestion & Pain Nighttime (PSE)
12 ct 4.19
Medicated Chest Rub
4 oz 4.99
Ear and Eye Care
QTY
Price
(Cuidado de la Vista y Oido)
Cantidad Precio
Artificial Tears
0.5 oz 4.29
Eye Drops
0.5 ml 3.69
Earache Drops
0.4 oz 7.99
Ear Wax Drops
0.5 oz 3.99
Dental Teeth Related
QTY
Price
(Dental)
Cantidad Precio
Denture Tabs
40 ct 5.39
Denture Adhesive Regular
2.5 oz 4.69
Toothbrush
each 0.99
Dental Floss Waxed
100 yd 1.99
Phone:
(Telefono):
Item
C8
F1
F10
F11
F2
F21
F22
F24
F29
F34
F35
F4
F5
F61
F62
F7
F9
Item
O1
O2
Item
B18
M1
M3
M6
M50
First Aid
(Primeros Auxilios)
Thermometer Digital
Bandage Self-Adherant 3"
Diaper Rash Ointment
Anti-Itch Cream
Muscle Rub
PV Iodine
PV Mercurochrome
PV First-Aid Kit
Anti-Itch Gel
Hot/Cold Therapy
Medicated Callous Remover
Calamine Lotion
Hydrocortisone Cream 1%
Triple Antibiotic Ointment Plus
First Aid Tape 0.5"
Triple Antibiotic Ointment
Clear Plastic Bandages
Anti-Fungals
(Antimicóticos)
Clotrimazole
Tolnaftate
Miscellaneous
Vitamin E Cream
Sunblock SPF 30
Medicated Lip Balm
Sleep Aid
Lubricating Jelly
QTY
Price
Cantidad Precio
each 5.39
3.29
4 oz 4.29
1 oz 3.29
4 oz 5.29
1 oz 2.19
1 oz 1.99
each 6.69
4 oz 4.69
each 5.39
6 ct 3.19
6 oz 2.19
1 oz 4.99
1 oz 6.69
5 yd 1.99
0.5 oz 4.39
30 ct 2.49
QTY
Price
Cantidad Precio
1 oz 9.99
1 oz 5.59
QTY
Price
4 oz 4.69
4 oz 4.29
0.5 oz 1.19
16 ct 4.99
4 oz 3.69
Item
A1
A4
A7
A8
L1
L2
L11
L4
L5
L6
L7
L13
D1
D3
D4
Item
H3
Item
P1
P11
P13
P14
P17
P19
P20
P2
P9
P3
P4
P44
P6
P8
Antacids / Digestion / Laxatives
QTY
Price
(Antiácidos / Digestión / Laxantes) Cantidad Precio
Effervescent Pain Relief
36 ct 4.69
Calcium Antacid ES Tablets (Mixed Fruit)
96 ct 4.29
Ranitidine 75mg
30 ct 9.19
Anti-acid Tabs
100 ct 6.39
Bisacodyl Tabs
100 ct 8.89
Stool Softener
60 ct 6.69
Colon Cleanser
120 ct 7.99
Natural Vegetable Laxative
100 ct 11.99
Cascara Sagrada
90 ct 5.99
Glycerin Suppositories Adult
25 ct 3.69
Fiber Capsules
160 ct 11.49
Enema Single
each 1.99
Anti-Diarrheal Tablets
18 ct 5.59
Pink Bismuth Tablets Chewable
30 ct 4.39
Gas Relief E/S
30 ct 5.59
Anti-Hemorroidals
QTY
Price
(Contra Hemorroides)
Cantidad Precio
Hemorroidal Ointment
2 oz 6.69
Pain Relief
QTY
Price
(Analgésicos)
Cantidad Precio
Ibuprofen Tabs 200mg
50 ct 4.19
Non-Aspirin Chew 80mg
30 ct 4.99
Non-Aspirin Suspension Cherry
4 oz 3.29
Hot and Cold Patches
5 ct 7.99
Migraine Relief Caplets
100 ct 6.69
Naproxen 220mg
10 ct 7.89
Glucose Chewable Tabs Orange
10 ct 2.29
Aspirin 325mg
100 ct 2.79
Aspirin Coated
100 ct 1.99
Enteric Aspirin 325mg
100 ct 5.39
Low-Dose Aspirin Enteric Coated
120 ct 5.49
Therapeutic Blue Gel
4 oz 4.19
Acetaminophen 500mg Tablets
100 ct 6.99
Chewable Aspirin 81mg
36 ct 5.39
YOU WILL RECEIVE THE GENERIC
EQUIVALENT OF ALL ITEMS.
USTED RECIBIRA EL GENERICO DE
TODOS LOS PRODUCTOS.
Item Vitamins / Minerals • Dual Purpose Items* QTY
Price
(Vitamins / Minerales) • (Producto de doble propósito*)
Precio
*Must consult with Primary Care Physician
prior to ordering a dual-purpose item.
*Consulte su Médico Primario antes de ordenar
un producto de doble propósito.
V1 B-Complex Vitamin 100% RDA*
100 ct 4.29
V10 Glucosamine/Chondroitin*
50 ct 10.69
V11 Calcium 500mg +D*
75 ct 5.39
V14 Vitamin A 10,000 IU Natural*
100 ct 3.69
V15 Chewable Multivitamins*
100 ct 6.59
V16 Vitamin E 400 IU*
100 ct 9.99
V17 Folic Acid 800mcg*
100 ct 3.19
V18 Iron Supplement*
100 ct 5.39
V19 Omega-3 Fish Oil 1000mg*
100 ct 7.49
V2 Vitamin C 500mg*
100 ct 5.89
V20 Soya Lecithin 1200*
100 ct 6.99
V21 Urinozinc Capsules*
60 ct 14.99
V26 Vitamin D 400 IU*
100 ct 3.19
V22 Collagen 500mg*
100 ct 8.79
V3 Calcium Carbonate + D*
60 ct 4.29
V5 Coenzyme Q-10 10mg*
30 ct 5.39
V6 Daily Multi Vitamin*
100 ct 4.59
V7 Complete Senior Vitamins*
100 ct 8.39
V32 Vitamin D 1,000 IU*
100 ct 3.49
V33 Vitamin B-12 1000mcg*
100 ct 7.99
V34 Resveratol Xtra Formula*
30 ct 4.99
V35 Magnesium 500mg*
100 ct 3.99
V36 Zinc Gluconate 50mg*
100 ct 4.69
V38 Co-Q10 30mg*
90 ct 9.99
B72 Blood Pressure Monitor*
each 15.99
VM Blood Pressure Monitor Semi
each 24.99
Item
Adult Incontinence**
QTY
Price
(Incontinencia**)
Cantidad Precio
**These items are only available to members enrolled in
Simply Care (HMO SNP) and Simply Comfort (HMO SNP)
**Estos productos son solo disponibles para aquellos afiliados
inscritos en Simply Care (HMO SNP) y
Simply Comfort (HMO SNP)
B73 Underpads Regular 17X23.5
36 ct 8.99
B74 Bladder Control Pads Super
20 ct 6.59
B75 Adult Underwear Small/Medium
20 ct 12.99
B76 Adult Underwear Large
18 ct 12.99
B77 Adult Underwear X-Large
16 ct 12.99
B78 Adult Briefs Medium
22 ct 12.99
B79 Adult Briefs Large
18 ct 12.99