2018 Over-the-Counter (OTC) Order Form

Transcription

1 Michigan Complete Health (Medicare-Medicaid Plan) 2018 Over-the-Counter (OTC) Order Form TTY: Monday through Friday 9 a.m. to 5 p.m. Michigan Complete Health is pleased to provide its members with an Over-the-Counter (OTC) benefit. This is a convenient way to get OTC health and wellness supplies by mail at no extra cost to you. Be sure to take full advantage of this great benefit. To get started, select all the item(s) you want to complete your order. You may place one order per benefit period. Remember, your order total cannot exceed your allowable benefit, and we cannot accept payment to purchase items over your benefit. Please note, if you exceed the benefit amount your order cannot be processed. Additionally, your OTC allowance does not carry over to the following benefit period. Michigan Complete Health OTC Benefit Listing Plan Benefit Amount Benefit Period Michigan Complete Health $20 Every month H9487_18_OTCOrdBklt_Approved_ FLY018245EO00 Page 1

2 Ordering is Easy! ORDER BY PHONE: To place your order by phone, call , TTY: , from 9 a.m. to 5 p.m., Monday through Friday. ORDER BY INTERNET: Place your order online: MIcompletehealthMMP.otchs.com ORDER BY MAIL: 1. Clearly write your name, address, telephone number and member ID number in the space at the top of the form. 2.Enter quantity of 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 9675 NW 117th Avenue, Suite 202 Miami, FL A replacement order form will be included in the package containing your order. The replacement order form may be used for your next eligible order. ORDER BY FAX: To order by fax, fill in your form and fax it to: Orders will be shipped to your home at no extra charge. Please allow 7-10 business days for delivery. This product list is subject to change. This service is only available if your plan offers an OTC benefit. Please review your member handbook or contact Member Services for more information. Page 2

3 Michigan Complete Health (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. Limitations, restrictions, and patient pay amounts may apply. This means that you may have to pay for some services and that you need to follow certain rules to have Michigan Complete Health pay for your services. For more information, call Michigan Complete Health Member Services or read the Michigan Complete Health Member Handbook. Benefits may change on January 1 of each year. If you do not speak English, language assistance services, free of charge, are available to you. Call (TTY: 711), from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. The call is free. Page 3

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5 Michigan Complete Health (Medicare-Medicaid Plan) 2018 Over-the-Counter (OTC) Order Form Name: Address: Member Id: Date: Order Month: Phone: Reminder: Any unused amounts cannot be carried over to the next benefit period. You will receive the generic equivalent of all items Antacids, Digestion and Laxatives A1 Effervescent Pain Relief Alka-Seltzer 36 CT $4.49 A2 Dairy Relief Chewable Lactaid 60 CT $12.49 A8 Heart Burn Relief Tablets Gaviscon 100 CT $6.49 A15 Motion Sickness Tablets Dramamine 12 CT $3.99 L6 Glycerin Suppository Adult Fleet 25 CT $3.99 L7 Fiber Capsules Metamucil 160 CT $10.99 L10 Daily Fiber Sugar Free Metamucil 10 OZ $7.99 P20 Glucose Tablets Orange Dex4 10 CT $1.49 Q4 Gas Relief E/S Soft Gel Gas-X 30 CT $4.49 Q5 BeanAid Capsules Beano 30 CT $5.99 Dental Care M2 Toothbrush Each $0.99 M3 Lip Balm Original SPF 15 Chapstick 0.15 OZ $1.99 M4 Sens Tooth Paste White Sensodyne 4 OZ $4.99 M35 Dental Floss Waxed J&J 100 yd $2.49 M52 Oral Pain Relief Anbesol 0.33 OZ $5.99 M71 Flosser Picks Flosser Picks 90 CT $2.99 X2 Denture Cleanse Tab A/B Mint Polident 84 CT $5.49 X5 Denture Cleans Tab A/B Efferdent 40 CT $2.99 X6 Denture Adhesive Regular Poligrip 2.4 OZ $4.49 Page 5

6 C1 Nasal Spray Regular Afrin Sinus 1 OZ $5.49 C3 Cold Flu & Sore Throat Max Mucinex 6 OZ $9.99 C7 Medicated Chest Rub Vicks VapoRub 3.5 OZ $5.99 C8 Thermometer Digital 1 CT $4.99 C11 Sore Throat Lozenges Cepacol 18 CT $3.99 C12 Tussin CF Max Strength Robitussin CF 4 OZ $5.49 C13 Tussin DM Robitussin DM 4 OZ $4.99 C16 Nasal Decongest Pseudo Free Sudafed PE 18 CT $4.49 C19 Chest Congest Relief 400mg 60 CT $9.49 C20 Child Allergy Elixir Pseudo Free Benadryl 4 OZ $4.99 C24 Daytime Cold/Flu Pseudo Free Soft gels DayQuil 16 CT $4.49 C52 Nasal Spray Saline Ocean 1.5 OZ $3.49 C54 Nighttime Cold & Flu NyQuil 16 CT $4.49 C56 Sinus Acetaminophen Tylenol Sinus 24 CT $4.99 C57 Sore Throat Spray Chloraseptic 6 OZ $4.49 C58 Child's Cold Cough & Sore Throat Mucinex 4 OZ $8.99 C60 Cough & Cold (HBP) Coricidin 16 CT $5.99 C62 Cold Sore Treatment Abreva 0.07 OZ $16.99 C64 Air Shield Orange Tablets Airborne 10 CT $6.49 C65 You will receive the generic equivalent of all items Cough, Cold and Allergy Honey Lemon SF Cough Drops Halls 25 CT $1.99 E1 Dry Eye Relief Visine Tears 0.5 OZ $4.49 E2 Eye and Ear Care Eye Drops Redness Relief Visine Original 0.5 OZ $3.49 X16 Ear Wax Removal Kit Murine Kit $5.99 Page 6

7 You will receive the generic equivalent of all items First Aid Medical Supplies F1 Elastic Bandage 4" FUTURO Elastic 1 CT $3.99 F2 Muscle Rub Bengay 3 OZ $5.99 F3 Bandage Antbtc One Size Band-Aid Antibiotic 20 CT $3.99 F4 Calamine Lotion Plus Caladryl 6 OZ $4.99 F9 Bandage Clear Assort. Sizes Band-Aid 45 CT $3.99 F11 Anti-Itch Cream Benadryl 1 OZ $4.99 F12 Bandage Sheer One Size Band-Aid Sheer 40 CT $2.99 F21 Iodine 1 OZ $2.49 F22 First Aid Antsep Merthiolate 2 OZ $4.99 F29 Anti-Itch Gel Benadryl 4 OZ $4.99 F34 Hot/Cold Multi Compress 1 CT $8.99 F36 Reusable Ice Pack 1 CT $4.99 F61 Bacitracin 1 OZ $5.99 F62 First Aid Tape 1 CT $1.99 F65 Gauze Pad 2X2 25 CT $3.99 F68 Petroleum Jelly Vaseline 2.5 OZ $3.49 F69 Butterfly Closures 12 CT $3.49 F70 Hydrogen Peroxide Spray 8 OZ $2.49 F71 Epsom Salt 64 OZ $3.99 F72 Sharps Container EACH $11.99 M45 Alcohol Prep Pads BD 100 CT $3.99 M53 Gauze Roll 2" X 2 yds 1 CT $1.99 M57 Gloves Nitrile Large 50 CT $7.49 Page 7

8 You will receive the generic equivalent of all items Foot Care F35 Corn & Callus Remover Kit Dr. Scholl's 0.5 OZ $3.99 O3 Wart Removal Compound W 0.5 OZ $5.99 O4 Odor Control Spray Powder Odor-Eaters 4 OZ $4.99 O5 Moleskin Padding Dr. Scholl's 2 CT $2.49 X74 Pads-Bladder Control Moderate Poise 20 CT $5.99 X75 Underwear Women S/M Depends 20 CT $13.99 X77 Underwear Men S/M Depends 18 CT $13.99 X83 X84 Adult Incontinence Unisex Overnight Underwear XL 58"-68" Unisex Overnight Underwear L 44"-58" Depends 12 CT $13.99 Depends 14 CT $13.99 M23 Hand Sanitizer Purell 2 OZ $1.49 M49 Tablet Cutter Each $6.49 M51 7 Day Pill Box Each $2.49 M75 M76 *X72 Mosquito Repellent with 30% Deet Mosquito Repellent Deet Free Blood Pressure Monitor Manual 8.7" x 12.6" Miscellaneous OFF! Repellant OFF! Repellant 6 OZ $ OZ $6.49 Each $17.99 X81 Maxi Reg Always 24 CT $3.49 *Limit of 1 BP monitor per year / Must consult with Primary Care Physician prior to ordering a dual-purpose item. Page 8

9 H2 Hemorrhoid Suppositories Preparation H 12 CT $4.99 H3 Hemorrhoid Ointment Preparation H 2 OZ $7.49 M6 You will receive the generic equivalent of all items Sleep Aid Pain Relievers and Sleep Aids Tylenol Simply Sleep 24 CT $3.99 M46 Urinary Relief Max Strength Azo 12 CT $4.99 P14 Hot/Cold Patch Icy Hot 5 CT $6.99 P17 Headache Pain Relief Excedrin 100 CT $7.49 P45 Acetaminophen Pain Relief PM Tylenol PM 24 CT $4.49 P50 Menstrual Pain Relief Max Midol 24 CT $4.99 Personal Care F10 Diaper Rash Ointment Desitin 2 OZ $3.99 F64 Acne Treatment 10% Clearasil 1 OZ $4.99 M1 Sunblock SPF 45 3 OZ $8.49 M9 Cotton Swab 375 CT $2.49 M91 Facial Tissue 2 PK $0.99 M11 Baby Powder 4 OZ $1.99 M31 Oil Free Acne Wash Neutrogena 6 OZ $3.99 M33 Unscented Wipes 56 CT $3.49 M34 Diabetic Skin Lotion Gold Bond 13 OZ $6.99 Page 9

10 Vitamins and Minerals Dual Purpose Items Must consult with Primary Care Physician prior to ordering a dual-purpose item. You will receive the generic equivalent of all items V2 Vitamin C 500mg 100 CT $6.99 V3 Calcium Carbonate + D Caltrate 600+D 60 CT $4.49 V5 Coenzyme Q-10 50mg 30 CT $9.99 V10 Glucosamine/ Chondroitin Osteo Bi-Flex 80 CT $15.99 V16 Vitamin E 400 IU Soft Gel 100 CT $11.99 V17 Folic Acid 800mcg Tablet 100 CT $3.49 V19 Fish Oil Omega mg Puritan 120 CT $8.99 V32 Vitamin D 1000 IU 100 CT $3.49 V35 Magnesium 500mg 100 CT $4.49 V36 Zinc Gluconate 50mg 100 CT $4.49 V41 Chewable Multivitamins Flintstones 60 CT $6.99 V48 Biotin 10000Mc Soft Gel 60 CT $11.49 V49 Melatonin Gummy 5mg 60 CT $10.49 V54 Calcium Supplement Gummy 50 CT $10.49 V56 Vitamin A 8,000 IU Nat 100 CT $4.99 V57 Vitamin B mcg 100 CT $8.99 V58 B Complex Plus Vitamin C Nature's Bounty 130 CT $6.99 V59 V60 Potassium gluconate 550Mg Adult Daily Multiple Vitamin Nature's Bounty 100 CT $4.99 One A Day 365 CT $6.99 V61 B-6 Vitamins Nature's Bounty 100 CT $5.99 V62 Adult Daily Women's 50+ Adv. One A Day 50 CT $6.99 V63 Adult Daily Men's 50+ Adv. One A Day 50 CT $6.99 V64 Lutein 40mg Soft Gels Ocuvite 30 CT $17.99 Page 10

11 Notice of Non-Discrimination. Michigan Complete Health (Medicare-Medicaid Plan) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Michigan Complete Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Michigan Complete Health: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Michigan Complete Health s Member Services at (TTY: 711) from 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day. If you believe that Michigan Complete Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Michigan Complete Health s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD: ). Complaint forms are available at

12 Language Services ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). ملحوظة: إذا كنت تتحدث اللغة العربیة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請電 (TTY:711) ܝ ܐ ܡ ܨܝ ܬܘ ܢ ܕܩ ܒܠܝ ܬܘ ܢ ܢ ܠ ܫ ܢ ܐ ܐ ܬܘܪ ܢ ܟ ܐ ܗ ܡܙ ܡܝ ܬܘ ܙܘ ܗ ܪ ܐ: ܐ ܢ ܐ ܚܬܘ ܚ ܠܡ ܬ ܐ ܕܗ ܝ ܪܬ ܐ ܒܠ ܫ ܢ ܐ ܡ ܓ ܢ ܐܝ ܬ. ܩܪܘ ܢ ܥ ܠ ܡ ܢܝ ܢ ܐ (711 (TTY: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ল য কর ন য দ আপ ন ব ল, কথ বল ত প রন, ত হ ল ন খরচ য় ভ ষ সহ য়ত প র ষব উপল আ ছ ফ ন কর ন ১ (TTY: 711) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: 711). OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711).