OH OTC Form 2014

Name (Nombre)
Address (Dirección)
AETNA BETTER HEALTH® OF OHIO
Member ID ( Numero de Membresia)
Phone (Telefono)
Item
 Antacids / Digestion / Laxatives
(Antiácidos / Digestión / Laxantes)
Qty
Brand
Price
Precio
Item
Dental Teeth Related (Dental)
Qty
Brand
Price
Precio
A7
Ranitidine 75 mg
30 ct
Zantac
7.99
X2
Denture Tabs
40 ct
Efferdent
5.49
Q1
Anti -Diarrheal Tabs
18 ct
Imodium
5.49
X6
Denture Adhesive Regular
2.5 oz
Fixodent
4.99
L4
Laxative (Natural Vegetable)
100 ct
Senokot
10.99
M2
Toothbrush
1 ct
Oral-B
0.99
L5
Cascara Sagrada
90 ct
5.99
M35
Dental Floss Waxed
100 yd
J&J
1.99
L7
Fiber Capsules
160 ct
Metamucil
10.99
L6
Glycerin Suppositories
25 ct
Fleet
3.49
Item
Anti-Hemorrhoidals (Contra
Hemorroides)
Qty
Brand
 rice
P
Precio
L11
Colon cleanser
120 ct
FDC
7.99
H3
Hemorrhoidal Ointment
2 oz
Preparation H
6.49
L13
Enema Single
1 ct
Fleet
1.99
Item
Ear and Eye Care (Cuidado de la vista
y Oido)
Qty
Brand
 rice
P
Precio
Item
Pain Relief (Analgésicos)
Qty
 rand
B
Marca
 rice
P
Precio
E3
Ear Drops
0.4 oz
Similisan
7.99
Qty
Brand
 rice
P
Precio
A1
Effervescent Pain Relief
36 ct
Alka-Seltzer
4.49
Item
Miscellaneous / Sunscreen Lotion
(Misceláneo / Locion Protectora Del
Sol)
F2
Muscle Rub
4 oz
Bengay
5.49
X54
Ribbed Lubricated Condom
12 ct
Trojan
8.99
F34
Hot/Cold Patches (Reusable)
1 ct
Icy Hot
4.99
X74
Bladder Control Pads Super
20 ct
Poise
5.99
P1
Ibuprofen Pain Relief 200 mg
50 ct
Advil
4.49
X75
Adult Underwear Small/Medium
20 ct
Poise
12.99
P6
Acetaminophen 500 mg
100 ct
Tylenol
6.99
X76
Adult Underwear Large
18 ct
Poise
12.99
P11
Non-Aspirin (Chewable) 80mg
30 ct
Tylenol
4.49
X77
Adult Underwear X-Large
16 ct
Poise
12.99
P13
Non-Aspirin Suspension
4 oz
Tylenol
3.49
X80
Maxi Regular
24 ct
Always
3.49
P14
Hot/Cold Patches
5 ct
Icy Hot
6.99
X82
Tampon Plastic
20 ct
Tampax Pearl
3.99
P17
Migraine Relief
100 ct
Exedrin
7.49
M23
Hand Sanitizer
2 oz
Purel
1.49
P19
Naproxen 220mg
100 ct
Aleve
7.99
M39
Insoles Air Foam Mens
1 pr
Dr. Scholl's
1.99
P44
Muscle Therapeutic Blue Gel
4 oz
Mineral Ice
3.99
M40
Insoles Air Foam Womens
1 pr
Dr. Scholl's
1.99
M41
Standard Emery Boards
10 ct
0.99
 rice
P
Precio
M42
Nail Care Sticks
1 ct
0.99
Item
Cough / Cold / Allergy (Tos / Catarros
/ Alergia)
C7
Chest Rub-Medicated
3.5 oz Vick's Vaporub
4.99
M43
Square Tweezers
1 ct
0.99
C11
Sore Throat Lozenges
18 ct
3.49
M44
Nail Clipper
1 ct
1.99
M50
Lubricating Jelly
4 oz
K-Y
4.49
 rice
P
Precio
M1
Sunscreen SPF 30
4 oz
Coppertone
3.99
4.49
M48
Oil of Beauty
6 oz
Olay
5.99
Qty
 rand
B
Marca
Chloraseptic
Item
 First Aid
Primeros Auxilios
Qty
 rand
B
Marca
X18
Vitamin E Cream
4 oz
F4
Calamine Lotion
6 oz
Caladryl
2.49
F35
Medicated Callus Remover
1 ct
Dr. Scholls
3.49
F5
Hydrocortisone Cream 1%
1 oz
Cortaid
4.99
F64
Benzoyl Peroxide 10%
1 oz
Oxy Balance
3.99
F10
Skin Rash Ointment
2 oz
Desitin
3.99
M12
Baby Wipes
20 ct
J&J
1.99
F11
Anti -Itch Cream
1 oz
Benadryl
3.49
M37
Pregnancy Stick Single
1 ct
E.P.T
7.99
F29
Anti- Itch Gel
4 oz
Benadryl
4.99
M51
7 Day Pill Box
each
Apex
$1.99
M11
Skin Powder
4 oz
J&J
1.99
M3
Medicated Lip Balm
.35 oz
Chap Stick
0.99
X72
*Blood Pressure Monitor
1 ct
Omron
17.99
C8
Thermometer Digital
1 ct
APEX
4.99
F1
Self-Adherent Bandages
3"
Ace
3.49
F9
Clear Plastic Bandage
30 ct
Band Aid
2.49
F21
Iodine
1 oz
Dr. Sana
1.99
F22
Mercurochrome
1 oz
Dr . Sana
2.49
F24
First Aid Kit
1 ct
J&J
6.99
F62
First Aid Tape
5 yd
J&J
1.99
*Limit (1) per order • *Límite de (1) por orden
Medicines, ointments and sprays with active medical ingredients that cure, diminish or remove symptoms
Medicamentos, ungüentos y aerosol con ingredientes medicinales activos que curan o eliminan los síntomas
You will receive the generic equivalent of all items.
Usted recibira el generico de todos los productos. 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 Call 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 can get this information for free in other languages. Call 1-855-364-0974 (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.
Waxaad macluumaadkaan oo lacag la'aan ah ku heli kartaa luqado kale. Wac 1-855-364-0974 (TTY: 711) 24 saac maalintii, 7 maalin halkii todobaad. Wicidda waa lacag la'aan.
This information is available for free in other languages and formats like Braille or audio CD.
OH-15-01-01
H7172_15_025 CMS APPROVED
Item
Vitamins / Minerals (Vitaminas /
Minerales)
Qty
 rand
B
Marca
 rice
P
Precio
Item
Vitamins / Minerals (Vitaminas /
Minerales)
Qty
 rand
B
Marca
 rice
P
Precio
V2
Vitamin C 500 mg
100ct
Nature Made
5.99
V22
Collagen 500 mg
100ct
Botanic Choice
8.49
V4
Cat's Claw 350 mg
60ct
5.49
V23
Colostrum 500 mg
120ct
Swanson Ultra
14.99
V8
Echinacea 400 mg
60ct
7.49
V24
Garlic Odorless 2000 mg
100ct
V9
Gingko Biloba 400 mg
50ct
6.49
V33
Vitamin B 12
100ct
Nature Made
8.49
V10
Glucosamine/Chondroitin (Tablets)
50ct
Nature's Bounty 10.99
V34
Resveratol Xtra Formula
30ct
FDC
4.99
V14
Vitamin A 10,000 IU Natural
100ct
Nature's Bounty
4.49
V36
Zinc Gluconate 50 mg Chelated
100ct
FDC
4.49
V16
Vitamin E 400 mg IU
100ct
Nature Made 11.99
V38
CO- Q10 30 mg
90ct
Nature's Bounty
9.99
V20
Soya Lecithin 1200 mg
100ct
V40
Selenium 50 mg
100ct
FDC
4.49
V21
Urinozinc
60ct
Sundown
6.99
5.99
14.99
 ust consult with Primary Care Physician prior to ordering a dual-purpose item.
M
Debe consultar con su médico de cabecera antes de ordenar un producto de doble propósito.
Over-the-Counter Drug Catalog Program $20 Monthly Benefit
Aetna Better Health Ohio
Aetna Better Health Ohio is pleased to provide its members with the Overthe-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.
HOW TO ORDER BY MAIL:
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.
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.
Programa de Catálogo de Medicamentos sin Receta
Beneficio de $20 Mensual
Aetna Better Health Ohio
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
COMO ORDENAR POR CORREO:
1. 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. 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. Fold and seal the form with tape.
3. Doble y selle el formulario con cinta adhesiva.
4. Place a first class postage stamp on the address side (out-side) of
the form and mail.
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.
4. Coloque una estampilla de Primera Clase en la parte de afuera de este
formulario.
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.
ORDER ONLINE: aetnaoh.otchs.com
por internet: aetnaoh.otchs.com
Name: _______________________________________________
Address: _____________________________________________
City: _____________________ State: __________ Zip: ________
OTC Health Solutions
9400 NW 104 Street
Medley, FL 33178