2018 over-the-counter (otc) order form 2018 formulario de ... · número de teléfono y su número...

lunes a viernes 9 a.m. a 5 p.m.

2018 Formulario de Artículos OTC2018 Over-the-Counter (OTC) Order Form

866-528-4679 TTY: 1-877-672-2688

Monday through Friday 9 a.m. to 5 p.m.

Allwell 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.

Allwell se complace en proveer a sus meimbros el beneficio de Medicamentos Sin Receta o OTC. Es una forma conveniente de recibir por correo sus medicamentos y articulos para su salud y bienestar del OTC sin costo addicional. Asegúrese de aprovechar al máximo este gran beneficio.

Para empezar, seleccione sus artículos hasta completar su orden. Recurede que solo puede ordenar una sola vez por periodo de su beneficio, y que no aceptamos pago si se excede de el beneficio. Si su orden se excede de el beneficio no sera procesada. Cualquier restante que sobre de su beneficio OTC no es sumado al siguiente periodo.

Y0020_18_5220BROC_NM_11092017

Amount Benefit PeriodAllwell Dual Medicare (HMO SNP) Maricopa County $40 Every month

Arkansas: Allwell from Arkansas Health and Wellness

County Benefit Amount

Benefit Period

Allwell Medicare (HMO) Benton, Crawford, Sebastian and Washington Counties

$80 Every three months

Allwell Medicare (HMO) Garland, Pulaski and Saline Counties $80 Every three months

Allwell Medicare Select (HMO) Benton and Washington Counties $80 Every three months

Florida: Allwell from Sunshine Health County

Benefit Amount

Benefit Period

Allwell Dual Medicare (HMO SNP) Baker, Duval, Hardee, Hernando, Manatee, Marion, Martin, Polk and Volusia Counties $60 Every month

Allwell Dual Medicare (HMO SNP) Hillsborough, Lake, Orange, Osceola, Pasco, Pinellas, Seminole and St. Lucie Counties

$65 Every month

Allwell Dual Medicare (HMO SNP) Broward and Palm Beach Counties $80 Every month

Allwell Dual Medicare (HMO SNP) Miami-Dade County $85 Every month

Allwell Medicare (HMO) Miami-Dade County $55 Every monthAllwell Medicare Premier (HMO)

Miami-Dade County $35 Every month

Allwell Medicare Premier (HMO) Orange County $10 Every month

Allwell Medicare (HMO) Broward County $55 Every monthAllwell Medicare Premier (HMO)

Broward County $45 Every month

Georgia: Allwell from Peach State Health Plan County

Benefit Amount

Benefit Period

Allwell Dual Medicare (HMO SNP)

Butts, Chattahoochee, Clayton, Dawson, DeKalb, Fayette, Forsyth, Fulton, Greene, Gwinnett, Harris, Heard, Henry, Lumpkin, Marion, Morgan, Muscogee, Oconee, Pickens, Rabun, Rockdale, Taliaferro, Towns, Union and White Counties

$35 Every month

Allwell Medicare (HMO) Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale Counties

$15 Every month

Allwell Medicare (HMO) Chattahoochee, Harris and Muscogee Counties $35 Every month

Indiana: Allwell from MHS County Benefit Amount

Benefit Period

Allwell Medicare (HMO) Hamilton, Howard, and Marion Counties $65 Every three monthsAllwell Medicare (HMO) Allen, Elkhart, and St. Joseph Counties $65 Every three monthsAllwell Medicare (HMO) Vanderburgh Counties $65 Every three months

Benefit Arizona: Allwell from Health Net

County

Allwell Medicare (PPO) Hamilton, Howard, and Marion Counties $65 Every three monthsAllwell Medicare (PPO) Allen, Elkhart, and St. Joseph Counties $65 Every three monthsAllwell Medicare (PPO) Vanderburgh Counties $65 Every three monthsKansas: Allwell from Sunflower Health Plan

CountyBenefit Amount

Benefit Period

Allwell Medicare (HMO) Johnson and Wyandotte Counties $50 Every three monthsLouisiana: Allwell from Louisiana Healthcare Connections County

Benefit Amount

Benefit Period

Allwell Medicare (HMO) Ascension, East Baton Rouge, Livingston, West Baton Rouge,and Tangipahoa Counties


Allwell Medicare (HMO) St. Tammany County $65 Every three monthsMissouri: Allwell from Home State Health


Benefit Period

Allwell Medicare (HMO) Barry, Christian, Greene, Jasper, Lawrence, and Newton Counties


Allwell Medicare (HMO) Cass, Clay, Jackson, and Platte Counties $50 Every three months

Ohio: Allwell from Buckeye Health Plan


Benefit Period

Allwell Medicare (HMO) Columbiana, Cuyahoga, Mahoning, Stark, and Trumbull Counties


Allwell Medicare (HMO) Butler, Greene, Hamilton, and Montgomery County



Allen, Ashtabula, Auglaize, Brown, Carroll, Clark, Clermont, Cuyahoga, Defiance, Erie, Fulton, Geauga, Greene, Hamilton, Hancock, Hardin, Henry, Holmes, Huron, Lake, Lorain, Lucas, Medina, Montgomery, Ottawa, Paulding, Portage, Putnam, Sandusky, Seneca, Stark, Summit, Tuscarawas, Van Wert, Warren, Wayne, Williams, Wood and Wyandot Counties


Pennsylvania: Allwell from PA Health & Wellness County

Benefit Amount

Benefit Period

Allwell Dual Medicare (HMO SNP)Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and Westmoreland Counties

$75 Every month

Allwell Dual Medicare (HMO SNP) Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties $45 Every month

Allwell Medicare (HMO) Allegheny, Armstrong, Beaver, Butler, Fayette, and Westmoreland Counties $50 Every three months

Allwell Medicare (HMO) Calhoun, Fairfield, Kershaw, Richland, and Saluda Counties


Allwell Medicare (HMO) Greenville, Pickens, and Spartanburg Counties $85 Every three months


Abbeville, Allendale, Bamberg, Barnwell, Beaufort, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield, Florence, Georgetown, Greenville, Hampton, Jasper, Kershaw, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg, Pickens, Richland, Saluda, Spartanburg ,Union, and Williamsburg Counties


Allwell Dual Medicare Essentials (HMO SNP)

Abbeville, Allendale, Bamberg, Barnwell, Beaufort, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield, Florence, Georgetown, Greenville, Hampton, Jasper, Kershaw, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg, Pickens, Richland, Saluda, Spartanburg ,Union, and Williamsburg Counties


Texas: Allwell from Superior HealthPlan


Benefit Period

Allwell Medicare (HMO) Bexar County $30 Every three monthsAllwell Medicare (HMO) Collin, Dallas, Denton, Smith and Tarrant Counties $50 Every three monthsAllwell Medicare (HMO) Cameron and Hidalgo Counties $60 Every three monthsAllwell Medicare (HMO) El Paso County $45 Every three monthsAllwell Medicare (HMO) Neuces County $45 Every three monthsAllwell Dual Medicare (HMO SNP)

Collin and Rockwall Counties $50 Every three months

Allwell Dual Medicare (HMO SNP) Cameron and Hidalgo Counties $100 Every three months

Allwell Dual Medicare (HMO SNP) Dallas and Tarrant Counties $110 Every three months

Allwell Dual Medicare (HMO SNP) Bexar and Neuces Counties $60 Every month

South Carolina: Allwell from Absolute Total Care County

Benefit Amount

Benefit Period

Allwell Medicare (HMO)

Abbeville, Allendale, Bamberg, Barnwell, Chester, Chesterfield, Clarendon, Dillon, Edgefield, Florence, Georgetown, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg, Union, and Williamsburg Counties


Allwell Medicare (HMO) Beaufort, Charleston, Colleton, Hampton, and Jasper Counties $85 Every three months

Washington: Allwell from Coordinated Care


Benefit Period

Allwell Medicare (HMO) Spokane County $50 Every three monthsAllwell Medicare Plus (HMO) Spokane County $140 Every three monthsWisconsin: Allwell from MHS Health Wisconsin


Benefit Period


Adams, Brown, Calumet, Clark, Columbia, Dodge, Fond du Lac, Green Lake, Jefferson, Kenosha, Kewaunee, Langlade, Lincoln, Manitowoc, Marathon, Marinette, Marquette, Menominee, Milwaukee, Oconto, Outagamie, Ozaukee, Portage, Racine, Shawano, Sheboygan, Taylor, Walworth, Washington, Waukesha, Waupaca, Waushara, Winnebago and Wood Counties

$65 Every month

ORDER BY PHONE:To place your order by phone, call 866-528-4679, TTY/TTD: 1-877-672-2688, from 9 a.m. to 5 p.m., Monday through Friday.

ORDER BY INTERNET:Place your order online: Allwell.otchs.com

ORDER BY MAIL:

1. Clearly write your name, address, telephonenumber and member ID number in the space at the top of the form.

2. Enter quantity of items you want on the orderform that add up to your benefit amount or less.

3. Fold this form and put in an envelope. Place afirst class postage stamp on the envelope and send it to:

OTC Health Solutions,9675 NW 117th Avenue, Suite 202

Miami, FL 33178

4. A replacement order form will be included inthe package containing your order. The replacement order form may be used for your next eligible order.

ORDER BY FAX: To order by fax, fill out your form and send it to: 866-682-6733

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 Evidence of Coverage or contact member services for more information.

PEDIDO POR TELEFONO:Para realizar su pedido por teléfono, llame al 866- 528-4679, TTY/TTD: 1-877-672-2688 de 9 am a 5 pm, de lunes a viernes.

PEDIDO POR INTERNET:Envíe por internet: Allwell.otchs.com

PEDIDO POR CORREO:

1. Escriba claramente su nombre, dirección,número de teléfono y su número de afiliado en el espacio indicado.

2. Marque la cantidad de los artículos que desee ysume hasta la cantidad establecida de su beneficio o menos.

3. Coloque este formulario dentro de un sobre conuna estampilla de primera clase y envíenosla a:

OTC Health Solutions,9675 NW 117th Avenue, Suite 202

Miami, FL 33178

4. Un formulario de remplaso sera incluido en elpaquete con su orden. El Formulario es para usar en su siguente orden.

PEDIDO POR FAX:Para ordenar por fax, complete su formulario y

envielo a: 866-682-6733

Los pedidos serán enviados a su domicilio sin cargo adicional. Por favor permita 7 -10 dias laborables para la entrega.

Esta lista de productos está sujeta a cambios. Este beneficio sólo está disponible si su plan ofrece el servicio de OTC como beneficio. Por favor revise su Evidencia de Cobertura o llamar a servicios para los miembros si requiera mas informacion.

Ordering is Easy! Ordenar es Fácil!

Allwell has a contract with Medicare to offer HMO, PPO and HMO SNP plans. Allwell has a contract with Medicare and the state Medicaid program to offer HMO SNP coordinated care plans. Enrollment in an Allwell plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

This information is available for free in other languages. Please contact our customer service number 866-528- 4679 and for TTY/TTD assistance please dial 1-877-672-2688.

Allwell tiene un contrato con Medicare para ofrecer planes HMO, PPO y HMO SNP. Allwell tiene un contrato con Medicare y el programa estatal de Medicaid para ofrecer planes de atención coordinada de HMO SNP. La inscripción en un plan de Allwell depende de la renovación del contrato.

Esta información no es una descripción completa de los beneficios. Póngase en contacto con el plan para obtener más información. Se pueden aplicar limitaciones, copagos y restricciones. Los beneficios, primas y / o copagos / coseguros pueden cambiar el 1 de enero de cada año. Debe continuar pagando su prima de la Parte B de Medicare.

Esta información está disponible gratis en otros idiomas. Por favor, póngase en contacto con nuestro número de servicio al cliente al 866-528-4679. Para assistancia TTY/TTD por favor marque 1-877-672-2688.

Name: Date:(Nombre): (Fecha):Address: Order Month:(Dirección): (Mes de Orden):Member Id: Phone:(Numero De Membresia): (Teléfono):

QTYCode

CódigoProduct

Compare toComparado a

CountCantidad

PricePrecio

A1 Effervescent Pain Relief Alka-Seltzer® 36 CT $4.49

A2 Dairy Relief Chewable Lactaid® 60 CT $12.49

A4 Antacid Calcium E/S Tab Tums® 96 CT $3.99

A7 Ranitidine 75mg Zantac 75® 30 CT $7.99

A8 Heart Burn Relief Tablets Gaviscon® 100 CT $6.49

A9 Omeprazole Tabs 14 CT $11.49

A13 Antacid Calcium Smooth TUMS® 60 CT $3.99

A14 Acid Controller Tabs Pepcid AC® 30 CT $6.99

A15 Motion Sickness Tablets Dramamine® 12 CT $3.99

L1 Bisacodyl Laxative Tabs Dulcolax® 25 CT $4.49

L2 Stool Softener Colace® 100 CT $9.99

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

Q1 Anti-Diarrheal Caplets Imodium® 12 CT $5.49

Q3 Pink Bismuth Chewable Pepto-Bismol® 30 CT $3.99

Q4 Gas Relief E/S Soft Gel Gas-X® 30 CT $4.49

Q5 BeanAid Capsules Beano® 30 CT $5.99

2018 Formulario de Artículos de OTC

2018 Over-the-Counter (OTC) Order Form

Cápsulas para alivio de gases

Tabletas para aliviar gases

Bismuto rosado masticables

Tabletas antiácidas

Antiácidos con calcio

Supositorios de glicerina

Cápsulas de fibra

Fibra diaria sin azúcar

Tabletas antidiarreicos

Omeprazol en tabletas

Alivio de acidez estomacal

Comprimidos DramaminaBisacodilo en tabletas laxantesAblandador de heces

Tabletas de Glucosa de Naranja

Ranitidina 75mg

Reminder: Any unused amount cannot be carried over to the next benefit period You will receive the generic equivalent of all items / Usted recibirá el genérico de todos los productos

Antacids, Digestion and Laxatives / Antiácidos, Digestión y Laxantes

Analgésico efervescente

Alivio De Lácteos Masticable

Antiácido de calcio en tabletas

Producto

QtyCode

CódigoProduct


CountCantidad

PricePrecio

C1 Nasal Spray Regular Afrin Sinus® 1 OZ $5.49

C2 Allergy Relief Tablets Benadryl® 24 CT $3.99

C3 Cold Flu & Sore Throat Max Mucinex® 6 OZ $9.99

C7 Medicated Chest RubVicks® VapoRub™

3.5 OZ $5.99

C8 Thermometer Digital 1 CT $4.99

C10 Loratidine 10mg Claritin® 10 CT $7.99

C11 Sore Throat Lozenges Cepacol® 18 CT $3.99

C12 Tussin CF Max Strength Robitussin CF® 4 OZ $5.49

C13 Tussin DMRobitussin 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

C20Child Allergy Elixir Pseudo Free

Benadryl® 4 OZ $4.99

C24Daytime Cold/FluPseudo Free Soft gels

DayQuil™ 16 CT $4.49

C52 Nasal Spray Saline Ocean® 1.5 OZ $3.49

C53 Allergy Cetirizine 10mg Tabs Zyrtec® 14 CT $9.99

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

C58Child's Cold Cough & Sore Throat

Mucinex® 4 OZ $8.99

C59 Fluticasone Nasal Spray Flonase® 0.34 OZ $14.99

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 Honey Lemon SF Cough Drops

Halls® 25 CT $1.99

Antihistamínico para resfriado

Para las astas bucalesTabletas para soporte del sistema inmune

Propionato de fluticasona, spray nasal

Pastillas de miel y limon para la tos

Descongestionante nasal seudo libre

Fricción medicinal para el pecho

Termómetro digital

Loratidina 10 mg

Medicina para la tos Tussin DM

Tussin CF

Pastillas para la irritación de garganta

You will receive the generic equivalent of all items / Usted recibirá el genérico de todos los productosCough, Cold and Allergy / Tos, Catarros y Alergia

Aerosol nasal regular

Tabletas para el alivio de alergia

Para La gripe y dolor de garganta

Producto

Medicina para la tos,resfriado y dolor de garganta para ninos

Descongestionante del pecho 400 mg

Alivio de alergia en líquido para niños

Cápsulas diurnas de gel para la gripe

Aerosol nasal de agua salina

Cetirizina 10 mg tabletas para alergia

Medicina nocturna para el resfriado y la gripe

Spray para el dolor de garganta

Acetaminofen Sinusal

QtyCode

CódigoProduct


CountCantidad

PricePrecio

E1 Dry Eye Relief Visine Tears® 0.5 OZ $4.49

E2 Eye Drops Redness Relief Visine Original® 0.5 OZ $3.49

E4 Eye Itch Relief Zaditor® 0.17 OZ $10.99

X16 Ear Wax Removal Kit Murine® Kit $5.99

QtyCode

CódigoProduct


CountCantidad

PricePrecio

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

F5 Hydrocortisone Cream 1% Cortizone® 1 OZ $4.99

F7 Triple Antibiotic Ointment Neosporin® 0.5 OZ $4.49

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

F25 Lice Treatment 8 OZ $15.99

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

Gota Para El Picor De Los Ojos

You will receive the generic equivalent of all items / Usted recibirá el genérico de todos los productos

Eye and Ear Care / Ciudado de la Vista y Oido

Producto

Alivio para ojos resecos

Gotas para el alivio de ojos rojos

Vendajes un solo tamaño

Kit para la cera en los oídos

First Aid Medical Supplies / Primeros Auxilios

Producto

Vendas Elásticas

Crema muscular

Vendaje De Tejido Antibacterial

Loción de calamina

Hidrocortisona en crema al 1%

Pomada triple antibiótica

Vendas tamaños surtidos

Crema contra la picazón

Peróxido de Hidrogeno en spray

Yodo

Mertiolato antiséptico

Tratamiento de piojos

Gel contra la picazón

Compresa fria y caliente

Paquete de hielo reutilizable

Bacitracina

Cinta para primeros auxilios

Gasa Estéril 2X2

Jalea de petróleo

Cierres de mariposas

Sulfato de Magnesio

Sistema Eliminador de Agujas

Almohadillas de alcohol

Gasa

Guantes de nitrilo grandes

QtyCode

CódigoProduct


CountCantidad

PricePrecio

F35 Corn & Callus Remover Kit Dr. Scholl's® 0.5 OZ $3.99

O2Tolnaftate Athlete's Foot Cream

Tinactin® 1 OZ $6.99

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

QtyCode

CódigoProduct


CountCantidad

PricePrecio

X74Pads-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

X83Unisex Overnight Underwear XL 58"-68"

Depends® 12 CT $13.99

X84Unisex Overnight Underwear L 44"-58"

Depends® 14 CT $13.99

QtyCode

CódigoProduct


CountCantidad

PricePrecio

M23 Hand Sanitizer Purell® 2 OZ $1.49

M49 Tablet Cutter Each $6.49

M51 7 Day Pill Box Each $2.49

M75Mosquito Repellant with 30% Deet

OFF! Repellant®

6 OZ $6.49

M76Mosquito Repellant Deet Free

OFF! Repellant®

6 OZ $6.49

*X71Blood Pressure MonitorSemi Auto 8.7" x 16.5"

Each $24.99

*X72Blood Pressure MonitorManual 8.7" x 12.6"

Each $17.99

X81 Maxi Reg Always® 24 CT $3.49

Pañales pequeños/ medianos MPañales absorbentes unisexo para la noche XL - 58" - 68"Pañales absorbentes unisexo para la noche L - 44" - 58"

You will receive the generic equivalent of all items / Usted recibirá el genérico de todos los productos

Producto

Atomizador de control de olores en polvoRelleno Moleskin

Eliminador medicinal de callos

Crema para el pie de atleta tolnaftato

Eliminación de verrugas

Foot Care / Cuidado de los pies

Adult Incontinence / Incontinencia

Producto

Almohadillas para incontinencia

Pañales pequeños/ medianos F

*Limit of 1 BP monitor per year / Must consult with Primary Care Physician prior to ordering a dual-purpose item.*Limite de 1 BP monitor annual / Consulte su Médico de cabecera antes de ordenar un producto de doble propósito.

Desinfectante de manos

Toallas sanitarias regular

Miscellaneous / Misceláneo

Cortador de tabletas

Pastillero de 7 dias

Producto

Monitor de presión arterial semi auto 8.7" x 16.5"Monitor de presión arterial8.7" x 12.6"

Repelentes de mosquitos con 30% de dietiltoluamidaRepelentes de mosquitos sin dietiltoluamida

QtyCode

CódigoProduct


CountCantidad

PricePrecio

H2 Hemorrhoid Suppositories Preparation H® 12 CT $4.99H3 Hemorrhoid Ointment Preparation H® 2 OZ $7.49

M6 Sleep AidTylenol® Simply Sleep

24 CT $3.99

M46 Urinary Relief Max Strength Azo® 12 CT $4.99P1 Ibuprofen Tabs 200mg Advil® 50 CT $4.49

P4Low Dose Enteric Aspirin 81mg

Ecotrin® 120 CT $5.49

P6 Acetaminophen 500mg Tylenol® 100 CT $6.99

P8 Aspirin Chewable 81mgBayer Chewable®

36 CT $2.49

P11 Child Non Aspirin Chew 80mg 30 CT $3.99

P12 Child Ibuprofen Suspension Motrin® 4 OZ $6.49P13 Child Non Aspirin Suspension Tylenol® 4 OZ $4.49P14 Hot/Cold Patch Icy Hot® 5 CT $6.99P17 Headache Pain Relief Excedrin® 100 CT $7.49P19 Naproxen 220mg Aleve® 24 CT $4.49

P45Acetaminophen Pain Relief PM

Tylenol PM® 24 CT $4.49

P50 Menstrual Pain Relief Max Midol® 24 CT $4.99P51 Aspirin Enteric Coated 325Mg Ecotrin® 100 CT $6.49

P52Acetaminophen 325 Regular Strength

Tylenol® 90 CT $8.99

QtyCode

CódigoProduct


CountCantidad

PricePrecio

F10 Diaper Rash Ointment Desitin® 2 OZ $3.99F64 Acne Treatment 10% Clearasil® 1 OZ $4.99M1 Sunblock SPF 45 3 OZ $8.49M9 Cotton Swab 375 CT $2.49

M91 Facial Tissue 2 PK $0.99M11 Baby Powder 4 OZ $1.99

M30Miconazole 7 day Vaginal Cream

7 CT $7.99

M31 Oil Free Acne Wash Neutrogena® 6 OZ $3.99M33 Unscented Wipes 56 CT $3.49M34 Diabetic Skin Lotion Gold Bond® 13 OZ $6.99

QtyCode

CódigoProduct


CountCantidad

PricePrecio

M60 Nicotine Gum 4mg 20 CT $10.99M62 Nicotine Gum 2mg 20 CT $10.99

Somnífero

You will receive the generic equivalent of all items / Usted recibirá el genérico de todos los productosPain Relievers and Sleep Aids / Analgésicos y Artículos para ayudarle a dormir

Producto

Supositorios HemorroidalesUngüento para hemorroides

Naproxen 220mg

Alivio Urinario fuerza máximaIbuprofeno 200 mgAspirina entérica y recubierta de 81mgAcetaminofeno 500mg

Aspirina masticable 81mg

Acetaminofeno masticable 80mg niñosIbuprofeno en supensión para niñosAcetaminofeno en supensión niñosParches calientes y friosAlivio de dolor de cabeza

Talco para bebé

Acetaminofeno PM

Alivio de dolor menstrualAspirina recubierta 325MGAcetaminofeno 325MG Regular Strength

Personal Care / Cuidado personal

Producto

Ungüento para erupciones en la pielTratamiento de acné 10%Protector solar SPF 45Hisopos de algodónPañuelo de Papel

Producto

Chicle con Nicotina 4mgChicle con Nicotina 2mg

Tratamiento Vaginal Miconazole

Lavado de acné sin aceiteToallitas humeda sin olorLoción para la piel diabética

Nicotine Replacement Therapy / Tratamiento de reemplazo de Nicotina

QtyCode

CódigoProduct


CountCantidad

PricePrecio

V2 Vitamin C 500mg 100 CT $6.99V3 Calcium Carbonate + D Caltrate 600+D® 60 CT $4.49V5 Coenzyme Q-10 50mg 30 CT $9.99

V10 Glucosamine/ Chondroitin Osteo Bi-Flex® 80 CT $15.99V16 Vitamin E 400 IU Soft Gel 100 CT $11.99V17 Folic Acid 800mcg Tablet 100 CT $3.49V18 Iron Supplement 65mg Feosol® 90 CT $5.49V19 Fish Oil Omega-3 1000mg Puritan® 120 CT $8.99V32 Vitamin D 1000 IU 100 CT $3.49V35 Magnesium 500mg 100 CT $4.49V36 Zinc Gluconate 50mg 100 CT $4.49V41 Chewable Multivitamins Flintstones™ 60 CT $6.99V48 Biotin 10000Mc Soft Gel 60 CT $11.49V49 Melatonin Gummy 5mg 60 CT $10.49

V54Calcium Supplement Gummy

50 CT $10.49

V56 Vitamin A 8,000 IU Nat 100 CT $4.99V57 Vitamin B12 500 mcg 100 CT $8.99

V58 B Complex Plus Vitamin C Nature's Bounty®

130 CT $6.99

V59 Potassium gluconate 550Mg

Nature's Bounty®

100 CT $4.99

V60 Adult Daily Multiple Vitamin One A Day® 365 CT $6.99

V61 B-6 Vitamins Nature's Bounty®

100 CT $5.99

V62Adult Daily Women's 50+ Adv.

One A Day® 50 CT $6.99

V63 Adult Daily Men's 50+ Adv. One A Day® 50 CT $6.99V64 Lutein 40mg Soft Gels Ocuvite® 30 CT $17.99

QtyCode

CódigoProduct


CountCantidad

PricePrecio

M2 Toothbrush Each $0.99M3 Lip Balm Original SPF 15 Chapstick® 0.15 OZ $1.99M4 Sens Tooth Paste White Sensodyne® 4 OZ $4.99

M35 Dental Floss Waxed J&J® 100 yd $2.49M52 Oral Pain Relief Anbesol® 0.33 OZ $5.99M71 Flosser Picks Flosser Picks® 90 CT $2.99

X2Denture Cleanse Tab A/B Mint

Polident® 84 CT $5.49

X5 Denture Cleans Tab A/B Efferdent® 40 CT $2.99X6 Denture Adhesive Regular Poligrip® 2.4 OZ $4.49Pegamento para dentales regular

Hilo dental enceradoAlivio del dolor oralPortahilo Dental

Tabletas para dentaduras menta

Tabletas para dentaduras

Dental Care / Ciudado Dental

Producto

Cepillo dentalBalsamo para labiosPasta dental blanqueadora

Luteina 40MG capsula de gelatina

Magnesio 500 mgVitamina D 1000 mg IU

Ácido fólico 800 mg

Multivitaminas suplemento para adulto

Vitamina B6

Complejo B más vitamina C

Vitamina E 400 mg IU Capsulas de gelGlucosamina/Condroitina

Suplemento de hierro 65mgAceite de pescado Omega-3 1000 mg

Multivitamina para hombre 50+

Melatonina Gomitas 5 mg

Suplemento de calcio en gomitas

Gluconato de potasio 550MG

Multivitamina para mujer 50+

Gluconato de zinc 50 mgVitaminas masticables

Vitamina A 8,000 IUVitamina B-12 500 mcg

Biotina 10000 mcg capsulas de gelatina

Vitamins and Minerals • Dual Purpose Items / Vitaminas y Minerales • Producto de doble propósito Must consult with Primary Care Physician prior to ordering a dual-purpose item.

Consulte su Médico de cabecera antes de ordenar un producto de doble propósito.You will receive the generic equivalent of all items / Usted recibirá el genérico de todos los productos

Vitamina C 500 mgCarbonato de calcio 600 mg + DCoenzima Q-10 50mg

Producto

Y0020_18_2830MLI_Accepted_07142017

Section 1557 Non-Discrimination Language Notice of Non-Discrimination

Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Allwell:

Provides free aids and services to people with disabilities to communicate effectively with us, suchas 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 Allwell’s Member Services telephone number listed for your state on the Member Services Telephone Numbers by State Chart. From October 1 to February 14, you can call

us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.

If you believe that Allwell 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 in the

chart below and telling them you need help filing a grievance; Allwell’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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf 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, 1-800-368-1019 (TDD: 1-800-537-7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Member Services Telephone Numbers By State Chart

State Telephone Number and Plan Type

Arizona 1-800-977-7522 (HMO and HMO SNP); 1-877-935-8020 (Allwell Dual

Medicare (HMO SNP)) (TTY: 711) Arkansas 1-855-565-9518 (HMO) (TTY: 711) Florida 1-844-293-2636 (HMO); 1-877-935-8022 (HMO SNP) (TTY: 711)

Georgia 1-844-890-2326 (HMO); 1-877-725-7748 (HMO SNP) (TTY: 711) Indiana 1-855-766-1541 (HMO and PPO) (TTY: 711)

Kansas 1-855-565-9519 (HMO) (TTY: 711) Louisiana 1-855-766-1572 (HMO) (TTY: 711)

Mississippi 1-844-786-7711 (HMO) (TTY: 711)

Missouri 1-855-766-1452 (HMO) (TTY: 711) Ohio 1-855-766-1851 (HMO); 1-866-389-7690 (HMO SNP) (TTY: 711)

Pennsylvania 1-855-766-1456 (HMO); 1-866-330-9368 (HMO SNP) (TTY: 711) South Carolina 1-855-766-1497 (HMO and HMO SNP) (TTY: 711)

Texas 1-844-796-6811 (HMO); 1-877-935-8023 (HMO SNP) (TTY: 711)

Washington 1-855-848-6940 (HMO) (TTY: 711) Wisconsin 1-877-935-8024 (HMO SNP) (TTY: 711)

Section 1557 Non-Discrimination Language Multi-Language Interpreter Services

SPANISH: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia

lingüística. Llame al número de Servicios para afiliados que figura para su estado en la tabla de números de teléfono de Servicios para afiliados por estado.

VIETNAMESE: CHÚ Ý: Nếu quý vị nói tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ, miễn phí, cho quý vị.

Gọi số dịch vụ hội viên được liệt kê cho tiểu bang của quý vị trên Bảng Số Điện thoại Dịch vụ Hội viên theo

Tiểu bang.

CHINESE: 注意：如果您使用繁體中文，則可得到免費的語言助手服務。請致電《會員服務電話號碼表（

按州排列）》上列出的您所在州的會員服務號碼。

FRENCH CREOLE (HAITIAN CREOLE): ATANSYON: Si ou pale Kreyòl Ayisyen, w ap jwenn sèvis asistans nan lang k ap disponib, gratis. Rele nimewo sèvis pou manm lan pou eta kote w ye a ki make

sou Tablo ki gen Nimewo Telefòn Sèvis pou Manm lan pou Chak Eta.

KOREAN: 참조 : 한국어를 사용하시면, 무료로 언어지원서비스를 이용할 수 있습니다. 주 차트에 있는

회원 서비스 전화번호를 통해 각 주에 등록된 회원서비스로 전화하십시오.

ARABIC: تنبيه: إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوفر لك مجاًنا. اتصل برقم خدمات األعضاء المدرج لواليتك في أرقام

هاتف خدمات األعضاء حسب مخطط الواليات.

FRENCH: ATTENTION : Si vous parlez français, les services d'assistance linguistique vous sont

accessibles gratuitement. Appelez le numéro des services aux membres indiqué pour votre pays dans les Numéros de téléphone pour les membres répertoriés dans la Carte des pays.

RUSSIAN: ВНИМАНИЕ: если вы говорите на русском языке, вам могут предоставить бесплатные услуги

перевода. Позвоните по номеру, указанному для вашего штата в таблице номеров телефонов Службы

поддержки участников по штатам.

GERMAN: ACHTUNG: Wenn Sie deutsch sprechen, stehen Ihnen kostenlose Sprachassistentendienste

zur Verfügung. Rufen Sie die Mitgliederservicenummer für Ihren Bundesstaat an, die Sie auf der Bundesstaaten-Übersicht der Mitgliederservicenummern finden.

TAGALOG: PAUNAWA: Kung nagsasalita ka ng Tagalog, may makukuha kang mga libreng serbisyo ng tulong sa wika. Tawagan ang numero ng mga serbisyo sa miyembro na nakalista para sa iyong estado

sa Chart ng Mga Numero ng Telepono Ayon sa Estado ng Mga Serbisyo sa Miyembro (Member Services Telephone Numbers by State Chart).

PORTUGUESE: ATENÇÃO: se for falante de Português, os serviços gratuitos de assistência linguística estão disponíveis para você. Ligue para o número de serviço de membro listado para o seu estado nos Números de Telefone dos Serviços aos Membros por Estado.

PENNSYLVANIAN DUTCH: GEB ACHT: Wann du Pennsylvaanisch Deitsch schwetzt, Schprooch Helfe, mitaus Koscht, sin meeglich. Ruff die Member Services Nummer fer dei State uff die Member Services

Telephone Nummere vun State Chart.

GUJARATI: ધ્યાન આપો: જો તમે ગજુરાતી બોલતા હો તો ભાષાકીય સેવાઓ તમને વવના મલૂ્યે ઉપલબ્ધ છે. સ્ટેટ ચાટટ દ્વારા મેમ્બર સવવિસીઝ ટેલલફોન નબંરો પર તમારા રાજ્ય માટે આપેલા મેમ્બર સવવિસ નબંર પર કૉલ કરો.JAPANESE: 注意：日本語を話される場合は無料の言語支援サービスをご利用いただけます。地域別メンバーサービス電話番号表に記載されている、お住まいの地域の電話番号にお掛けください。

ITALIAN: ATTENZIONE: se parla italiano, sono disponibili per Lei alcuni servizi di assistenza linguistica gratuiti. Contatti il numero del reparto Servizi per i membri del Suo stato consultando l'apposito elenco denominato "Member Services Telephone Numbers by State" (Numeri di telefono dei reparti Servizi per i

membri per stato).

2018 over-the-counter (otc) order form 2018 formulario de ... · número de teléfono y su número...

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