Information on how to place your OTC order can be found on the last page. As a member of Ultimate Health Plans, you have an Over-the-Counter (OTC) benefit every quarter. This benefit allows you to get OTC products you may need such as bandages, cold and allergy medicines, pain relievers, and vitamins. Simply call the toll-free number OR fill out and mail the order form provided. Your order will be shipped directly to your door. Your benefit amount is $45 every three months. The benefit amount may accumulate from quarter to quarter for a total yearly benefit of $180. You pay $0 copay for covered OTC items, medications and products up to the available benefit limit each quarter.
*B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D.
H2962_Convey OTC Order Form v116
2016 OVER-THE-COUNTER (OTC)
BENEFIT CATALOG
Special Health
Plan Benefit
Get Over-the-Counter
Products
Every Quarter
Categories
The Over-the-Counter (OTC) items listed below have been assigned to one of the following categories: Eligible Over-the-Counter Items, Dual-Purpose OTC Medications and Products. A detailed description of both categories can be found below.
Eligible OTC Items
– includes medicines or products that alleviate or treat injuries or illness. You do not need to provide a statement from a medical provider or indicate a diagnosis.
Dual Purpose OTC Medications & Products
– do not require a letter of medical necessity from a physician, however, Ultimate Health Plans encourages members to have appropriate conversations with their personal
provider and have their personal provider orally recommend the OTC item for a specific diagnosable condition prior to purchase.
Acne Treatment Acne Gel 10%
Benzoyl Peroxide 1.5 oz 1076 $7.00 Allergy, Cold, Flu, Decongestant and Sinus All Day Allergy Tablets
14 tabs, 10 mg 1090 $7.00 All-Nite Cold/Flu 6 oz, 6.25 mg 1361 $6.00 Children's Dimaphen 4 oz 2.5 mg/5 ml 1426 $7.00 Children's Diphenhydramine HCL 4 oz, 12.5 mg/5 ml 1428 $6.00 Chlorpheniramine Maleate 100 tabs, 4 mg 1008 $6.00 Cromolyn Sodium (Allergy
Nasal Spray), 26 ml 1356 $14.00 Cough & Cold for High
Blood Pressure 16 tabs 1166 $7.00 Diphenhist 100 tabs, 25 mg 1308 $7.00 Diphenhydramine HCL
24 capsules, 25 mg 1009 $6.00 Multi Symptom
Cold Formula 24 tabs 1357 $7.00 Nasal Decongestant
Spray 12 Hr, 1oz, 0.05% 1091 $6.00 Nasal Spray (Saline)
1.5 oz, 0.655% 1052 $6.00 Sudogest PE 36 tabs, 10 mg
(Nasal and Sinus Decongestant) 1352 $6.00 Vapor Rub 1 oz 1164 $7.00 Antacids and Acid Reducers
Alka-Seltzer 36 tabs 1313 $11.00 Antacid/Anti-Gas Liquid 1006 $7.00 Chewable Antacid 150 tabs, 500mg 1346 $7.00 Effervescent Pain Reliever 36 tabs 1314 $8.00 Gas-X 36 chewables, 80 mg 1312 $10.00 Anti-Arthritic
Arthritis Pain Reliever
100 tabs, 650 mg 1311 $13.00 Capsaicin 2 oz, 0.025% 1367 $9.00 Glucosamine Joint/Muscle 1114 $9.00 60 capsules, 500 mg Glucosamine/Chondroitin 60 caps, 200 mg, 250-200 mg 1003 $11.00 Anticandidal (Yeast)
Clotrimazole Vaginal Cream
w/applicator *D 45 gm, 1% 1115 $8.00 Micanozole 3-Day Treatment 2% 1117 $14.00 Tioconazole 1-Day Treatment
with applicator, 6.50% 1119 $20.00 Antidiarrheal Bismatrol (Bismuth Subsalicylate) 30 tabs, 262 mg 1045 $7.00 Loperamide HCL *D 12 tabs, 2 mg 1133 $7.00 Pepto-Bismol 12 oz, 262 mg 1317 $12.00 Pink Bismuth 8 oz, 262 mg 1318 $8.00
Antifungal Clotrim Cream 1 oz, 1% 1047 $7.00
Miconazole 2% Cream 1 oz 1135 $7.00 Terbinafine HCL Tube .5 oz, 1%1046 $12.00 Tolnaftate Cream .5 oz, 1% 1064 $8.00 2.
Antacids and Acid Reducers (continued)
Eligible OTC Items
*B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. Anti-Itch Lotions and Creams
Bactine Solution 4 oz 1142 $10.00 Diphenhydramine HCL/
Zinc Acetate 1 oz 1140 $6.00 Hydrocortisone 1% Cream 1 oz 1074 $6.00 Pramoxine Topical Analgesic
6 oz, 1% 1144 $8.00
Cold Sore, Fever Blister and Medicated Lip Products
Abreva 2 gm, 10% 1152 $25.00 Herpecin-L Lip Balm 0.1 oz, 1% 1153 $10.00 Releev Cold Sore Treatment
6 ml, 0.13% 1359 $24.00 Contact Lens Supplies
Multi Purpose Contact
Lens Solution 120 ml 1468 $8.00 Cough Suppressants and Expectorants Cough Drops
Cherry, 30 lozenges 1056 $6.00 Cough Drops (Sugar Free)
Cherry, 25 lozenges, 5 gm 1182 $6.00 Cough Syrup, Expectorant
4 oz, 100 mg 1054 $6.00 Guaifenesin Cough
Expectorant 60 tabs, 200 mg 1180 $9.00 Mucus Relief DM (Guaifenesin
Expectorant / Dextromethorphan Cough Suppressant)
30 tabs, 400-20 mg 1178 $9.00 Sore Throat Lozenges
Cherry,18 lozenges 1176 $7.00 Dental/Denture Care
Dental Floss 55 yards 1455 $6.00 Denture Cleaning 40 tabs 1032 $7.00 Fixodent 0.75 oz 1187 $7.00
Orajel Pain Relief 7 gm, 20% 1454 $12.00 Oral Pain Relief 0.5 oz, 20% 1286 $8.00 Polident Denture Cream 3.9 oz 1324 $9.00 Rechargeable Toothbrush 1450 $36.00 Tooth Brush, Tek Pro
Straight Soft 1412 $4.00 Tooth Paste • Pepsodent 6 oz 1414 $5.00 Diabetes Diabetic Socks White Medium 1489 $7.00 White Large 1490 $7.00 Black Medium 1491 $7.00 Black Large 1492 $7.00 Digestive Health Beano 30 tabs 1316 $10.00 Enema 4.5oz 1733 $7.00 Lactase Capsules 60 capsules, 9000 FCC units 1067 $10.00 Ear Care Ear Drops 15 ml, 6.50% 1190 $6.00 Ear Wax Removal System
with Rubber Bulb, 15 ml 1363 $8.00 Eye Care
Artificial Tears Drops 0.5 oz 1192 $6.00
Artificial Tears Ointment 3.5 gm 1194 $8.00 Clear Eyes Eye Drops 0.20 oz 1199 $8.00 Eye Drops Redness Relief 15 ml 1061 $6.00 Eye Wash Solution 4 oz 1196 $7.00 First Aid and Medical Supplies
Adhesive Bandages (Sheer)
60 bandages 1344 $7.00 Alcohol Pads *D 100 pads 1200 $6.00
3. Dental/Denture Care (continued)
Ankle Support 1225 $9.00 Antiseptic Towelettes 100 pack 1201 $7.00
Automatic Blood
Pressure Monitor Desktop 1253 $34.00 Back Support 24-46" 1487 $16.00 Back Support (with lumbar) 1488 $26.00 Bath Mat (non-skid) 1459 $14.00 Bath Seat w/ Back 1728 $70.00 Bath Seat w/o Back 1727 $54.00 Bath Tub Safety Rail 1730 $37.00 Conforming Gauze Sterile *B
12 pads, 3” X 4 yd 1223 $8.00 Digital Ear Thermometer 1285 $23.00 Elastic Bandage *B 2” X 5 yd 1207 $5.00 3” X 5 yd 1209 $5.00 4” X 5 yd 1211 $6.00 6” X 5 yd 1213 $6.00 Elbow Support 1224 $11.00 First Aid Kit 48-piece 1215 $10.00 Foam Ring Cushion 1732 $21.00 Folding Cane Ergonomic Handle1726 $21.00 Gel Foam Seat Cushion 1466 $26.00 Hot/Cold Pack for Injury
Pack - 1 small and 1 large 1062 $7.00 Hydrogen Peroxide 8 oz, 3% 1228 $5.00 Knee Stabilizer 1465 $22.00 Knee Support
SMALL 1481 $9.00
MEDIUM 1482 $9.00
LARGE 1483 $9.00 Knee Support with stays
SMALL 1484 $15.00
MEDIUM 1485 $15.00
LARGE 1486 $15.00
Lantiseptic Skin Protectant
Ointment 2.5 oz, 50$ 1202 $9.00 Lumbar Cushion 1731 $21.00
Neosporin Plus 0.5 oz 1326 $11.00 Night Wrist Support
Smart Glove 1463 $26.00 Povidone Iodine 4 oz 1203 $7.00 Raised Toilet Seat 1729 $35.00 Rib Belt One size fits most
MALE 1456 $19.00
FEMALE 1457 $19.00 Shower Mat (non-skid) 1460 $15.00 Tape, Paper Surgical *B
1” X 10 yd 1217 $5.00 2” X 10 yd 1218 $6.00 Tape, Silk Surgical *B
1” X 10 yd 1219 $6.00
2” X 10 yd 1220 $7.00 Tape, Transparent Surgical *B
1” X 10 yd 1221 $6.00 2” X 10 yd 1222 $6.00 Thermometer Digital 1063 $7.00 Wintergreen Isopropyl Alcohol 16 oz, 70% 1229 $7.00 Wrist Splint 1230 $17.00 Wrist Support 1227 $11.00 Foot Care
Callus Remover Pads 6 pads 1238 $8.00 Corn Remover Pads 9 pads 1236 $7.00 Medicated Foot Powder 4 oz 1240 $7.00 4.
First Aid and Medical Supplies (continued)
Hemorrhoidal Preparations Anu-Med Suppository box of 12 1245 $7.00 Hemorrhoidal Ointment 2 oz 1066 $8.00 Hemorrhoidal Suppository 1247 $7.00 box of 12 Preparation H Cream 26 gm, 17% 1248 $13.00 Pre-Moist Hemorrhoid Pads 1364 $8.00
100 pads Incontinence Supplies A&D Ointment 12 oz 1300 $7.00 Adult Briefs Med 32" - 44” waist 1303 $9.00 LG 45” - 58” waist 1304 $13.00 XL 59” - 64” waist 1305 $14.00 Barrier Cream 4 oz 1302 $9.00 Bladder Control Liner
MODERATE Absorbency 24 pk 1478 $16.00 HEAVY Absorbency 24 pk 1479 $17.00 MAXIMUM Absorbency 18 pk 1480 $16.00 Disposable Underwear MEDIUM34" - 44” waist 20 pk 1021 $14.00 LARGE44" - 58” waist 18 pk 1026 $14.00 XLARGE58" - 68” waist 14 pk 1027 $14.00 Underpads 23" x 36" 25 pads 1299 $11.00 23" x 24" 25 pads 1476 $14.00 30" x 30" 10 pads 1477 $8.00 Washcloth w/Lanolin Pack of 64 1348 $8.00 Laxatives Bisacodyl 100 tabs, 5 mg 1128 $6.00 Docusate Sodium 100 capsules, 100 mg 1126 $7.00 Ex-Lax 8 tabs, 15 mg 1124 $8.00 Glycerin Suppository 25 tabs, 2 gm 1125 $7.00 Methylcellulose 16 oz, 480 gm 1354 $13.00 Milk of Magnesia 12 oz, 400 mg1011 $7.00 Natural Vegetable Laxative
13 oz 1340 $10.00
Polycarbophil Fiber Tablets
90 tabs, 625 mg 1012 $11.00 Senna Plus 60 tabs, 8.6-50 mg 1130 $7.00 Migraine Relief
Migraine Relief
100 tabs, 250-250-65 mg 1365 $8.00 Wellpatch Migraine box of 4 1261 $9.00 Minerals
Calcium Carbonate Tabs
60 tabs, 600 mg 1291 $6.00 Calcium-Vitamin D 60 tabs, 600 mg/400u 1373 $7.00 Ferrous Sulfate 100 tabs, 325 mg 1376 $6.00 Niacin 100 tabs, 100 mg 1378 $7.00 Niacin 100 tabs, 500 mg 1394 $7.00 Magnesium 110 tabs, 250 mg 1418 $7.00 Magnesium Oxide 100 tabs, 250 mg 1377 $8.00 Rena-Vite 100 tabs 1395 $13.00 Zinc Chelated 100 tabs, 50 mg 1419 $7.00 Motion Sickness
Dramamine Orange
8 chews, 50 mg 1264 $9.00 Driminate 12 tabs, 50 mg 1263 $6.00 *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. 5.
Meclizine 100 tabs, 12.5 mg 1366 $8.00 Pain Relievers and Fever Reducers
Acetaminophen
100 tabs, 325 mg 1001 $6.00 Acetaminophen
50 tabs, 500 mg 1105 $6.00 Aspirin Enteric Coated
100 tabs, 325 mg 1096 $6.00 Aspirin Low Dose 1002 $6.00
120 tabs, 81 mg Children's Acetaminophen 30 chewables, 80 mg 1423 $7.00 Children's Ibuprofen 4 oz, 100 mg/ 5 ml 1421 $9.00 Ibuprofen 100 tabs, 200 mg 1004 $7.00 Naproxen *D 100 tabs, 220 mg 1097 $10.00 Pain Reliever PM
Extra Strength 100 tabs 1332 $10.00 Pain Relieving Muscle Rub
2 oz, 2.50% 1475 $6.00
Pediculicide Lice Treatment Shampoo 4 oz 1271 $11.00
Permethrin Cream Rinse
59 ml, 1% 1269 $11.00 Personal Care
Aloe Vera Cream 240 ml 1070 $6.00 Ammonium Lactate 8 oz, 12% 1368 $10.00 Hand Sanitizer 8 oz, 62% 1065 $6.00 Sunscreen Lotion
SPF 303.5 oz 1284 $6.00
Sleep Aids
Nasal Strips box of 30
SMALL/MEDIUM 1724 $13.00
MEDIUM/LARGE 1725 $13.00 Sleep Tabs 50 tabs, 25 mg 1276 $7.00 Smoking Cessation
Nicorelief Gum 50 pack, 4 mg 1372 $22.00 Nicotine Patches box of 14
STEP 1 21 mg/24 hr 1369 $36.00 STEP 2 14 mg/24 hr 1370 $36.00 STEP 3 7 mg/24 hr 1371 $36.00 Nicotine Lozenges 72 lozenges, 4 mg 1281 $45.00 Support Items
Men's Compression Knee Hi Socks
BLACK - LGShoe size 101/2-12
(15-20 mmhg) 1399 $19.00
WHITE - MEDShoe Size 8-10
(15-20 mmhg) 1400 $19.00
WHITE - LGShoe Size 101/2-12
(15-20 mmhg) 1401 $19.00 Women's Compression Knee Hi Socks
NUDE - SM Shoe Size 4-5
(8-15 mmhg) 1406 $12.00
NUDE - MED Shoe Size 51/2-71/2
(8-15 mmhg) 1407 $12.00 NUDE - LG Shoe Size 8-101/2
(8-15 mmhg) 1408 $12.00
BLACK - SM Shoe Size 4-5
(8-15 mmhg) 1409 $12.00
BLACK - MED Shoe Size 51/2-71/22
(8-15 mmhg) 1410 $12.00
BLACK -LG Shoe Size 8-101/2
(8-15 mmhg) 1411 $12.00 Topical Antibiotics
Bacitracin Ointment
1 oz, 500U/gm 1020 $7.00 Triple Antibiotic Ointment 1 oz 1014 $7.00 6.
Wart Remover Dr. Scholl’s Wart
Removal System 18 pack 1288 $13.00 Wart Remover 0.5 oz, 17% 1075 $9.00
Wartners Wart
Removal System Kit 1289 $19.00
7. Vitamins (continued)
Diagnostic Supplies Desktop Talking Blood
Pressure Monitor 8.7" to 13.4" 1503 $33.00 Finger Pulse Oximeter 1505 $30.00 Wrist Blood Pressure Monitor 1501 $21.00 Wrist Talking Blood
Pressure Monitor 9" to 14.6" 1502 $25.00 Home Diagnostics
Colon Cancer Test 1416 $13.00 Home Access Cholesterol Test 1251 $24.00 Hormone Replacement DHEA 25 mg, 100 tablets 1736 $15.00 DHEA 50 mg, 50 tablets 1737 $12.00 Vitamins Centrum Silver 60 tabs 1420 $20.00
Daily Multiple Vitamin Tabs
with Minerals 100 tabs 1385 $7.00 Ferrous Gluconate (Iron
Supplement) 100 tabs, 240 mg 1375 $7.00
Dual Purpose OTC Items
Iron 110 tabs, 27 mg 1417 $8.00 Multi Vitamin Children's
100 chewables 1422 $8.00
Prenatal Vitamins 100 tabs 1274 $9.00 Vitamin A 100 tabs, 10 mu 1379 $7.00 Vitamin B-Complex 100 tabs 1382 $7.00 Vitamin B-1 100 tabs, 100 mg 1016 $7.00 Vitamin B-6 100 tabs, 50 mg 1380 $7.00 Vitamin B-6 100 tabs, 100 mg 1388 $7.00 Vitamin B-12 100 tabs, 500 mg 1389 $7.00 Vitamin B-12 100 tabs, 1000 mcg 1381 $8.00 Vitamin C 500 mg, 100 tabs 1017 $7.00 Vitamin Century Senior
90 tabs 1392 $10.00
Vitamin D 100 tabs, 1000 iu 1390 $7.00 Vitamin D 100 tabs, 400 iu 1383 $7.00 Vitamin E 100 tabs, 100 iu 1391 $7.00 Vitamin E 100 tabs, 400 iu 1384 10.00 Vitamin One A Day 90 tabs 1393 $7.00 Vitamins & Minerals - Weight Loss
Fiber Well Fit 90ct 1735 $18.00 Stress Formula Tablets 1734 $9.00 with Zinc 60 Tablets
Helpful Information
• If you have questions or would like to place an order over the phone, OTC Advocates are available Monday – Friday from 8:00am to 8:00pm EST at 1-855-422-0039 (TTY: 711).
• Your benefit amount is $45 every three months. The benefit amount may accumulate from quarter to quarter for a total yearly benefit of $180. You pay $0 copay for covered OTC items, medications and products up to the available benefit limit each quarter.
• If you place your order using an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29th, but we receive it on July 1st, your order total will be applied to your July (or third quarter) benefit, not your June (or second quarter) benefit.
If you’re getting close to the end of the quarter and you do not think your order form will be received in time, you can call in your order.
• We encourage you to use your full quarterly benefit amount in one order.
• Cash, checks or money orders are not accepted under this OTC benefit.
• Orders may only be placed by the member, an authorized representative verbally approved by the member at time of the order, and/or the member’s power of attorney representative on file. • To use your benefit, you must select products from this catalog that will help you with a health or
medical need. Your order total may not exceed your benefit amount. OTC products are intended for member's use only. Ultimate Health Plans prohibits the use of this benefit to order OTC items for family members and friends. OTC items are available through mail-order only.
• Once your order is received, please allow 7 - 10 business days for delivery.
• Products may not be purchased at a local retail pharmacy or through any other source other than the Ultimate Health Plans Benefit Catalog.
• If you disenroll from Ultimate Health Plans, your OTC benefit will automatically terminate.
• Returns are not accepted. If an item is damaged during shipping, it will be exchanged for an identical item, at no cost, within 30 days of purchase.
• Some items listed in this catalog may also be covered under your Medicare Part B (medical) benefit or Part D (pharmacy) benefit. These items have a *B or a *D after their name. For example, alcohol pads are covered under Part D if they are used for administering insulin. For all other purposes, this item is covered under your OTC benefit.
• Items in the 2016 OTC Benefit Catalog may change throughout the year. A copy of this catalog is also available on the Ultimate Health Plans website at www.chooseultimate.com. For up-to-date information, please call our OTC Advocates Monday - Friday 8:00am to 8:00pm EST at 1-855-422-0039 (TTY:711).
Ultimate Health Plans is an HMO with a Medicare contract. Enrollment in Ultimate Health Plans depends on contract renewal. Limitations, co-payments and restrictions may apply. Benefits may change on January 1 of each year. This information is not a complete description of benefits. Contact the plan for
Member ID (found on Health ID card) Date of Birth
First Name Last Name MI
Street Number Street Name Apt/Suite #
City State Zip Code
Please check box if this is a new address
Daytime Phone Email (Optional)
@ .com
H2962_Convey OTC Order Form v116
Please mail the completed form back in the postage-paid envelope provided.
Your benefit amount is $45 every three months. The benefit amount may accumulate from quarter to quarter for a total yearly benefit of $180. You pay $0 copay for covered OTC items, medications and products up to the available benefit limit each quarter.
If you place your order using an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29th, but we receive it on July 1st, your order total will be applied to your July (or third quarter) benefit, not your June (or second quarter) benefit.
Cash, checks or money orders are not accepted under this Over-the-Counter (OTC) benefit. STEP 2 - PRODUCT SELECTION:
STEP 1 - COMPLETE YOUR INFORMATION BELOW:
2016 OVER–THE–COUNTER (OTC) BENEFIT ORDER FORM
Total Order $
Item # Product Name
1 2 3 4 5 Price Quantity
