2018 Over-the-Counter (OTC) Order Form 2018 Formulario de ... · número de teléfono y su número...
Transcript of 2018 Over-the-Counter (OTC) Order Form 2018 Formulario de ... · número de teléfono y su número...
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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
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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
$60 Every three months
Allwell Medicare (HMO) St. Tammany County $65 Every three monthsMissouri: Allwell from Home State Health
CountyBenefit Amount
Benefit Period
Allwell Medicare (HMO) Barry, Christian, Greene, Jasper, Lawrence, and Newton Counties
$50 Every three months
Allwell Medicare (HMO) Cass, Clay, Jackson, and Platte Counties $50 Every three months
Ohio: Allwell from Buckeye Health Plan
CountyBenefit Amount
Benefit Period
Allwell Medicare (HMO) Columbiana, Cuyahoga, Mahoning, Stark, and Trumbull Counties
$90 Every three months
Allwell Medicare (HMO) Butler, Greene, Hamilton, and Montgomery County
$70 Every three months
Allwell Dual Medicare (HMO SNP)
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
$55 Every three months
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
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Allwell Medicare (HMO) Calhoun, Fairfield, Kershaw, Richland, and Saluda Counties
$85 Every three months
Allwell Medicare (HMO) Greenville, Pickens, and Spartanburg Counties $85 Every three months
Allwell Dual Medicare (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
$100 Every three months
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
$85 Every three months
Texas: Allwell from Superior HealthPlan
CountyBenefit Amount
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
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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
$85 Every three months
Allwell Medicare (HMO) Beaufort, Charleston, Colleton, Hampton, and Jasper Counties $85 Every three months
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Washington: Allwell from Coordinated Care
County Benefit Amount
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
County Benefit Amount
Benefit Period
Allwell Dual Medicare (HMO SNP)
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
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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!
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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.
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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
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QtyCode
CódigoProduct
Compare toComparado a
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
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QtyCode
CódigoProduct
Compare toComparado a
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
Compare toComparado a
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
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QtyCode
CódigoProduct
Compare toComparado a
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
Compare toComparado a
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
Compare toComparado a
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
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QtyCode
CódigoProduct
Compare toComparado a
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
Compare toComparado a
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
Compare toComparado a
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
Page 13
QtyCode
CódigoProduct
Compare toComparado a
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
Compare toComparado a
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)
Page 14
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。
Page 15
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).
Page 16