Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)

2018 Over-the-Counter (OTC) Order Form

2018 Formulario de Artculos OTC

1-866-528-4679

TTY: 1-877-672-2688

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

lunes a viernes 9 a.m. a 5 p.m. Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 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.

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 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. Asegrese de aprovechar al mximo este gran beneficio.

Para empezar, seleccione sus artculos 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 no es sumado al siguiente periodo.

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) OTC Benefit Listing Plan Benefit Amount / Monto del Beneficio Benefit Period / Periodo del Beneficio

Health Net Cal MediConnect Plan $25(Medicare-Medicaid Plan) Every 3 months / Meses

H3237_18_OTCOrdBkltR_Approved_01242018 BRO018478EO00 (1/18) Page 1

Ordering is Easy!

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

ORDER BY INTERNET: Place your order online: HealthNet.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 Solutions9675 NW 117th Avenue, Suite 202

Miami, FL 33178

4. 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: 1-866-682-6733

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 member handbook or contact Member Services for more information.

Ordenar es Fcil!

PEDIDO POR TELEFONO: Para realizar su pedido por telfono, llame al 1-866-528--4679, TTY: 1-877-672--2688 de 9 a.m. a 5 p.m., de lunes a viernes.

PEDIDO POR INTERNET: Enve por internet: HealthNet.otchs.com

PEDIDO POR CORREO: 1. Escriba claramente su nombre, direccin, nmero de telfono y su nmero de afiliado en el espacio indicado.

2. Marque la cantidad de los artculos que desee y sume hasta la cantidad establecida de su beneficio o menos.

3. Coloque este formulario dentro de un sobre con una estampilla de primera clase y envenosla a:

OTC Health Solutions9675 NW 117th Avenue, Suite 202

Miami, FL 33178

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

PEDIDO POR FAX: Para ordenar por fax, complete su formulario y envielo al: 1-866-682-6733

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

Esta lista de productos est sujeta a cambios. Este servicio slo est disponible si su plan ofrece el servicio de venta libre como beneficio. Por favor revise el manual de membreca o contacte a Member Services para obtener ms informacin.

Page 2

Health Net Community Solutions, Inc. is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Limitations, copayments, and restrictions may apply. For more information, call Health Net Cal MediConnect Member Services or read the Health Net Cal MediConnect Member Handbook. Benefits and/or copayments 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 1-855-464-3571 in Los Angeles or 1-855-464-3571 in San Diego (TTY: 711) from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you can leave a message. Your call will be returned within the next business day. The call is free.

Page 3

Health Net Community Solutions, Inc. es un plan de salud que tiene contrato con Medicare y Medi-Cal para proporcionar beneficios de ambos programas a los afiliados.

Esta informacin no es una descripcin completa de los beneficios. Contctese con el plan para ms informacin. Se pueden aplicar limitaciones, copagos y restricciones. Los beneficios, las primas y / o los copagos / coseguros pueden cambiar el 1 de enero de cada ao.

Si usted habla espaol, hay servicios de asistencia de idiomas disponibles para usted sin cargo. Llame al 1-855-464-3571 en Los Angeles County y al 1-855-464-3572 en San Diego County (los usuarios de TTY deben llamar al 711), de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Despus del horario de atencin, los fines de semana y los das feriados puede dejar un mensaje. Le devolveremos la llamada el siguiente da hbil. La llamada es gratuita.

Page 4

2018 Over-the-Counter (OTC) Order Form

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) 2018 Formulario de Artculos de OTC Name: Date:

(Nombre): (Fecha):

Address: Order Month:

(Direccin): (Mes de Orden):

Member Id: Phone:

(Numero De Membresia): (Telfono):

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

Antacids, Digestion and Laxatives / Anticidos, Digestin y Laxantes

Code Compare to Count Price QTY Product Producto

Cdigo Comparado a Cantidad Precio

A1 Effervescent Pain Relief Analgsico efervescente Alka-Seltzer 36 CT $4.49

A2 Dairy Relief Chewable Alivio De Lcteos Masticable Lactaid 60 CT $12.49

A8 Heart Burn Relief Tablets Tabletas anticidas Gaviscon 100 CT $6.49

A15 Motion Sickness Tablets Comprimidos Dramamina Dramamine 12 CT $3.99

L2 Stool Softener Ablandador de heces Colace 100 CT $9.99

L6 Glycerin Suppository Adult Supositorios de glicerina Fleet 25 CT $3.99

Tabletas de Glucosa de P20 Glucose Tablets Orange Dex4 10 CT $1.49

Naranja

Q1 Anti-Diarrheal Caplets Tabletas antidiarreicos Imodium 12 CT $5.49

Q5 BeanAid Capsules Cpsulas para alivio de gases Beano 30 CT $5.99

Dental Care / Ciudado Dental

Code Compare to Count Price Qty Product Producto

Cdigo Comparado a Cantidad Precio

M2 Toothbrush Cepillo dental Each $0.99

M3 Lip Balm Original SPF 15 Balsamo para labios Chapstick 0.15 OZ $1.99

M4 Sens Tooth Paste White Pasta dental blanqueadora Sensodyne 4 OZ $4.99

M35 Dental Floss Waxed Hilo dental encerado J&J 100 yd $2.49

M52 Oral Pain Relief Alivio del dolor oral Anbesol 0.33 OZ $5.99

M71 Flosser Picks Portahilo Dental Flosser Picks 90 CT $2.99

Tabletas para dentaduras

X2 Denture Cleanse Tab A/B Mint Polident 84 CT $5.49

menta

X5 Denture Cleans Tab A/B Tabletas para dentaduras Efferdent 40 CT $2.99

Pegamento para dentales X6 Denture Adhesive Regular Poligrip 2.4 OZ $4.49

regular

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

Cough, Cold and Allergy / Tos, Catarros y Alergia

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio

C1 Nasal Spray Regular Aerosol nasal regular Afrin Sinus 1 OZ $5.49

C3 Cold Flu & Sore Throat Max Para La gripe y dolor de garganta Mucinex 6 OZ $9.99

C7 Medicated Chest Rub Friccin medicinal para el pecho Vicks

VapoRub 3.5 OZ $5.99

C8 Thermometer Digital Termmetro digital 1 CT $4.99

C11 Sore Throat Lozenges Pastillas para la irritacin de garganta Cepacol 18 CT $3.99

C12 Tussin CF Max Strength Tussin CF Robitussin

CF 4 OZ $5.49

C13 Tussin DM Medicina para la tos Tussin DM Robitussin

DM 4 OZ $4.99

C16 Nasal Decongest Pseudo Free Descongestionante nasal seudo libre Sudafed PE 18 CT $4.49

C19 Chest Congest Relief 400mg Descongestionante del pecho 400 mg 60 CT $9.49

C20 Child Allergy Elixir Pseudo Free Alivio de alergia en lquido para nios Benadryl 4 OZ $4.99

C24 Daytime Cold/Flu Pseudo Free

Soft gels Cpsulas diurnas de gel para la gripe DayQuil 16 CT $4.49

C54 Nighttime Cold & Flu Medicina nocturna para el resfriado y

la gripe NyQuil 16 CT $4.49

C56 Sinus Acetaminophen Acetaminofen Sinusal Tylenol

Sinus 24 CT $4.99

C57 Sore Throat Spray Spray para el dolor de garganta Chloraseptic 6 OZ $4.49

C58 Child's Cold Cough & Sore

Throat

Medicina para la tos,resfriado y dolor

de garganta para ninos Mucinex 4 OZ $8.99

C60 Cough & Cold (HBP) Antihistamnico para resfriado Coricidin 16 CT $5.99

C62 Cold Sore Treatment Para las astas bucales Abreva 0.07 OZ $16.99

C64 Air Shield Orange Tablets Tabletas para soporte del sistema

inmune Airborne 10 CT $6.49

C65 Honey Lemon SF Cough Drops Pastillas de miel y limon para la tos Halls 25 CT $1.99

Eye and Ear Care / Ciudado de la Vista y Oido

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio

E1 Dry Eye Relief Alivio para ojos resecos Visine Tears 0.5 OZ $4.49

E2 Eye Drops Redness Relief Gotas para el alivio de ojos rojos Visine

Original 0.5 OZ $3.49

X16 Ear Wax Removal Kit Kit para la cera en los odos Murine Kit $5.99

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

First Aid Medical Supplies / Primeros Auxilios

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio F1 Elastic Bandage 4" Vendas Elsticas FUTURO Elastic 1 CT $3.99 F2 Muscle Rub Crema muscular Bengay 3 OZ $5.99

F3 Bandage Antbtc One Size Vendaje De Tejido Antibacterial Band-Aid Antibio 20 CT $3.99

F4 Calamine Lotion Plus Locin de calamina Caladryl 6 OZ $4.99

F7 Triple Antibiotic Ointment Pomada triple antibitica Neosporin 0.5 OZ $4.49

F9 Bandage Clear Assort. Sizes Vendas tamaos surtidos Band-Aid 45 CT $3.99

F11 Anti-Itch Cream Crema contra la picazn Benadryl 1 OZ $4.99

F12 Bandage Sheer One Size Vendajes un solo tamao Band-Aid Sheer 40 CT $2.99

F21 Iodine Yodo 1 OZ $2.49

F22 First Aid Antsep Merthiolate Mertiolato antisptico 2 OZ $4.99

F29 Anti-Itch Gel Gel contra la picazn Benadryl 4 OZ $4.99

F34 Hot/Cold Multi Compress Compresa fria y caliente 1 CT $8.99

F36 Reusable Ice Pack Paquete de hielo reutilizable 1 CT $4.99

F62 First Aid Tape Cinta para primeros auxilios 1 CT $1.99

F65 Gauze Pad 2X2 Gasa Estril 2X2 25 CT $3.99

F68 Petroleum Jelly Jalea de petrleo Vaseline 2.5 OZ $3.49

F69 Butterfly Closures Cierres de mariposas 12 CT $3.49

F70 Hydrogen Peroxide Spray Perxido de Hidrogeno en spray 8 OZ $2.49

F71 Epsom Salt Sulfato de Magnesio 64 OZ $3.99

F72 Sharps Container Sistema Eliminador de Agujas EACH $11.99

M45 Alcohol Prep Pads Almohadillas de alcohol BD 100 CT $3.99

M53 Gauze Roll 2" X 2 yds Gasa 1 CT $1.99

M57 Gloves Nitrile Large Guantes de nitrilo grandes 50 CT $7.49

Foot Care / Cuidado de los pies

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio F35 Corn & Callus Remover Kit Eliminador medicinal de callos Dr. Scholl's 0.5 OZ $3.99

O3 Wart Removal Eliminacin de verrugas Compound W 0.5 OZ $5.99

O4 Odor Control Spray Powder Atomizador de control de olores en

polvo Odor-Eaters 4 OZ $4.99

O5 Moleskin Padding Relleno Moleskin Dr. Scholl's 2 CT $2.49

Adult Incontinence / Incontinencia

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio

X74 Pads-Bladder Control

Moderate Almohadillas para incontinencia Poise 20 CT $5.99

X75 Underwear Women S/M Paales pequeos/ medianos F Depends 20 CT $13.99

X77 Underwear Men S/M Paales pequeos/ medianos M Depends 18 CT $13.99

X83 Unisex Overnight Underwear

XL 58"-68"

Paales absorbentes unisexo para

la noche XL - 58" - 68" Depends 12 CT $13.99

X84 Unisex Overnight Underwear

L 44"-58"

Paales absorbentes unisexo para

la noche L - 44" - 58" Depends 14 CT $13.99

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You will receive the generic equivalent of all items / Usted recibir el genrico de todos los productos Pain Relievers and Sleep Aids / Analgsicos y Artculos para ayudarle a dormir

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio H2 Hemorrhoid Suppositories Supositorios Hemorroidales Preparation H 12 CT $4.99 H3 Hemorrhoid Ointment Ungento para hemorroides Preparation H 2 OZ $7.49

M6 Sleep Aid Somnfero Tylenol Simply

Sleep 24 CT $3.99

M46 Urinary Relief Max Strength Alivio Urinario fuerza mxima Azo 12 CT $4.99 P6 Acetaminophen 500mg Acetaminofeno 500mg Tylenol 100 CT $6.99 P8 Aspirin Chewable 81mg Aspirina masticable 81mg Bayer Chewable 36 CT $2.49

P14 Hot/Cold Patch Parches calientes y frios Icy Hot 5 CT $6.99 P17 Headache Pain Relief Alivio de dolor de cabeza Excedrin 100 CT $7.49 P45 Acetaminophen Pain Relief PM Acetaminofeno PM Tylenol PM 24 CT $4.49 P50 Menstrual Pain Relief Max Alivio de dolor menstrual Midol 24 CT $4.99

P52 Acetaminophen 325 Regular

Strength

Acetaminofeno 325MG Regular

Strength Tylenol 90 CT $8.99

Personal Care / Cuidado personal

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio F10 Diaper Rash Ointment Ungento para erupciones en la piel Desitin 2 OZ $3.99 F64 Acne Treatment 10% Tratamiento de acn 10% Clearasil 1 OZ $4.99 M1 Sunblock SPF 45 Protector solar SPF 45 3 OZ $8.49 M9 Cotton Swab Hisopos de algodn 375 CT $2.49

M91 Facial Tissue Pauelo de Papel 2 PK $0.99 M11 Baby Powder Talco para beb 4 OZ $1.99

M31 Oil Free Acne Wash Lavado de acn sin aceite Neutrogena 6 OZ $3.99 M33 Unscented Wipes Toallitas humeda sin olor 56 CT $3.49 M34 Diabetic Skin Lotion Locin para la piel diabtica Gold Bond 13 OZ $6.99

Miscellaneous / Miscelneo

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio

M23 Hand Sanitizer Desinfectante de manos Purell 2 OZ $1.49

M49 Tablet Cutter Cortador de tabletas Each $6.49

M51 7 Day Pill Box Pastillero de 7 dias Each $2.49

M75 Mosquito Repellant with 30%

Deet

Repelentes de mosquitos con 30% de

dietiltoluamida OFF! Repellant 6 OZ $6.49

M76 Mosquito Repellant Deet Free Repelentes de mosquitos sin

dietiltoluamida OFF! Repellant 6 OZ $6.49

*X71 Blood Pressure Monitor

Semi Auto 8.7" x 16.5"

Monitor de presin arterial semi auto

8.7" x 16.5" Each $24.99

*X72 Blood Pressure Monitor

Manual 8.7" x 12.6"

Monitor de presin arterial

8.7" x 12.6" Each $17.99

X81 Maxi Reg Toallas sanitarias regular 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.

*Limite de 1 BP monitor annual / Consulte su Mdico de cabecera antes de ordenar un producto de doble propsito.

Page 8

Vitamins and Minerals Dual Purpose Items / Vitaminas y Minerales Producto de doble propsito

Must consult with Primary Care Physician prior to ordering a dual-purpose item.

Consulte su Mdico de cabecera antes de ordenar un producto de doble propsito.

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

Qty Code

Cdigo Product Producto

Compare to

Comparado a

Count

Cantidad

Price

Precio

V2 Vitamin C 500mg Vitamina C 500 mg 100 CT $6.99

V3 Calcium Carbonate + D Carbonato de calcio 600 mg + D Caltrate 600 +D 60 CT $4.49

V5 Coenzyme Q-10 50mg Coenzima Q-10 50mg 30 CT $9.99

V10 Glucosamine/ Chondroitin Glucosamina/Condroitina Osteo Bi-Flex 80 CT $15.99

V16 Vitamin E 400 IU Soft Gel Vitamina E 400 mg IU Capsulas de gel 100 CT $11.99

V19 Fish Oil Omega-3 1000mg Aceite de pescado Omega-3 1000 mg Puritan 120 CT $8.99

V32 Vitamin D 1000 IU Vitamina D 1000 mg IU 100 CT $3.49

V35 Magnesium 500mg Magnesio 500 mg 100 CT $4.49

V36 Zinc Gluconate 50mg Gluconato de zinc 50 mg 100 CT $4.49

V41 Chewable Multivitamins Vitaminas masticables Flintstones 60 CT $6.99

V48 Biotin 10000Mc Soft Gel Biotina 10000 mcg capsulas de gelatina 60 CT $11.49

V49 Melatonin Gummy 5mg Melatonina Gomitas 5 mg 60 CT $10.49

V54 Calcium Supplement Gummy Suplemento de calcio en gomitas 50 CT $10.49

V57 Vitamin B12 500 mcg Vitamina B-12 500 mcg 100 CT $8.99

V58 B Complex Plus Vitamin C Complejo B ms vitamina C Nature's

Bounty 130 CT $6.99

V59 Potassium gluconate 550Mg Gluconato de potasio 550MG Nature's

Bounty 100 CT $4.99

V60 Adult Daily Multiple Vitamin Multivitaminas suplemento para adulto One A Day 365 CT $6.99

V61 B-6 Vitamins Vitamina B6 Nature's

Bounty 100 CT $5.99

V62 Adult Daily Women's 50+

Adv. Multivitamina para mujer 50+ One A Day 50 CT $6.99

V63 Adult Daily Men's 50+ Adv. Multivitamina para hombre 50+ One A Day 50 CT $6.99

V64 Lutein 40mg Soft Gels Luteina 40MG capsula de gelatina Ocuvite 30 CT $17.99

Page 9

Health Net Cal MediConnect Nondiscrimination Notice

Health Net Community Solutions, Inc. (Health Net Cal MediConnect Plan (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. Health Net Cal MediConnect does not exclude people or treat

them differently because of race, color, national origin, age, disability, or sex.

Health Net Cal MediConnect:

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 the Health Net Cal MediConnect

Customer Contact Center at 1-855-464-3571 (Los Angeles),

1-855-464-3572 (San Diego) (TTY: 711) from 8 a.m. to 8 p.m.,

Monday through Friday. After hours, on weekends and on holidays,

you can leave a message. Your call will be returned within the next

business day. The call is free.

If you believe that Health Net Cal MediConnect 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; the Health Net Cal

MediConnect Customer Contact Center 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,

1-8003681019, (TDD: 1-8005377697). Complaint forms are available at

http://www.hhs.gov/ocr/office/file/index.html.

CMC Nondiscrimination Notice_LP FLY015186EO00 (8/17)

CA_MMP_2017_NDN_08242017

Page 10

Multi-Language Insert Multi-language Interpreter Services

English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Spanish: ATENCIN: Si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Chinese Mandarin: 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711)

Chinese Cantonese: 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego)TTY: 711

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Vietnamese: CH : Nu bn ni Ting Vit, c cc dch v h tr ngn ng min ph dnh cho bn. Gi s 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Korean: : , 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). .

Russian: : , . 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

:Arabic: . .(TTY: 711) (San Diego) 1-855-464-3572 (Los Angeles) 1-855-464-3571

Hindi: : 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711). .

Japanese: 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

:Farsi . : .(TTY: 711) 1-855-464-3572 (San Diego), 1-855-464-3571 (Los Angeles)

Thai: : 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

H3237_17_MLI_Accepted_09092017

Page 11

Armenian: , : 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711)

Cambodian: , 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Punjabi: : , 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711)

Laotian: : , . 1-855-464-3571 (Los Angeles), 1-855-464-3572 (San Diego) (TTY: 711).

Cal MediConnect Member Multi-Language Insert FLY015174ZO00 (8/17)

Page 12

2018 Order Booklet Healthnet Cal Mediconnect A102018 Order Booklet Healthnet Cal Mediconnect A9Hn Cal