Over-the-Counter Benefit Product Catalog - Keystone First VIP … · 2020. 12. 18. · Dear Member:...

1-844-981-1614www.keystoneotcstore.com2021

Over-the-Counter Benefit Product Catalog

Y0093_OTH_1000772_C

Dear Member:

By enrolling in Keystone First VIP Choice (HMO-SNP), you receive a quarterly benefit of $365 to spend on over-the-counter (OTC) products that are exclusively available from this catalog. Your OTC benefit allows you to select items such as cold and cough medicines, incontinence products, vitamins, dental care items, and much more. Items ordered from this catalog will be shipped directly to you, at no cost to you!

What is covered with your OTC benefit?Eligible items include OTC remedies or medicines to alleviate or treat illness or injury, such as dental care items, eye and ear care items, and incontinence supplies (adult diapers). These items do not require a prescription from a health care provider.

Dual-purpose items are items that may serve more than one purpose. These items are sometimes used to alleviate or treat a medical condition or they may be used to promote general health and well-being. These items do not require a prescription from your provider to purchase; however, Keystone First VIP Choice (HMO-SNP) strongly recommends that you discuss these items with your provider prior to ordering or using. For your convenience, we have identified these categories throughout the catalog.

Your quarterly benefit can be used anytime during the quarter to order OTC items from this catalog. You cannot spend out-of-pocket beyond your benefit allowance and any unused benefit is forfeited at the end of each quarter. In addition, any out-of-pocket OTC items purchased by you will not be eligible for reimbursement from the benefit plan or Fieldtex Products Inc. If mailing your order form, be sure to allow seven days for your order to reach us.

Welcome to Keystone First VIP Choice (HMO-SNP) 2021 over-the-counter benefit

State Plan name BenefitPennsylvania Keystone First VIP Choice $365 Per Quarter

Each quarter, choose the items you would like and write the number on your order form. Have the filled-out form available when you call or go online for faster and easy ordering.

Total all the items, and be sure to stay within your available allowance. If you go over your $365 benefit, you will not be able to complete your order.

Be sure to have your member ID number (found on the front of your ID card). You will need to provide your member ID number and your date of birth to access your account online or over the phone.

How to order

Ordering process

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There are three easy ways you can place your order: by mail, by phone, or online. Whatever way you choose to place your order, be sure to have your member ID number and date of birth available to access your benefit. By mail: Fill out the attached mail order form and drop it in the mail to:

2921 Brighton-Henrietta TL RD Rochester, NY 14623

Be sure to give the order seven days to reach us. The order will be processed in the quarter that it is received, unless otherwise specified. A new mail order form is sent with each of your quarterly shipments. By phone: Call us at 1-844-981-1614 (TTY 711) Monday – Friday 8 a.m. to 5 p.m., Saturday from 9 a.m. to 5 p.m., and Sunday from 10 a.m. to 5 p.m., and our friendly customer service representatives will take your order. Online: Visit us at www.keystoneotcstore.com and log in to place your order. Online, you can shop in the privacy of your home while being able to keep track of what you have ordered, check the status of orders, and check your benefit allowance.

• Your OTC benefit covers only the items included in this catalog.

• The website is available 24 hours a day, seven days a week, unless down for maintenance. The call center is available to take orders Monday –Friday from 8 a.m. to 5 p.m., Saturday 9 a.m. to 5 p.m., and Sunday 10 a.m. to 5 p.m. If you want to place your order by mail, please give at least seven days for the mail order form to reach us.

• Please allow seven to 10 days for delivery of in-stock items. You will be notified if an item is out of stock and may take longer for delivery. Mail orders will be processed in the quarter in which they are received, unless otherwise specified. The catalog's products may be substituted without notice.

• Quantity purchase limits may be applied periodically for high-demand items.

• Our commitment to you: We will never substitute a brand name product with a generic version.

• If you receive a damaged item, call Fieldtex Products Inc. immediately at 1-800-353-7763 (TTY 711) Monday – Friday 8 a.m. to 5 p.m. The item will be exchanged for an identical item at no cost to you. Please note that only damaged products can be exchanged within 30 days of purchase. No other returns are allowed.

• Keystone First VIP Choice (HMO-SNP) and Fieldtex Products Inc. are not responsible for lost or stolen packages. For delivery issues, please contact your carrier.

• Fieldtex Products is the supplier of all the products in this catalog and can only answer questions pertaining to your order. Medical information regarding the use of these products is not available. Please consult your provider.

• The OTC benefit only guarantees members a credit, per membership term, to use while ordering items listed in this catalog. Please note, however, that the items themselves are not offered or guaranteed by Keystone First VIP Choice (HMO-SNP).

• The health information provided in this catalog is general in nature and is not medical advice or a substitute for professional health care. It is provided for your information and convenience only. Fieldtex Products, Inc. does not guarantee the accuracy or completeness of the information, and does not recommend or endorse the products which are referenced in this catalog.

• Products in this catalog should only be ordered for the use of the enrolled member.

• Items in the OTC Benefit Catalog may change throughout the year. A copy of this catalog is also available on the Keystone First VIP website at www.keystonefirstvipchoice.com.

• To purchase dual-purpose items under your plan, your primary care provider (PCP) must recommend them to you for a specific diagnosed condition. Please speak to your PCP before ordering these items. For your convenience, we have identified dual-purpose items in the Eligible Items section of the catalog.

• Please note that certain items in this catalog may be covered under Medicare Part B or Part D. When the item is covered under Part B or Part D, you may not be able to use this OTC benefit. In those instances, you must use your Keystone First VIP Choice (HMO-SNP) medical or outpatient drug benefit to obtain the item if medically appropriate.

Important things to remember Please keep this catalog for your entire 2021 benefit year.

Table of contentsAllergy .........................................................................................................6-7Cold and flu ..................................................................................................7-9Cough drops .................................................................................................9-10Dental care (denture, dry mouth, toothbrush, and toothpaste) ...............................10-14Diabetic supplies .........................................................................................14Diabetic supplies — socks ............................................................................15 Diagnostic equipment ..................................................................................15Diagnostic equipment (blood pressure monitors, scales, and thermometers) ..........16-17Ear care ........................................................................................................17-18Eye care .......................................................................................................18-19Feminine and UTI .........................................................................................19Fiber supplements .......................................................................................19First aid (bandages, dressings and gauze, tape, and kits) ........................................20-22 Foot care ......................................................................................................22-23 Hemorrhoid .................................................................................................23-24Home testing ...............................................................................................24Hot and cold therapy ...................................................................................24-25Incontinence ................................................................................................25-26Incontinence, reusable .................................................................................26Lactose ........................................................................................................26Lice ..............................................................................................................27 Lip care ........................................................................................................27Menopause relief ........................................................................................27 Motion sickness medication .........................................................................28Ointments and topicals (analgesics and cleaners) ..............................................28-30 Pain relief ....................................................................................................31-33Personal protective equipment (PPE) ............................................................34PPE — first aid gloves ...................................................................................34Respiratory relief .........................................................................................34Skin care ......................................................................................................35Skin care — sunscreen ..................................................................................35-36Sleep aid ......................................................................................................36Smoking cessation .......................................................................................36-37Stomach — antacids and acid reducers ........................................................37-38Stomach and laxatives ..................................................................................39-40Supports (ankle, back, elbow, knee, stockings, and wrist) ......................................40-43Vitamins, minerals, and supplements ..........................................................44Weight loss ..................................................................................................45 Weight loss — kitchen scales ........................................................................45

Eligible items

6 To order online, visit us at www.keystoneotcstore.com

Fexofenadine tablets (generic Allegra) 30 ct.00301$11.00

Complete allergy medicine tablets 25mg (diphenhydramine) 100 ct.11569N$2.50

Benadryl Allergy tablets 24 ct.10874$6.00

Claritin Reditabs 10 ct.11580$16.50

All-day allergy tablets (cetirizine) 30 ct.90584$8.00

Allegra 12-Hour 60mg tablets 12 ct.91071$14.25

Allegra 24-Hour 180mg tablets 30 ct.90980$26.00

Allergy 10mg tablets (loratidine) 30 ct.90582$4.00

Allergy/sinus headache caplets 20 ct.90580$4.50

Alka Seltzer Plus Severe Sinus Congestion liquigels 20 ct.99038$9.75

Allergy

Allergy relief capsules 25mg (diphenhydramine HCL) 24 ct.90581$3.25

Nasacort allergy 24-hour 60 sprays10222$24.00

Zyrtec 10mg tablets 14 ct.91073$19.00

Flonase nasal spray for allergies 144 sprays10703$38.00

Flonase nasal spray for allergies 72 sprays10701$25.00

Eligible items

77To order by phone, call us toll-free at 1-844-981-1614 (TTY 711) Monday – Friday 8 a.m. to 5 p.m., Saturday 9 a.m. to 5 p.m., and Sunday 10 a.m. to 5 p.m.

Mentholatum ointment 1 oz. jar90444$3.50

Mentholatum no-mess roll-on 1.76 oz.10639$7.00

Greaseless mentholatum 1.76 oz.10641$7.00

Afrin No Drip Allergy/Sinus .5 oz.10624$12.00

Alka Seltzer Plus Cold and Cough liquigels 20 ct.99912$9.25

Careall medicated chest rub 3.53 oz.99093$2.50

Cold-Eeze lozenges honey lemon flavor 18 ct.10650$7.50

Coricidin HPB liquigels 20 ct.11575$9.50

Cough/cold high blood pressure tablets 16 ct.90090$3.00

Airborne Original orange tablets 10 ct.90553$8.75

Allergy Zyrtec 10mg tablets 30 ct.00203$28.00

Zyrtec 90 ct.10629$55.00

Cold and flu

Effervescent cold relief tablets 20 ct.90579$5.25

Delsym cough suppressant 6 fl. oz.10013$20.00

Eligible items


Tussin DM 4 fl. oz.90446$3.25

Tussin DM sugar free 4 fl. oz.90578$4.25

Sambucol Cold and Flu quick dissolve tablets 30 ct.10626$13.25

Theraflu Night Time Severe Cough and Cold 6 ct.10401$9.50

Silver immune support 16 oz.10637$27.00

Robitussin Cough and Chest sugar free 4 fl. oz.90516$10.00

Saline nasal spray 1.5 oz.90640$2.75

Mucinex DM tablets 20 ct.11561$19.50

Mucinex Fast-Max Cold, Flu, and Sore Throat 6 fl. oz.10691$21.00

Cold and fluMucus relief DM tablets 30 ct.90576$9.00

Nasal decongestant spray (generic Afrin) 1 oz.90897$3.75

Nasal spray extra moisture 1 oz.90898$3.25

NyQuil Cold and Flu LiquiCaps 24 ct. 00302$16.50

Night time cold and flu relief softgels 16 ct.90639$5.00

Original Afrin NoDrip .5 oz.10631$13.00

Eligible items


Zicam citrus Rapidmelts 25 ct.10668$13.50

Tylenol Cold and Flu Severe caplets 24 ct.99065$9.50

Vicks DayQuil Cold and Flu LiquiCaps 24 ct.11952$13.50

Vicks VapoInhaler Menthol Scent10463$7.25

Cold and flu

Vicks VapoRub 3.53 oz.11625$12.00

Vicks DayQuil Cold and Flu LiquiCaps 8 ct.91076$8.00

Black cherry sugar-free cough drops 25 ct.90643$2.00

Chloraseptic lozenges citrus 18 ct.11562$5.25

Halls Defense assorted sugar-free citrus 25 ct.90912$3.25

Halls honey lemon cough drops 30 ct.11601$3.25

Halls menthol-lyptus cough drops 30 ct.11703$3.25

Cough dropsHalls Defense assorted citrus 30 ct.90913$3.25

Zicam Cold Remedy nasal swabs 20 ct.10663$14.00

Eligible items


Honey lemon cough drops 30 ct.99054$2.00

Luden's sugar-free wild cherry throat drops 25 ct.99083$2.50

Luden's wild cherry throat drops 30 ct.11584$2.50

Ricola cherry honey throat drops 24 ct.99114$3.25

Ricola cough drops 21 ct.11571$3.25

Ricola sugar-free lemon mint throat drops 19 ct.90447$3.25

Cough drops

Sucrets sore throat cherry lozenges 18 ct.11591$4.50

Vitamin C drops 30 ct.90914$2.75

Dental careDentek Instant Pain Relief 50 applications00303$8.00

Floss waxed unflavored 100 yds.90652$1.75

Freshmint wax mint dental floss 100 yds.90612N$1.50

Reach waxed mint floss 55 yds.90077$2.50

Gum Soft-Picks 50 ct.10666$3.50

Mint flossers with pick 90 ct.10673$2.50

Eligible items


Denture bath with basket10657$2.00

Denture brush90909$0.50

Fixodent adhesive Neutral zinc-free 2.4 oz.99107$8.50

Red Cross Canker Sore pain relief medicine .25 oz10638$5.50

Steripod manual tongue cleaner 2/Pk10522$3.25

Dental care

Dental care — denture

Fixodent Free cream 2.4 oz.99109$8.50

Fixodent Original 1.4 oz.90128$4.50

Fixodent plus Scope adhesive 2 oz.99110$8.50

Freshmint denture adhesive 2.4 oz.90908$3.50

Freshmint denture cleanser tablets 40 ct.90906$2.50

Freshmint denture cleanser tablets 90 ct.90655N$5.50

Oral B denture brush twin head90126$3.25

Polident 3 minute tablets 40 ct.99049$6.00

Polident overnight tablets 40 ct.91079$6.00

Eligible items


Polident overnight tablets 84 ct.90486$9.50

Polident tablets for smokers 40 ct.99050$5.75

Poligrip Super Extra Care 2.2 oz.90490$8.25

Dental care — denture

Poligrip Super Original 2.4 oz.90491$8.25

Poligrip Super SPG Free 2.4 oz.99047$8.25

ACT Dry Mouth lozenges 18 ct.10226$6.50

ACT Total Care Dry Mouth rinse mint 18 oz.00438$9.25

Biotene Dry Mouth balance gel 1.5 oz.00340$9.50

Biotene Dry Mouth oral rinse 16 fl. oz.00304$9.50

Biotene Dry Mouth lozenges 27 ct.10644$9.00

Biotene Dry Mouth moisturizing mouth spray 1.5 fl. oz.10224$9.75

Dental care — dry mouth

Eligible items


Colgate medium toothbrush 99181 $3.00Colgate Plus soft toothbrush 90156A $3.00Complete Clean medium toothbrush 10481 $2.00Complete Clean soft toothbrush 10476 $2.00Freshmint nylon toothbrush 90910 $0.50Oral B 3D White soft toothbrush 90988 $5.00

Interplak rechargable cordless toothbrush 00352 $45.00Interplak toothbrush replacement heads 2 ct. 00370 $22.00Sonicare rechargeable toothbrush 10645 $37.75 Sonicare replacement heads 3 ct. 10646 $45.00

Dental care — toothbrush

Dental care — toothbrush electric

Aim toothpaste 5.5 oz.10466$2.00

Aquafresh Cavity Protection toothpaste 5.6 oz.99044$4.00

Biotene fresh mint toothpaste 4.3 oz.99045$9.75

Close-Up cinnamon flavored toothpaste 4 oz.10512$2.50

Colgate Total clean mint toothpaste 4.8 oz.90157$5.75

Crest Gum Detoxify deep clean toothpaste 4.1 oz.10508$9.75

Crest Cavity Protection regular toothpaste 4.2 oz10509$3.50

Freshmint sensitive toothpaste 4.3 oz.10616$2.00

Freshmint anticavity toothpaste 4.6 oz.90911$1.50

Dental care — toothpaste

Eligible items


Sensodyne Deep Clean toothpaste 4 oz.90485$9.25

Listerine Essential Care Original Gel toothpaste 4.2 oz.99147$6.50

Parodontax Extra Fresh toothpaste 3.4 oz.00305$9.25

Pepsodent Complete Care toothpaste 5.5 oz.90617$2.00

Diabetes health pack 30 ct.00353$23.00

Glucose tablets 4 gram orange flavor 10 ct.00295$3.00

Glucose tablets 4 gram orange flavor 50 ct.00296$8.00

Glucose SOS instant dissolve powder fruit medley 6 ct.10446$11.00

Gold Bond diabetic foot cream 3.4 oz.10223$10.00

Dental care — toothpaste

Diabetic supplies

Eligible items


Cotton diabetic socks — black$8.50

10609 — Small/medium 1 pair

10610 — Large/XL 1 pair

10621 — King size XXL 1 pair



10617 — King size XXL 1 pair





Cotton diabetic socks — white$8.50

Polyester diabetic socks — black $8.50

Polyester diabetic socks — white $8.50

Pulse oximeter10447$25.00

Diabetic socks

Diagnostic equipment


Advocate blood pressure monitor XL cuff (cuff circumference: 12.6 in. – 20.5 in.) 00112$35.00

Healthmate cuff digital blood pressure monitor (cuff circumference: 9 in. – 13 in.)90327$43.50

Omron upper arm blood pressure monitor (cuff circumference: 9 in. – 17 in.)00358$59.00

Perfect Measure blood pressure monitor (cuff circumference: 9.4 in. – 13.4 in.)00374$52.75

Thinner analog scale by ConAir (maximum weight: 330 lbs.) 10405$47.25

Diagnostic equipment — blood pressure monitors

Diagnostic equipment — scales

Dual-purpose items

Health-O-Meter digital scale (maximum weight: 397 lbs.) 01078$69.00

Stainless steel digital scale (maximum weight: 500 lbs.) 01072$49.00

Platform digital scale (maximum weight: 440 lbs.)01070$32.75

Eligible items


Advocate non-contact infrared thermometer (speaks English/Spanish)99159$46.25

Digital ear thermometer10611$25.00

Digital thermometer (nine-second read)10460$6.00

Ear and forehead infrared thermometer (one-second read)10486$46.00

Handheld digital temple touch infrared probe thermometer99169$16.00

Infrared forehead thermometer (one-second read)99170$46.00

Touch-free infrared thermometer10635$60.00

Digital thermometer10511$6.00

Ear wax removal kit .5 fl. oz.90641$5.00

Lipo-Flavonoid ear ringing relief caplets 72 ct.00319$31.00

Debrox earwax removal drops .5 fl. oz.11848$8.00

Diagnostic equipment — thermometers

Ear care

Non-contact infrared thermometer10694$68.00

Eligible items


Swim-Ear drops 1 fl. oz.11655$5.00

Blink Contacts lubricating eye drops 10mL90917$8.75

Clear Eyes Itchy Eye Relief .5 fl. oz.91080$5.75

Clear Eyes Triple Action Relief .5 fl. oz.91045$5.50

Eye drops original .5 fl. oz.90453N$2.00

PreserVision AREDS 2 Chewables 60 ct.10661$28.00

Sterile irritation eye drops .5 fl. oz.90588$2.75

Stye eye ointment 0.125 oz.11668$9.00

Visine A.C. Seasonal Itching .5 fl. oz.91047$6.25

Visine Advanced Redness Plus Irritation Relief .5 fl. oz.10514$5.50

PreserVision AREDS 2 plus Multivitamin 100 ct. 10656$39.00

Murine ear wax removal system .5 fl. oz. 99082$8.50

Eye care kit55009$16.00

Naphcon A eye drops .5 fl. oz.00371$15.25

Ear care

Eye care

Eligible items


Monistat 7-Day91092$16.50

Monistat chafing relief powder gel 1.5 oz.91101$10.00

Urinary pain relief max strength tablets 24 ct.10528$5.00

Uristat Ultra with Cranberry UTI pain relief tablets 30 ct.00226$10.00

Benefiber 38 servings00830$15.00

Benefiber assorted sugar-free chewables 100 ct.99021$17.25

Best Fiber powder sugar-free 62 Servings90575$11.00

Metamucil capsules .52 gram 100 ct.00359$22.00

Dmanna UTI prevention packets 35 ct.10627$20.00

Visine Eye Allergy Relief eye drops .5 fl. oz.99064$8.00

FiberCon caplets 36 ct.11839$9.75

Fiber-Tabs 90 ct.90880$8.75

Eye care

Feminine and UTI

Fiber supplements

Eligible items


All-in-one finger dressing — three sterile dressings91060$4.00

Antibacterial sheer bandages assorted 20 ct.90876$2.75

Armor Gel wound dressing 1.5 oz.10605$10.00

Curad bandage variety pack 200 ct.10488$8.50

Curad Flex-Fabric assorted bandages 100 ct.10487$4.00

Curad Soothe and Cool assorted burn bandages 8 ct.00375$5.00

Curad Truly Ouchless XL bandages 8 ct. 1.65 in. x 4 in. 00377$5.00

Elastic bandage 2 in. x 5 yds.00011$1.25



Band-Aid Flexible Fabric bandages 30 ct.3/4 in. x 3 in. 10319$5.00

Band-Aid Flexible Fabric assorted bandages 30 ct.10317$5.00

Band-Aid Flexible Fabric bandages XL 10 ct. 1 3/4 in. x 4 in. 10320$5.00

Band-Aid Hydro Seal all-purpose large bandages 6 ct.10420$5.75

First aid — bandages

Curad Flex-Fabric bandages 30 ct. 3/4 in. x 3 in.10494$2.00

Eligible items


Band-Aid large waterproof pad bandages 6 ct.10410$5.00

Band-Aid Flexible Fabric assorted bandages 100 ct.10489$7.25

New Skin liquid bandage 50 applications10322$5.50

Sheer plastic spot bandages 100 ct. 7/8 in. 10135BX100$2.00

Cohesive elastic bandage 3 in. x 5 yds.00010$2.50

Cotton balls 100% cotton 300 ct.90773$2.00

Cotton swabs 300 ct.90891$2.50

Band-Aid gauze pads 10 ct. 4 in. x 4 in. 10907$4.25

Gauze pads 100 ct. 4 in. x 4 in. 10676$19.50

Krimptex bandage roll 4.5 in. x 4.1 yds.07104$2.00

Covered tape 1/2 in. x 5 yds. 00035 $2.00Waterproof tape 1 in. x 10 yds. 00101 $2.50Waterproof tri-cut tape 2 in. x 5 yds. 10039 $2.50

Band-Aid plastic bandages 60 ct. 3/4 in. x 3 in. 10866$3.50

Band-Aid Flexible Fabric bandages 100 ct. 1 in. x 3 in. 10490$8.25

First aid — bandages

First aid — dressings and gauze

First aid — tape

Eligible items


Burn care kit911-90050$8.00

Curad 175-piece first aid kit99079$14.50

Johnson and Johnson 140-piece first aid kit90564$19.50

Mini first aid kit90457$2.50

Personal soft-sided first aid kit911-93901-10999$8.00

Clotrimazole cream USP 1% 1 oz.90610$2.50

Compound W plantar pads 20 ct.99078$11.50

Corn and callus remover .3 fl. oz.90608$4.25

Corn cushions 9 ct.90609$2.00

Band-Aid Hydro Seal blister toe bandages 8 ct.10431$5.50

Band-Aid Hydro Seal extreme blister cushions 5 ct.10425$5.50

Foot care kit911-90061$9.00

Contains:175 pieces and includes all first aid essentials

Contains:two gauze pads four burn gel packets one roll of tape

Contains:140 essential items to treat cuts and scrapes

Contains:six alcohol swabstwo gauze padsone bandage rolland more

Contains:ten bandagesthree gauze padsfour alcohol wipesand more

Freeze Off original spray 8 applications99081$19.25

First aid kits

Foot care

Liquid wart remover .31 fl. oz.90605$4.75

Eligible items


Micatin antifungal cream .5 oz.10655$7.00

Toe Separators:• Two small. • Two medium. • Two large.

90636$5.00

Lotrimin spray 4.6 oz.90943$9.75

Medicated corn remover pads 9 ct.11950$2.25

Tolnaftate antifungal cream .5 oz.90905$2.00

Zeasorb athletes foot powder 2.5 oz.00324$9.50

Hemorrhoid relief ointment 2 oz.90139$4.50

Medicated pads 100 ct.90651$5.50

Preparation H cooling gel .9 oz.99157$10.25

Preparation H suppositories 24 ct.99145$21.00

Preparation H totable wipes 10 ct.99152$5.25

Moleskin plus 4 sheets90604$3.25

Hemorrhoidal suppositories 12 ct.90154$3.50

Foot care

Hemorrhoid

Eligible items


One-step pregnancy test 1 ct.00245$4.75

Air-activated heat wrap back/hip 2 ct.10634$5.50

Air-activated heat wrap neck/shoulder 3 ct.10640$5.50

Reusable gel cold pack 10.5 in. x 14.5 in.10654$13.00

Reusable gel neck cold pack 23 in. 10660$14.00

Cold and hot reusable eye compress 2.5 in. x 5 in.10103$1.25

Home testing

Maximum strength cold and hot pain relief liquid roll-on 2.5 fl. oz.90122$6.00

Migraine cooling mask10658$5.50

Advocate heating pad classic 12 in. x 15 in.90890$20.00

Tucks medicated cooling pads 40 ct.90940$7.00

Early result pregnancy test 1 ct.00246$4.75

Biofreeze roll-on 2.5 oz.10671$16.00

Hemorrhoid

Hot and cold therapy

Icy Hot cream 1.25 oz.10053$4.75

Select Heat heating Pad 12 in. x 14 in.00357$35.00

Select Heat heating pad king size 12 in. x 24 in.10404$40.00

Eligible items


Salonpas deep relieving gel 2.75 oz.91030$9.75

Salonpas pain relieving hot-gel patch 6 ct.90889$9.75

Soft touch reusable hot/cold gel packs 2 ct.10458$5.00

Thermacare lower back and hip heatwraps 2 ct.90885$10.00

Thermacare muscle and joint heatwrap 1 ct.91031$4.00

Thermacare neck to arm heatwraps 3 ct.90887$10.00

A & D ointment 15 oz. — generic 10485 $3.50 A & D Original ointment 1.5 oz. 11640 $5.00Vitamin A & D ointment 4 oz. — generic 99094 $2.00 Balmex adult cream 3 oz. 91043 $6.75Balmex zinc oxide cream 2 oz. 91088 $4.50Flushable adult wipes 48 ct. 10012 $4.00 Prevail 30 in. x 30 in. absorbent bed pads — disposable 10 ct. 90057 $8.50Prevail adult washcloths 48 ct. 11089 $4.50

Therma-Kool reusable cold/hot pack 6 in. x 10 in. boxed10693$4.00

Reusable ice bag medium 9 in.10089$6.00

Hot and cold therapy

Incontinence

Instant heat pack 5 in. x 9 in.00067$1.00

Extra strength cold and hot therapy patch 5 ct.90459$5.00

Combination hot water bottle w/enema system10403$10.75

Eligible items


Prevail bariatric "A" briefs with tabs 12 ct. Waist Size: 62 in. – 73 in. 10449 $18.00Prevail bariatric "B" briefs with tabs 10 ct. Waist Size: Up to 100 in. 10454 $24.00Prevail bladder control maximum pads 48 ct. 99161 $16.00Prevail bladder control moderate pads 20 ct. 99162 $7.00Prevail bladder control ultra thin pads 30 ct. 99163 $7.75Prevail Breezers360 large waist with tabs 18 ct. Waist Size: 45 in. – 62 in. 10496 $16.25 Prevail Breezers360 medium waist with tabs 16 ct. Waist Size: 26 in. – 48 in. 10495 $10.75 Prevail Breezers360 X-large waist with tabs 15 ct. Waist Size: 58 in. – 70 in. 10497 $16.00Prevail daily pant liners light to moderate size small 52 ct. 10498 $16.00 Prevail male guard pads 14 ct. 99164 $5.75Prevail Per-Fit protective underwear women X-large 14 ct. 99160 $14.50Prevail Per-Fit protective underwear women medium 20 ct. 99167 $14.50 Prevail Per-Fit protective underwear women large 18 ct. 99168 $14.50Prevail super plus underwear 2XL 12 ct. Waist Size: 68 in. – 80 in. 10455 $17.00 Procare protective underwear large 18 ct. Waist Size: 45 in. – 58 in. 10500 $16.00Procare protective underwear size medium 20 ct. Waist Size: 34 in. – 46 in. 10499 $16.00Procare protective underwear size X-Large 14 ct. Waist Size: 58 in. – 68 in. 10501 $16.00

Reusable bed pad 34 in. x 36 in. 91068 $17.50Stay Dry reusable bed pad 36 in. x 72 in. 10413 $41.00 Stay Dry reusable chair pad 17 in. x 24 in. 10433 $12.00

Dairy Aid original strength caplets 60 ct.11872$9.00

Schiff Digestive Advantage Defense caplets 32 ct.99146$13.50

Dairy digestive fast-acting caplets 60 ct.99052$13.50

Lactaid Fast Act caplets 32 ct.90145$11.75

Incontinence

Incontinence reusable

Lactose

Eligible items


Complete lice treatment kit (includes lice killing shampoo, nit combing gel, and bedding spray)00247$20.00

Rid lice control spray 5 oz.10421$10.25

Rid lice killing shampoo 8 oz.10434$28.00

Abreva Care Pump 2.0g99043$25.00

Blistex Medicated Lip Balm00325$3.00

Blistex Medicated Lip Ointment00326$2.75

Neosporin Lip Health Overnight Renewal .27 oz.10406$6.50

Campho-Phenique Cold Sore Treatment Gel .23 oz.11633$6.25

Estroven extra strength caplets 28 ct.10662$26.25

Estroven PM caplets 30 ct.10667$19.00

Lice

Lip care

Menopause relief

Medicated lip balm (generic Carmex)00327$1.75

Eligible items


Bonine motion sickness 16 ct.10653$8.00

Dramamine tablets 12 ct.90201$6.00

Motion sickness all-day less drowsy 8 ct.10643$3.00

Antifungal cream 1 oz.10752$4.00

Aveeno anti-itch lotion 4 oz.99056$9.00

Bacitracin ointment 1 oz.00065$2.50

Calamine lotion 6 fl. oz.90933$3.00

Hydrocortisone 1% cream with aloe anti-itch maximum strength90935$3.00

Hydrocortisone cream 1% 1 oz.10057$2.25

Itch relief cream extra soothing 1 oz.90095$3.50

Neosporin burn relief ointment .5 oz.10419$7.50

Neosporin ointment .5 oz.00835$6.00

Safetec first aid burn gel 4 oz.90471$4.25

Triple antibiotic ointment 1 oz. (generic Neosporin Plus)90932$6.75

Benadryl Extra Itch Cooling Spray 2 oz.99058$8.00

Motion sickness

Ointments and topicals

Eligible items


Pain relief lidocaine patches 5 ct.10457$6.00

Salonpas Lidocaine Plus cream 3 oz.10448$14.50

Salonpas Lidocaine Plus liquid roll-on 3 fl. oz.10453$14.50

Triple antibiotic ointment tube 1 oz.00049$2.50

Wound Seal + Applicator 4 ct.10482$14.25

Wound Seal topical powder 4 ct.10475$10.50

Aspercreme 1.25 oz.10050$5.00

Aspercreme with Lidocaine No Mess liquid roll-on 2.5 oz.00328$10.00

Bengay Greaseless topical analgesic cream 2 oz.10323$5.75

Bengay Vanishing Scent topical gel 2 oz.10424$6.00

Cortizone-10 cream 2 oz.99100$9.75

LidoAID pain relieving gel .17 oz10445 $8.00

Muscle and joint vanishing scent gel 3 oz.90901$3.00

Muscle rub ultra strength pain relieving cream 3 oz.90900$3.25

Flexall Ultra Plus 2 oz. 91082$8.00

Ointments and topicals

Ointments and topicals — analgesics

Eligible items


Tiger Balm Pain Relieving Patch 5 ct.10465$7.00

Tiger Balm Arthritis Rub 4 oz.10636$14.25

Tiger Balm Pain Relieving Hydrogel Patch large 4 ct.10464$9.00

Alcohol wipes 1 in. x 2 in. 200 ct.00050F$3.50

Bactine maximum pain relieving cleansing spray 5 fl. oz.00329$9.00

Decolorized iodine 2 fl. oz.91091$4.50

DynaWound wound cleanser 8 fl. oz.10484$5.00

Band-Aid Hurt Free antiseptic wash 6 fl. oz.10321$4.75

Ointments and topicals — analgesics

Ointments and topicals — cleaners

Voltaren topical gel 1% 100g10664$24.25

Tiger Balm Rub Ultra .63 oz.10462$8.00

Eligible items


Bayer aspirin tablets 325mg 200 ct.10619$20.50

Aleve Liquid Gels 220mg 80 ct.99117$19.50

Advil coated caplets 200mg 50 ct.91077$10.00

Advil coated tablets 200mg 100 ct.90658$16.00

Advil Liqui-Gels 200mg 80 ct.99097$16.50

Advil Migraine Liqui-Gels 200mg 20 ct.99098$6.00

Advil PM coated caplets 200mg 40 ct.91065$11.00

Aleve Back and Muscle Pain 220mg tablets 100 ct. 10625$21.50

Advil Liqui-Gels 200mg 20 ct.91059$6.00

Advil PM Liqui-Gels 200mg 20 ct.99099$9.00

Aleve Easy Open Cap 220mg gelcaps 40 ct.11704$10.00

Aleve Easy Open Cap 220mg caplets 100 ct.99116$15.50

Aleve PM caplets 220mg 20 ct.99023$7.50

Arthritis pain relief tablets APAP 650mg 24 ct.90601$4.50

Aspirin 81mg chewable tablets orange flavor 36 ct.90598$2.50

Pain relief

Eligible items


Extra Strength Tylenol 500mg 50 packets of two 100 ct.00098F$15.00

Bayer aspirin Low Dose tablets 81mg 120 ct.99026$9.75

Bayer aspirin tablets 325mg 100 ct.99027$10.00

Bayer Chewable aspirin tablets 81mg cherry flavor 36 ct.90662$4.50

Chewable aspirin 81mg tablets orange flavor 36 ct.90902$1.75

Ecotrin tablets 325mg 125 ct.00372$10.00

Excedrin Extra Strength 500mg caplets 100 ct.99101$15.00

Bayer Extra Strength 500mg caplets 100 ct.10620$16.25

Excedrin Migraine 500mg caplets 24 ct.99102$6.00

Headache relief extra strength acetaminophen tablets 500mg 50 ct.99106$3.75

Ibuprofen IB caplets 200mg 100 ct.90600N$3.25

Motrin IB 200mg tablets 100 ct.90659$12.00

Motrin IB 200mg tablets 50 ct.91074$8.50

Motrin IB liquid gels 200mg 20 ct.99103$6.00

Pain relief

Low-dose aspirin tablets 81mg 120 ct.11876N$2.75

Eligible items


Tylenol Extra Strength caplets 500mg 100 ct.99059$14.50

Tylenol Arthritis 8-HR 650mg 225 ct.10622$27.50

Tylenol 8-HR Arthritis Pain 650mg 100 ct.10416$16.00

Non-aspirin acetaminophen extra strength caplets 500mg APAP 100 ct.90599N$3.00

Naproxen (generic Aleve) caplets 220mg 100 ct.90602N$7.25

Non-aspirin acetaminophen PM caplets 500mg 50 ct.90904$2.25

Non-aspirin acetaminophen regular strength tablets 325mg 100 ct.90903$2.50

St. Joseph Low Dose Aspirin micro tablets 81mg 120 ct.91058$7.75

St. Joseph Low Dose chewable aspirin 81mg 36 ct.91057$2.50

Tens OTC Accu Dual Channel 3000 unit99115$58.00

Tylenol 8-HR Arthritis Pain 650mg 24 ct.10408$5.50

Tylenol PM 500mg caplets 24 ct.99061$6.75

Tylenol Regular Strength tablets 325mg 100 ct.99062$10.75

Tylenol Extra Strength caplets 500mg 24 ct.99060$5.50

Pain relief

Eligible items


Adult cotton mask with ear loop25000 $8.00

Adult cotton mask with earloop and neck lanyard20000$8.50

Hand sanitizer 8 oz.12002$6.00

Disposable face masks 50 ct.10695$18.00



Personal protection kit911-11410$7.50 Includes personal supply of: • Face masks.• Hand sanitizer.• Gloves.


Germ X hand sanitizer with pump 8 oz. 10692$6.00

Curad nitrile exam gloves 10 ct. — One size fits most 10492 Call or check online for pricing.Vinyl Gloves — size small 100 ct. 10008 Call or check online for pricing.Vinyl Gloves — size medium 100 ct. 10009 Call or check online for pricing.Vinyl Gloves — size large 100 ct. 10010 Call or check online for pricing.Vinyl Gloves — size extra large 100 ct. 10011 Call or check online for pricing.

Steam Inhaler10459$46.00

Cool Mist Humidifier10633$41.50

Personal protective equipment (PPE) Prices are subject to change

PPE — gloves Prices are subject to change

Respiratory relief

Eligible items


Dermarest medicated Psoriasis gel 4 fl. oz.00330$10.25

Gold Bond Eczema Relief cream 5.5 oz10220$13.00

Scar Away gel .35 oz.10628$18.50

Scar relief gel 1.76 oz.10523$9.00

Aloe with lidocaine gel 8 oz.90951$4.00

Banana Boat Sport SPF 30 3 oz.10516$5.00

Coppertone Sport sunscreen SPF 30 7 oz.10411$15.00

Banana Boat Sport SPF 50 8 oz.10517$13.25

Skin care

Skin care — sunscreen

Coppertone sunscreen SPF 30 8 oz.90058$13.75

Sunscreen SPF 50 8 oz.90063$8.50

Coppertone Sport sunscreen SPF 50 7 oz.10428$15.75

Eligible items


Rest Simply night time sleep-aid caplets 24 ct.10505$4.50

Sleep aid (generic Sominex) tablets 32 ct.90925$4.00

Unisom SleepGels 32 ct.10225$13.00

ZZZQuil sleep aid 24 ct.10524$11.50

Sleep aid (generic Unisom) 16 ct.90927$5.00

Sleep aid

Nicotine gum 4mg 40 ct.99914$25.00

Nicotine lozenges 2mg 72 ct.99915$46.00

Nicotine lozenges 4mg 72 ct.99916$46.00

Nicotine patch step 1 21mg 7 ct.99918$21.00


Nicotine gum 2mg 40 ct.99913$26.00

Smoking cessation




Eligible items



Smoking cessation

Stomach — antacids and acid reducers Antacid and pain reliever 36 ct.90649$5.00

Chewy Delights cherry (generic Tums) 32 ct. 00335$5.00

Famotidine acid reducer tablets 10mg (generic Pepcid) 30 ct.90648$6.75

Gelusil antacid 100 ct.10651$9.75

Lansoprazole (generic Prevacid) 15mg tablets 14 ct.90984$16.00

Omeprazole 20mg tablets (generic Prilosec) 14 ct.91070$18.00

Alka-Seltzer Heartburn Relief Chews assorted 36 ct.99025$8.00

Generic Tums 96 ct.90919$4.00

Alka-Seltzer Original foil tablets 36 ct.91048$8.00

Omeprazole 20mg tablets (generic Prilosec) 28 ct.90982$31.00

Pepcid Complete cool mint chewable tablets 25 ct.00206$14.00


Omeprazole dissolving tablets 42 ct. strawberry flavor10439$27.00

Eligible items


Pepcid Complete on-the-go chewable tablets 8 ct.10630$7.00

Prelief dietary supplement caplets 120 ct.00334$14.00

Pepto Bismol 4 fl. oz.90923$5.00

Stomach — antacids and acid reducers

Rolaids Softchews antacid 12 ct. flavors vary99155$3.50

Rolaids Ultra antacid chewable tablets fruit 72 ct.99156$7.25

Tums Chewy Bites 32 ct. assorted berry10623$6.25

Tums Chewy Delights cherry 32 ct.00336$8.50

Ultra strength antacid calcium chewable tablets flavors vary 72 ct.99144$4.50

Rolaids Advanced antacid plus anti-gas chewable tablets 60 ct.99154$7.25

Prilosec 20mg OTC tablets wildberry flavor 14 ct.91075$19.00

Prilosec 20mg OTC tablets 28 ct.99105$28.00

Tums 96 ct. flavors vary90466$7.50

Eligible items


Anti-diarrheal caplets 2mg 24 ct.90120$4.75

Anti-diarrheal/anti-gas 2mg tablets 12 ct.10504$4.50

Anti-nausea liquid cherry 4 fl. oz.90596$3.50

Stomach and laxatives

Beano tablets 30 ct.11824$8.00

Clearlax 17.9 fl. oz.10483$22.00

Clearlax 4.1 fl. oz.10477$7.00

Clearlax 8.3 fl. oz.10480$13.50

Enema laxative 4.5 oz.90918$2.25

Equalactin chews 48 ct. for nervous stomach00333$9.75

Ex-Lax chocolate 24 ct.91053$8.25

Gas relief and prevention caplets 20 ct.91054$6.00

Gas-X Extra Strength softgels 10 ct.91052$3.75

Imodium AD caplets 24 ct.00836$15.75

Imodium liquid 4 fl. oz.90657$8.00

Gentle stool softener 25 ct.90590$3.50

Eligible items


Laxative bisacodyl 25 ct.90589$2.50

Miralax OTC seven-dose 4.1 oz.90883$10.50

Phillips stool softner 30 ct.99035$6.75

Stomach and laxatives

Senna laxative tablets 100 ct.90644$4.50

Stomach relief tablets 30 ct.10429$4.25

Procare elastic ankle support large (This product contains latex.)90618$5.75

Procare elastic ankle support medium (This product contains latex.)90619$5.75

Procare elastic ankle support XL (This product contains latex.)90621$6.75

Procare elastic ankle support XXL (This product contains latex.)90629$6.75

Supports — ankle Adjustable ankle support10007$11.50

Procare elastic ankle support small (This product contains latex.)90620$5.75

Eligible items


Be sure to confirm your measurements before ordering any wearable item. Wearable items are non-returnable!

Back stabilizer large 39 in. – 50 in.90208$42.00

Back support small/medium 29 in. – 39 in.90449$42.00

Mueller back brace adjustable 28 in. – 50 in.90209$26.00

Supports — back

Mueller back brace lumbar universal fits 28 in. – 50 in. waist90210$35.25

Adjustable arm sling10659$9.25

Neoprene elbow support one size fits all10790$18.50

Procare elastic elbow support small 8 in. – 9 in. (This product contains latex.)90627$6.00

Procare elastic elbow support large 10 in. – 11.5 in. (This product contains latex.)90626$6.00

Procare elastic elbow support XL 11.5 in. – 13 in. (This product contains latex.)90628$6.00

Tera-Prene tennis elbow sleeve XL 12 in. – 14 in.99089$22.25

Supports — elbow

Eligible items



DJ Orthopedics Reddie Brace small 13 in. – 14 in.99920 $53.00

DJ Orthopedics Reddie Brace medium 14 in. – 15 in.99921 $53.00

DJ Orthopedics Reddie Brace large 15 in. – 17 in.99922 $53.00

Supports — knee

DJ Orthopedics Reddie Brace XL 17 in. – 19 in.99923 $53.00

DJ Orthopedics Reddie Brace 2XL 19 in.99084 $53.00

Extra Large Scott Specialties Tera-Prene knee support 21.75 in.99088 $33.50

Procare knee support small 15.5 in. – 8 in. (This product contains latex.) 90624 $6.25

Procare knee support medium 18 in. – 20.5 in. (This product contains latex.)90623 $6.25

Procare knee support large 20.5 in. – 23 in. (This product contains latex.) 90622 $6.25

Procare knee support X-large 23 in. – 25.5 in. (This product contains latex.) 90625 $6.25

Eligible items


Anti-embolism stocking inspection toe$12.50

10435 — Small10436 — Small Long 10442 — Medium10450 — Medium Long10443 — Large10451 — Large Long10444 — XL10452 — XL long

Unisex beige firm support $31.00

00386 — Small 30 – 40 mmHg 00387 — Medium 30 – 40 mmHg00388 — Large 30 – 40 mmHg 00389 — Extra Large 30 – 40 mmHg

Unisex beige medium support $30.00

00382 — Small 20 – 30 mmHg 00383 — Medium 20 – 30 mmHg 00384 — Large 20 – 30 mmHg 00385 — Extra Large 20 – 30 mmHg

Women's beige light support$20.00


Men's black light support $18.00


Adjustable wrist support unisize91095$8.50

Quick-fit wrist support left unisize91096$18.50

Quick-fit wrist support right unisize99119$18.50

Wristlet91097$4.00

Supports — stockings

Supports — wrist



B-12 1,000mcg melts 100 ct. 00294 $9.75 B-complex softgels 100 ct. 90298 $8.75 Biotin 10,000mcg 100 ct. 10642 $10.50 Calcium 500mg + D tablets 130 ct. 00339 $13.00 Calcium 600mg + D 200 IU tablets 60 ct. 90230 $3.00 Calcium citrate plus D3 tablets 60 ct. 10520 $7.00 Calcium citrate tablets 100 ct. 10506 $7.00 Chocolate calcium chews 60 ct. 90966 $7.25 CoQ10 100mg softgels 40 ct. 00360 $31.25 Daily men/women maximum vitamin pak 30 ct. 00361 $24.00 Daily One multivitamin for women 100 ct. 90961 $11.00 Ferosul 5 iron tablets 100 ct. 90245 $3.00 Fish oil 1,000mg softgels 120 ct. 90964 $8.00 Folic acid 400mcg tablets 250 ct. 00343 $7.50 Generic Centrum Silver 125 ct. 00345 $8.00 Geritol multivitamin 100 ct. 10652 $12.75 Glucoflex glucosamine and chondroitin caplets 60 ct. 11869 $15.00 Iron 65mg tablets 180 ct. 00346 $11.25 K 100mcg tablets 100 ct. 99069 $4.50 Magnesium 500mg tabs 100 ct. 90240 $4.75 Magnesium citrate 250mg softgels 60 ct. 00347 $14.75 Mega Red omega 3 krill oil 500mg 40 ct. 10471 $39.00 Multivitamin with iron 100 ct. 90257 $4.00 One-A-Day Proactive 65plus for men and women 150 ct. 99033 $13.50 One-A-Day Women's 50plus Advantage 65 ct. 90663 $12.25 Oyster shell 500mg plus D tablets 150 ct. 90237 $6.00 Potassium gluconate 595mg tablets 100 ct. 99076 $6.75 Sustain release B-complex tablets 60 ct. 11863 $9.00 Vitamin B-12 1,000mcg quick dissolve 200 ct. 10649 $14.50 Vitamin B-12 250mcg tablets 100 ct. 11864 $6.50 Vitamin B-12 500mcg tablets 100 ct. 91083 $10.50 Vitamin B-6 50mg tablets 100 ct. 90577 $4.25 Vitamin C 1,000mg tablets 100 ct. 00349 $17.25 Vitamin C chewable wafers 500mg 60 ct. 00350 $11.75 Vitamin C-500 tablets 100 ct. 11861 $4.50 Vitamin D 10mcg tablets 100 ct. (equivalent to 400 IU) 90309 $3.00 Vitamin D 5,000 IU softgels 100 ct. 99073 $20.00 Vitamin E 100 IU Dl-alpha softgels 100 ct. 90316 $4.00 Vitamin E-400 IU Dl-alpha softgels 90 ct. 11862 $7.75

Vitamins, minerals, and supplements

Dual-purpose items

Eligible items


Weight loss Please talk to your PCP before purchasing this product.

Weight loss — kitchen scales

Alli Weight Loss 60 ct.10402 $68.00

Digital kitchen food scale stainless10507 $20.00

Premium stainless steel digital food scale10521 $23.50

Keystone First VIP Choice (HMO-SNP) OTC Mail Order Form Keystone First VIP Choice (HMO-SNP) OTC Mail Order Form

For Benefit Month:For Benefit Month:

Item # Description Qty Price TotalItem # Description Qty Price Total ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Total: Total:

Important Things to RememberImportant Things to Remember

• You cannot use future allowance amounts when placing your order.

• Your unused quarterly allowance will not roll over to the next quarter.

• Keystone First VIP Choice and Fieldtex Products are not responsible for lost or stolen packages. For delivery issues, please contact your carrier.

• Mailorderswillbeprocessedwhentheyarereceived,unlessotherwisespecified.

Member Name:Member Name: _____________________________________________________________________________Member ID:Member ID:_________________________________________Date of Birth:Date of Birth: ___________________________

Ship To:Ship To: ___________________________________________________________________________________Address:Address: __________________________________________________________________________________Apt./Room #:__________________City:Apt./Room #:__________________City:________________________State:State:________Zip:Zip: _________________Phone: (Phone: ( ____ ____ )) _____________________________________________________________________________(PLEASE PRINT)(PLEASE PRINT)

• Please allow seven - 10 days for delivery of in- stockitems.Youwillbenotifiedifanitemisout of stock and may take longer for delivery. If mailing your order, please allow one week for mail delivery to Fieldtex. Mail orders will be processed when they are received, unless otherwisespecified

• If you receive a damaged item, call Fieldtex Products immediately at 1-800-353-7763 1-800-353-7763 (TTY Hearing Impaired: 711) (TTY Hearing Impaired: 711) Monday - Friday 8:00 a.m. to 5:00 p.m Monday - Friday 8:00 a.m. to 5:00 p.m. The item will be exchanged for an identical item at no cost to you. Please note that only damaged products can be exchanged within 30 days of purchase, no other returns are allowed.

• Products in the catalog should only be ordered for the enrolled member.

• For any other questions, please contact Keystone First VIP member services at 1-855-241-3648 (TTY 711) 8 a.m. to 8 p.m., seven days a week.

Personal Health Care Products Personal Health Care Products at NO COST to you!at NO COST to you!

Keystone First VIP Keystone First VIP Choice (HMO-SNP) Choice (HMO-SNP) OTC Benefit OTC Benefit 2021 Order Form2021 Order Form

Ordering is Easy!Ordering is Easy!

Simply choose one of the options below: Simply choose one of the options below: Mail order form, call Toll Free Mail order form, call Toll Free

or go onlineor go online

1. Be sure to have your Keystone First VIP Choice member ID number (found on the front of your ID card). You will need to provide your Keystone member ID number and your birthdate to access your account.

2. Choose the items you would like and write the number on your order form, or have them available when you call or go online.

3. Total all the items, be sure to stay within your available quarterly allowance.

Call us toll-free at (1-844-981-1614 TTY: 711)

Monday-Friday 8:00 a.m. to 5:00 p.m. Saturday from 9:00 a.m. to 5:00 p.m.Sunday from 10:00 a.m. to 5:00 p.m.

or visit us online at www.keystoneotcstore.comwww.keystoneotcstore.com


20212021

www.keystoneotcstore.com


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Over-the-Counter Benefit Product Catalog - Keystone First VIP … · 2020. 12. 18. · Dear Member:...

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Transcript of Over-the-Counter Benefit Product Catalog - Keystone First VIP … · 2020. 12. 18. · Dear Member:...