Writable Foreign Data Wrapper (JPUG Unconference 16-Feb-2013)
r2022.OTC.STS.DPC writable 110821
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You do not need a prescription to receive products in this program. You are allowed one (1) order per quarter. Items are subject to availability Please order at least 10 days before the end of the quarter. Each order you place must have a minimum total of $25, and you may spend up to $50 per quarter. Unused balances DO NOT carry over to the next quarter. Items usually arrive within ten (10) business days from the date your order is received and verified. You’re eligible as an Inter Valley Health Plan Service To Seniors (HMO) and Desert Preferred Choice (HMO) plan member, to get over-the-counter items delivered to your home at no cost. Your Over-the Counter Benefit Service To Seniors (HMO) H0545, Plan 001 Desert Preferred Choice (HMO) H0545, Plan 012 2022
Transcript of r2022.OTC.STS.DPC writable 110821
You do not need a prescription to receive
products in this program.
You are allowed one (1) order per quarter.
Items are subject to availability
Please order at least 10 days before the end of
the quarter.
Each order you place must have a
minimum total of $25, and you may
spend up to $50
per quarter. Unused balances DO NOT carry over to the next quarter.
Items usually arrive within ten (10)
business days from the date your
order is received and veri�ed.
You’re eligible as an Inter Valley Health Plan Service To Seniors (HMO) and Desert Preferred Choice (HMO) plan member, to get over-the-counter items delivered to your home at no cost.
Your Over-the Counter BenefitService To Seniors (HMO) H0545, Plan 001 Desert Preferred Choice (HMO) H0545, Plan 012
2022
Inter Valley Health Plan is a not-for-pro�t HMO with a Medicare contract. Enrollment in Inter Valley Health Plan depends on contract renewal. Inter Valley Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Inter Valley Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Inter Valley Health Plan
H0545_FUY2022_008_C
About OTC Products
Products on the Order Form are eligible for coverage. These are products you would likely �nd on the shelf at your local pharmacy or general store. Braces, bandages, ointments, pain relievers, and cotton balls are all examples of eligible products. Products you order will be mailed to the address you list on the Over-the-Counter Order Form.
Dual-purpose items If a product can be used either to treat a medical condition or for a general health purpose, it is considered a dual-purpose item. For example, vitamins are considered dual-purpose items. Talk to your doctor before ordering or using a dual-purpose product. Do not order a dual-purpose product if your doctor doesn’t recommend it.
If your doctor does advise you to use a dual-purpose item, you may order the item(s) through your OTC bene�t. On the order form, dual-purpose products are marked with an asterisk (*).
Some items may be covered under Medicare Part B or Part D. For example, rolled gauze may be covered under Part B when used as prescribed for covering or dressing a surgical wound. On the order form, these items are marked with two asterisks (**).
Items marked with 3 asterisks *** have limits and or requirements. All *** are limited to one order per member per year. The digital scale also can only be ordered by members with a con�rmed diagnosis of Chronic Heart Failure and or Liver Disease.
Items that are not eligible Items that are not eligible for your OTC bene�t include but are not limited to:
Deodorant and antiperspirants
Foods and meal replacement items
Birth control medications and contraceptives
Herbal supplements and alternative medications
Lotions, facial creams, and other cosmetic items
Household items including hand soaps, razors, etc.
Baby diapers, formulas, and other childcare products
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How to place your order…
Review the items on the following product list and select what you want to order.
You may place your order via phone, email, fax or mail. If using email, fax or mail please �ll out the order form below completely in
addition to marking which items you would like to order.
Please have the following information available when you call Costco Pharmacy.
Your Inter Valley Health Plan Member ID Card Your mailing address and phone number The items you want to order and total cost Your credit card. This will be used only if your order exceeds the allowance provided
What quarter would you like this order to be applied to?
To place your Over the Counter order call Costco Mail Order Pharmacy at 877-445-0984 (TTY 711)
We’re here to take your call Monday through Friday, 8 am to 7 pm (PT) and Saturday 9:30 am to 2 pm (PT)
Fax: 888-545-4615
Email: [email protected]
Costco Mail Order Pharmacy 215 Deininger Circle, Corona, CA 92878
$25 Minimum order required
$50 Quarterly allowance
Name DOB
Address Order Date
Phone Number Allergies
Inter Valley Member Number Grp Number Order Month Received by:
ORDER FORM
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Product Active Ingredient/Item Detail Package Price Qty Size
MISCELLANEOUS ITEMSDramamine Motion Sickness Tablet meclizine 25mg 8ct $8.00
Weekly Pill Box Planner Each compartment holds 22 aspirin tablets 1ct $4.00
ALLERGY4-Hour Allergy Tablet chlorpheniramine 4mg 100ct $6.00
Allergy Relief Nasal Spray �uticasone propionate 50mcg 18.2ml $13.00 50mcg/Act 144 sprays
Banophen 25mg Capsule diphenhydramine 25mg 24ct $6.00
Cetirizine 10mg Tablet cetirizine 10mg 30ct $7.00
Coricidin HBP Cough & Cold Tablet chlorpheniramine maleate 4mg 16ct $10.00 dextromethorphan hydrobromide 30mg
Cromolyn Sodium Nasal Spray cromolyn sodium 5.2mg per spray 26ml $11.00
LDR Allergy Relief 180mg Tablet fexofenadine 180mg 15ct $10.00
Loratadine 10mg Tablet loratadine 10mg 30ct $6.00
Saline Mist 0.65% Nose Spray sodium chloride 0.65% 44ml $5.00
ANTACIDS Acid Gone Antacid aluminum hydroxide 95mg, 355ml $9.00 magnesium carbonate 358mg
Bismatrol 262mg/15ml bismatrol 262mg/15ml 236ml $7.00
Bismatrol 262mg Chewable bismatrol 262mg chewable 30ct $4.00
Calcium Antacid 500mg calcium carbonate chew 500mg 150ct $7.00
Heartburn Relief 10mg Tablet famotidine 10mg 30ct $7.00
Omeprazole 20mg Tablet omeprazole 20mg 14ct $10.00
Simethicone Chew 125mg simethicone 125mg 60ct $7.00
CANDIDAL Clotrimazole 1% Cream clotrimazole 1% 45gm $6.00
Miconazole 3 miconazole Nitrate (200mg in each suppository); 1ct $10.00 miconazole nitrate 2% (external cream)
Monistat 1 Day tioconazole 300mg (6.5%) per applicator 4.6gm $18.00
ANTIDIARRHEAL & LAXATIVE Enema, Disposable sodium phosphate 133ml $6.00
Ex-Lax 15mg Tablet sennosides 15mg 8ct $4.00
Fleet Glycerin Suppositories glycerin 2 g 24ct $6.00
GERI-KOT sennosides 8.6mg 100ct $6.00
Loperamide 2mg Tablet loperamide 2mg 12ct $5.00
Product Active Ingredient/Item Detail Package Price Qty Size
ANTIDIARRHEAL & LAXATIVE (CONTINUED) Senna Plus 8.6-50mg Tablet sennosides 8.6mg/docusate sodium 50mg 60ct $4.00
SM Bisacodyl Gentle Laxative Tablet bisacodyl 5mg 25ct $4.00
Stool Softener 250mg Softgel docusate sodium 250mg 100ct $8.00
BRACES AND SUPPORT
Ace Elbow Support Sizing: 9 – 11 in (22.8 – 27.9 cm) 1ct $10.00
Ace Wrist Support Adjustable size 1ct $12.00
Ankle Stabilizer Adjustable size 1ct $10.00
Fut Sport Knee Support Sizing: 13.0 – 17.5 in (33.0 – 44.4 cm) 1ct $14.00
Sport Aid 2 inch Elastic Bandage** latex free 1ct $5.00
COUGH/COLD
All-Night Cold Flu Relief Liquid dextromethorphan 15mg/acetaminophen 237ml $5.00 325mg/doxylamine 6.25 per 15mL
Halls Cough Drops menthol 7.5mg 30ct $4.00
Halls Cough Drops Triple Soothing menthol 7.5mg 30ct $6.00 Action-Honey Lemon
Halls Cough Drops Sugar Free menthol 5mg 25ct $4.00
Mucinex DM Tablet dextromethorphan HBr 30mg 20ct $14.00 guaifenesin 600mg
Mucus & Chest Congestion guaifenesin 100mg/5mL 118ml $6.00
Mucus Relief 400mg Tablet guaifenesin 400mg 60ct $7.00
Oxymetazoline 0.05% Spray (Nasal) oxymetazoline 0.05% 30ml $6.00
Robafen CF guaifenesin 100mg/dextromethorphan 10mg/ 118ml $7.00 phenylephrine 5mg per 5mL
guaifenesin 100mg/dextromethorphan 118ml $7.00 Robafen DM Cough Clear 10mg per 5mL
Siltussin DM Cough Syrup guaifenesin 100mg/dextromethorphan 118ml $9.00 10mg per 5mL
Sore Throat Spray phenol 1.4% 177ml $6.00
Tylenol Cold Flu Severe acetaminophen 325mg/dextromethorphan HBr 240ml $10.00 10mg/guaifenesin 200mg/phenylephrine HCI 5mg per 15 mL
Vicks Vaporub camphor 4.8%/eucalyptus oil 100gm $11.00 1.2%/menthol 2.6%
DENTAL
Colgate Plus Toothbrush Soft 1ct $4.00
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Colgate Plus Toothbrush Medium 1ct $4.00
Dental Floss 55 yards 1ct $4.00
Fixodent 68gm $6.00
Floss Pick 90ct $6.00
Orajel benzocaine 10% 7ml $9.00
Pepsodent Complete Care sodium �uoride 0.24% 156gm $6.00
Polident Overnight Whitening 40ct $5.00
Sensodyne potassium nitrate 5%/sodium �uoride 0.25% 113gm $8.00 (w/v �uoride ion)
DIAGNOSTICS
Floor Scale Digital Audio Display 550lbs*** Single purchase item per year 1ct $35.00
Infrared Thermometer*** Single purchase item per year 1ct $35.00
Omron 3 Series Blood Pressure Monitor*** Single purchase item per year 1ct $35.00
Pulse Oximeter 1ct $24.00
DIGESTIVE HEALTH
Beano Food Enzyme Tablet alpha-galactosidase enzyme 30ct $8.00 300 per 2 tablets
Lactase lactase 3000 units per caplet 60ct $10.00
EAR CARE
Ear Syringe (2oz capacity) latex free 1ct $5.00
EYE CARE
Alaway Eye Itch Relief 0.025% ketotifen 0.025% (equivalent to Ketotifen 10ml $13.00 fumarate 0.035%)
Arti�cial Tears peg 400/hypromellose/glycerine 1– 0.2 – 0.2% 15ml $8.00
B&L Eye Wash puri�ed water 99.05% 118ml $8.00
Bausch & Lomb Soothe glycerin 0.6%; propylene glycol 0.6% 28ct $12.00 Single use droppettes
Clear Eyes Redness Relief 0.012% glycerin 0.25%; naphazoline 15ml $5.00 hydrochloride 0.012%
Healthy Eyes vitamin C 250mg, vitamin E 200IU, zinc 40mg, 120ct $18.00 Supervision 2 capsules copper 1mg, lutein 5mg , zeaxanthin 1mg
Ketotifen Fum 0.025% Eye Drops ketotifen 0.025% (equivalent to Ketotifen 5ml $11.00 fumarate 0.035%)
Lubricating Plus Drops 0.5% carboxymethylcellulose sodium 0.5% 30ct $7.00 Single use droppettes
Product Active Ingredient/Item Detail Package Price Qty Size
DENTAL (CONTINUED)
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EYE CARE (CONTINUED) Preservision AREDS 2 Softgel vitamin C 250mg, vitamin E 200IU, zinc 40mg, 60ct $18.00 copper 1mg, lutein 5mg, zeaxanthin 1mg
Preservision AREDS 2 Chewable vitamin C 250mg, vitamin E 200IU, zinc 40mg, 60ct $24.00 Mixed Berry �avor copper 1mg, lutein ˆ5mg, zeaxanthin 1mg
Refresh Tears 0.5% Drops carboxymethylcellulose sodium 0.5% 15ml $10.00
Stye Ointment mineral oil 31.9%; white petrolatum 57.7% 3.5gm $9.00
Systane Eye Drops polyethylene glycol 400 0.4%; 15ml $14.00 propylene glycol 0.3%
Thera Tears Dry Eye Drops sodium carboxymethylcellulose 0.25% 30ml $16.00
Thera Tears Liquid Gel Single Use Vials sodium carboxymethylcellulose 1% 30ct $13.00
FIBER SUPPLEMENTS
Citrucel Fiber Powder S/F methylcellulose 2g (a non-allergic �ber) 479gm $16.00 per heaping tablespoon
calcium polycarbophil 625mg equivalent Fiber Laxative Capsule 625mg to 500mg polycarbophil per caplet 90ct $9.00
Fiber Powder methylcellulose 2g (a non-allergic �ber) 454gm $12.00 per heaping tablespoon
Metamucil Sugar Free – Brand psyllium �ber supplement 425gm $18.00
Phillips Fiber Gummies inulin 4g 90ct $13.00
FIRST AID
Abreva Cream docosanol 10% 2gm $21.00
Americaine Hemorrhoidal Ointment benzocaine 20% 28gm $7.00
Aspercreme w/Lidocaine lidocaine HCL 4% 76.5gm $8.00
B/A Rolled Gauze** 1ct $7.00
Bacitracin 500 u/gm ointment bacitracin 500 units per gram 28gm $5.00
BD Single Use Swab (Alcohol) isopropyl alcohol 70% 100ct $4.00
Benzoyl Peroxide 10% Gel benzoyl peroxide 10% 42.5gm $4.00
Blistex Lip Balm dimethicone 2%/octinoxate 6.6%/octisalate 4.4% 1ct $6.00
Calamine Lotion 8-8% calamine/zinc oxide 177ml $4.00
Capsaicin 0.025% Cream capsaicin 0.25% 60gm $8.00
Compound W Max Strength salicylic acid 17% 9ml $9.00
Coppertone SPF 50 Lotion avobenzone 3%/homosalate 13%/octisalate 5% 237ml $10.00 /octocrylente 7%/oxbenzone 4%
Product Active Ingredient/Item Detail Package Price Qty Size
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Product Active Ingredient/Item Detail Package Price Qty Size
FIRST AID continued
Curad Sheer contains: 10 - 1.125 x 2.875 in (2.8 x 7.3 cm); 80ct $6.00 30 - .75 x 2.875 in (1.9 x 7.3 cm); 20 - .75 x 2.125 in (1.9 x 5.3 cm); 20 1 in (2.5 cm).* not made with natural rubber latex*
Extra Strength Muscle Rub Cream methyl salicylate 15%/menthol 10% 85gm $8.00
Hemorrhoidal Hygiene Pads witch hazel 50% 100ct $5.00
Hemorrhoidal Suppository cocoa butter 88.44%/phenylephrine HCI 0.25% 12ct $4.00
Hydrocortisone 1% Cream hydrocortisone 1% 28.4gm $4.00
Hydrocortisone 1% Ointment hydrocortisone 1% 28.4gm $4.00
Hydrogen Peroxide (Max 2 per order) hydrogen peroxide 3% 473ml $3.00
Icy Hot Advanced Pain Patch menthol 7.5% 5ct $10.00
Icy Hot Extra Strength Cream menthol 10%; menthyl salicylate 30% 85gm $7.00
J&J First Aid Kit to Go contains: 2 hand cleansing wipes, 4 gauze pads, 1ct $6.00 2 fabric adhesive bandages, 4 fabric adhesive bandages 5/8 in x 2-1/4 in
Mueller Ice Bag 9 inch capacity 1 quart, 946ml 1ct $11.00
Nexcare Tape Medium hold. Not made with natural rubber latex 1ct $8.00
Nix Créme Rinse permethrin 280mg (1%) per �uid ounce 59ml $11.00
Preparation H Hemorrhoidal Suppository cocoa butter 88.44%/ phenylephrine HCI .25% 12ct $11.00
Rid Shampoo with Comb piperonyl butoxide (4%); pyrethrum extract 118ml $13.00 (equivalent to 0.33% pyrethrins
Salonpas camphor 3.1%; menthol 6%; methyl Salicylate 10% 60ct $11.00
Salonpas Deep Pain Gel camphor 3.1%; menthol 10%; methyl Salicylate 15% 78gm $8.00
Salonpas Lidocaine Gel Patch lidocaine HCI 4% 6ct $10.00
SM Cotton Balls Jumbo 100ct $4.00
SM Epsom Salt Pouch (Max 2 per order) magnesium sulfate USP 100% 454gm $4.00
SM Heating Pad Dry/Moist Standard size 12x15 in 1ct $13.00
SM Hydrocortisone 1% Cream hydrocortisone 1% 28.4gm $4.00 W / Moisturizer
SM Sterile Alcohol Prep Pad isopropyl alcohol 70% 100ct $3.00
SM Triple Antibiotic Ointment bactiracin 400 Units; neomycin 3.5mg; 28gm $5.00 polymyxin B 5000 Units per gram
Vaseline Jelly white petrolatum, USP 100% 106gm $7.00
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FOOT CARE
Dr. Scholls Bunion Cushions 6ct $5.00
Dr. Scholls Corn/Callus Remover Liquid salicylic acid 17% 9.8ml $8.00
Dr. Scholls Corn Remover Pads salicylic acid 40% 9ct $5.00
Dr. Scholls Original Foot Powder talc; salicylic acid; methyl salicylate 198gm $8.00
Miconazole Nitrate 2% Cream miconazole nitrate 2% 28gm $7.00
SM Clotrimazole 1% Cream clotimazole 1% 30gm $6.00
Terbina�ne HCL 1% Cream terbina�ne 1% 15gm $11.00
Tolnaftate 1% Cream tolnaftate 1% 30gm $9.00
Tolnaftate 1% Powder tolnaftate 1% 45gm $7.00
INCONTINENCE SUPPLIES
A&D Ointment vitamins A and D/white petrolaum/lanolin 113gm $8.00
Attends Adult Underwear Medium 32 to 44 In. waist/hip 20ct $12.00
Attends Adult Underwear Large 44 to 58 In. waist/hip 18ct $12.00
Attends Adult Underwear XL 58 to 68 In. waist/hip 14ct $12.00
Attends Briefs Regular 44 to 56 In. waist/hip 20ct $15.00
Attends Classic Briefs Medium 32 to 44 In. waist/hip 24ct $15.00
Attends Classic Briefs Large 44 to 58 In. waist/hip 24ct $15.00
Attends Classic Briefs XL 58 to 63 In. waist/hip 20ct $15.00
Depend Fitted Briefs Small/Med 19 to 34 In. waist/hip 20ct $20.00
Fluff Underpad 23X36" 23 x 36 In. 15ct $7.00
Sensi-Care Protective Barrier Cream petrolatum 49%; zinc oxide 15% 113gm $10.00
Sure Care Heavy Absorbency Pad Male 6.5 x 13 In. 14ct $11.00
Sure Care Heavy Absorbency Pad Unisex 4 x 12.5 In. 16ct $11.00
Sure Care Heavy Absorbency Pad Unisex 4 x 14.5 In. 42ct $22.00
Sure Care Moderate Absorbency Pad Unisex 4 X 9.75 In. 22ct $10.00
Sure Care Moderate Absorbency Pad Unisex 4 x 10.75 In. 20ct $10.00
Tena Ultra Washcloth 48ct $6.00
Tranquility Hvy Absorb Overnight Pad Unisex 7.25 x 16.5 In. 24ct $17.00
PAIN RELIEVERS
Acetaminophen 325mg Tablet acetaminophen 325mg 100ct $6.00
Acetaminophen Extra Strength 500mg Tablet acetaminophen 500mg 100ct $6.00
Product Active Ingredient/Item Detail Package Price Qty Size
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Product Active Ingredient/Item Detail Package Price Qty Size
PAIN RELIEVERS (CONTINUED)
Alka-Seltzer Effervescent Tablet citric acid 1000mg/aspirin 325mg (NSAID) 12ct $7.00 /sodium bicarbonate 1916mg
All Day Relief Naproxen 220mg Tablet naproxen sodium 220mg (NSAID) 50ct $7.00
APAP - Diphenhydramine 500-25mg acetaminophen 500mg/diphenhydrAMINE 25mg 50ct $4.00
Aspirin 325mg Tablet aspirin 325mg (NSAID) 100ct $4.00
Aspirin 81mg Chew Tablet chewable aspirin 81mg 36ct $5.00
Aspirin EC 325mg Tablet enteric coated aspirin 325mg 100ct $5.00
Aspirin EC 81mg Tablet enteric coated aspirin 81mg 120ct $5.00
Cystex Plus Urinary Pain Relief Tablet methenamine 162mg/sodium salicylate 40ct $9.00 162.5mg (NSAID)
Ibuprofen 200mg Tablet ibuprofen 200mg 100ct $6.00
MAPAP Arthritis 650mg Tablet acetaminophen 650mg 100ct $11.00
Pain Reliever Plus (APAP/ASA/CAFF) aspirin 250mg/acetaminophen 250mg 100ct $7.00 /caffeine 65mg
Tylenol Arthritis 8hr Caplet - BRAND acetaminophen 650mg 100ct $15.00
VITAMINS
Calcium 500mg + D 400U Chewable* calcium carrbonate 500mg/vitamin D3 400IU 60ct $5.00
Calcium Carb w/D 600-400* calcium carrbonate 600mg/vitamin D3 400IU 60ct $6.00
Calcium Citrate/Vit D 315mg-200IU* calcium citrate 315mg/vitamin D3 2000IU 60ct $8.00
Centrum Silver Tablet* multivitamin 125ct $16.00
Cerovite Senior Tablet* multivitamin with minerals/lutein 60ct $7.00
Citracal Max Plus Caplets* vitamin D 500iu/calcium citarate 630mg 120ct $12.00
Coenzyme Q10 50mg Gel Capsule* coenzyme Q10 50mg 30ct $11.00
Daily-Vites Tablet* multivitamin 100ct $6.00
Daily-Vites w/Iron Tablet* multivitamin with iron 100ct $7.00
Ferrous Sulfate 325mg Tablet* ferrous sulfate 325mg 100ct $6.00
Fish Oil 1000mg Capsule* omega-3 fatty acids 340/�sh oil 1000mg 100ct $9.00
Folic Acid 400mcg Tablet* folic acid 400mcg 100ct $4.00
Glucosamine Chondrotin 500-400mg* glucosamine 500mg/chondrotin 400mg 60ct $9.00
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Product Active Ingredient Package Price Qty Size
VITAMINS (CONTINUED)
Iron Slow Release 45mg Tablet* iron 45mg (ferrous sulfate) 60ct $7.00
Magnesium 250mg Tablet* magnesium oxide 250mg 100ct $7.00
Melatonin 3mg Tablet* melatonin 3mg 60ct $5.00
Niacin 100mg Tablet* niacin 100mg 100ct $6.00
Niacin 250mg Time Release Capsule* niacin 250mg 90ct $10.00
NM Fish Oil 1000mg* �sh oil 1000mg (total omega-3 fatty 150ct $15.00 acids 300mg [omega-3 EPA & DHA] 250mg, omega-3 other 50mg) per capsule
Osteo Bi-Flex Triple glucosamine HCI 1,500mg/joint shield 5-loxin 80ct $23.00 Strength Coated Tablet* advanced boswellia serrata extract (resin) 100mg/methylsulfonylmethatne (MSM) 1,500 mg per 2 tablets
Oyster Shell Calcium + D 500mg/200u* calcium carbonate 500mg/vitamin D3 200IU 60ct $6.00
Oyster Shell Calcium 500mg* calcium carbonate 500mg 60ct $4.00
Vitafusion Melatonin Gummy* gummy melatonin 5mg 120ct $14.00
Vitafusion Multi Vites Gummy* gummy multivitamin 150ct $14.00
Vitamin B-12 1000mcg Tablet Sublingual* calcium (as diacalcium phosphate) 100mg/vitamin 100ct $9.00 B-12 (as cyanocobalamin) 1,000mcg
Vitamin B-12 100mcg Tablet* cyanocobalamin (vitamin B-12) 100mcg 100ct $6.00
Vitamin B-50 Complex Tablet* thiamin (vitamin B-1) 50 mg/ribo�avin (vitamin B-2) 60ct $9.00 50 mg/niacin 50 mg/vitamin B-6 (as pyridoxine hydrochloride) 50 mg/folic acid 400 mcg/vitamin B-12 (as cyanocobalamin) 50 mcg/biotin 50 mcg/pantothenic acid (as calcium pantothenate) 10 mg/ calcium (as calcium carbonate) 115 mg
Vitamin C 500mg Chew Tablet* ascorbic acid 500mg 100ct $7.00
Vitamin C 500mg Tablet* ascorbic acid 500mg 100ct $7.00
Vitamin D 2000 U Tablet* vitamin D3 (as cholecalciferol) 2000 IU 100ct $7.00
Vitamin E 400 unit Capsule* vitamin E (dl,tocopheryl acet) 400 units 100ct $7.00
Zinc Gluconate 50mg Tablet* zinc gluconate 50mg 100ct $4.00
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MED 406 STS/DPC 10/21
2022
300 S. Park AvenuePO Box 6002, Pomona, CA 91769-6002ivhp.com@intervalley
For more information please call the number below or visit us at www.ivhp.com.
Current Members call toll free: Pharmacy Care Team 1-800-523-3142, Member Care Team 1-800-251-8191, TTY users should call 711.
Prospective Members call toll free: 1-800-500-7018, TTY users should call 711.
Contact our Member Care Team or Pharmacy Care Team October 1 to March 31: 8 am to 8 pm, 7 days a week. We are closed on Thanksgiving Day and Christmas Day.
Contact us April 1 – September 30: 8 am to 8 pm, Monday through Friday. We are closed on federal holidays.
NOTE: When we are closed you have the option to leave a message. Messages received will be returned within one (1) business day.
You can see our plan’s provider/pharmacy directory on our website at www.ivhp.com.
You can see the complete Plan formulary (list of Part D prescription drugs) and restrictions on our website at www.ivhp.com
