Over-the-Counter (OTC) Catalog - ohanahealthplan.com · Over-the-Counter (OTC) Catalog ... Ibuprofen 200mg Liquid Gel Caps : 20 : $5 : 523 : Advil® Liquid Gel Caps : 20 : $6 : 24

Y0070_NA026552_WCM_OTC_ENG_FINAL_02 CMS Accepted 07162014 HI5OTCCAT60343E ©WellCare 2014 HI_06_14

2015 Over-the-Counter (OTC) Catalog�

Get the OTC items you need. — Medicare Advantage Plans —

Call Customer Service to order your OTC items | 1

HI5OTCCAT60343E�

The Benefits of ‘Ohana Add Up. What is ‘Ohana’s OTC benefit? Simply put, we give you a monthly dollar amount; you spend it on some of the over-the-counter (OTC) items you use every day. It’s that easy. The OTC benefit is part of your health plan. Every month you can get brand-name or generic OTC medications and products like bandages, pain relievers, cold medicine, toothpaste, vitamins and much more. You even have a few ways to get your items. You can use this catalog, then order online or by phone and we’ll ship your items right to your door. Or if you prefer, you can buy your selections at any retail store and we’ll pay you back. Each plan offers different OTC benefit amounts. Check your Evidence of Coverage or Summary of Benefits for your specific benefit amount for your plan. Remember that your benefit and items are only for your use. Use your benefit each month. It does not roll over to the next month.

How Do I Use My OTC Benefit? There are several ways to get your items. No matter how you order them, we’ll ship them right to your door. It’s that easy. Allow 7-10 days to receive your order. Find the items you want in this catalog, then:

1. Give us a call. Find the Customer Service number for your state/plan in the back of this catalog, to place your order.

2. Order Online Visit us at www.ohanahealthplan.com/medicare. Log on with your username and password. If you don’t have a username, it’s easy to sign up. Just follow the instructions. Once you’ve logged in, click on the OTC items link. Order items until they add up to your monthly benefit amount.

3. Buy your OTC items and we’ll repay you. Go to any retail store and buy eligible OTC items. Then send us an OTC claim form and a copy of your itemized receipt. We’ll pay you back for the costs up to your monthly OTC benefit amount. (You’ll have to pay for anything over that.) There is a blank form and instructions on how to use it in this catalog.

http://www.ohanahealthplan.com/medicare

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Alternative medicines such as botanicals, herbals, probiotics and nutraceuticals

Baby items such as diapers and formula

Contraceptives such as birth control pills and spermicides

Convenience and comfort items such as scales, fans and magnifying glasses

Cosmetic items such as mouthwash, bad breath remedies, deodorants and teeth whitening

Food products or supplements

Replacement items such as hearing aid batteries and contact lens containers

2 | Call Customer Service to order your OTC items�

What Can I Order With My OTC Selection?

Eligible items

On the next few pages, you’ll find a list of products. These are the items that you can order from us and have mailed to your home. Or if you prefer, you can buy these and other items at a local store and have us repay you. Eligible items include but are not limited to: fiber supplements, first aid supplies, medicines, ointments, sprays with active medical ingredients that alleviate symptoms, topical sunscreen, supportive items for comfort such as knee braces and adult incontinence products, and mouth care such as dental floss and toothbrushes.

Dual-purpose items

What are dual-purpose items? They’re medicines and products that can be used for either a medical condition or for general health and well-being. You can get dual-purpose items as part of your OTC benefit if you use them to treat a specific medical condition and your doctor recommends the product or medicine. Talk with your doctor before buying dual-purpose items. For your convenience, we’ve marked dual-purpose items with a (†).

Dual-purpose items include but are not limited to: Minerals and vitamins

In-home testing and monitoring

Hormone replacement

Weight-loss items

Some items, under certain circumstances, may be covered under either Part B or Part D. For example, gauze may be covered under Part B when it is being used, as prescribed, to perform surgical wound dressing changes. For your convenience, we’ve marked these items with a (**).

What’s not eligible?

The following categories and items listed are not eligible for the OTC benefit. You cannot order them from us, and if you buy these items at a store, we can’t repay you for them. Non-eligible items include but are not limited to:

Items You Can Order From Us or Buy at a Retail Store Do you prefer lower-cost generics or familiar brand-name products? Your OTC benefit lets you make the choice! Look over the list of eligible items on the next few pages. You can order online or by calling us and telling us the ID numbers of the items you want. We’ll send them to your home and deduct the amount from your monthly benefit.

Don’t see your items? You can buy these and other items at a store near you and get reimbursed by sending us your itemized receipt and the enclosed OTC claim form.

OUR CATALOG ITEMS

ID# GENERIC NAME QTY AMT ID# BRAND NAME QTY AMT

ALLERGY PREVENTION AND TREATMENT

1 Allergy Relief (Cetirizine) 10mg Tablets 30 $8 501 Zyrtec® 14 $15

2 Allergy Relief (Loratadine) 10mg Tablets 30 $7 502 Claritin® 10 $10

ANALGESICS / ANTIPYRETICS

3 Acetaminophen 325mg Tablets 100 $3 503 Tylenol® 325mg Regular

Strength Tablets 100 $10

4 Acetaminophen 500mg Tablets 100 $4 504 Tylenol® 500mg Extra

Strength Tablets 100 $16

5 Aspirin 325mg Tablets 100 $3 505 Bayer® Aspirin 325mg 100 $8

6 Aspirin 81mg Chewable 36 $3 N/A Bayer® Aspirin 81mg Chewable N/A N/A

7 Aspirin Enteric Coated 81mg Tablets 120 $3 507 Bayer® EC Aspirin 81mg

(Adult Regimen) 32 $4

8 Aspirin Enteric Coated 325mg Tablets 100 $4 508 Ecotrin® Tablets 100 $6

ANTACIDS AND ACID REDUCERS

9 Acid Reducer (Famotidine) 10mg Tablets 30 $6 509 Pepcid® AC Tab 30 $11

10 Acid Reducer (Omeprazole) 20mg 14 $10 510 Prilosec® 14 $12

11 Acid Reducer (Ranitidine) 75mg Tablets 30 $7 511 Zantac® Tablets 30 $15

* = Quantities and brands may vary depending upon availability. † = Dual-purpose items ** = Covered under either Part B or Part D

Call Customer Service to order your OTC items | 3�


ANTACIDS AND ACID REDUCERS

12 Antacid Tablets 150 $4 512 Tums® Tablets 150 $6

13 Effervescent Tablets 36 $4 513 Alka-Seltzer® 24 $7

14 Gas Relief Tablets Extra-Strength 30 $4 514 Gas-X® Extra Strength 18 $6

ANTICANDIAL (YEAST)

15 Miconazole Vaginal Cream 3 day 1 $12 515 Monistat® Vaginal Cream

3 day 1 $24

ANTIDIARRHEAL AND LAXATIVES

16 Adult Glycerin Suppositories 12 $3 516 Fleet® Adult

Suppositories 50 $5

17 Anti-Diarrheal Caplets 12 $4 N/A Imodium® A-D Caplets N/A N/A

18 Anti-Nausea Liquid 4 oz. $6 518 Emetrol® 4 oz. $9

19 Bisacodyl 5mg Tablets 25 $4 519 Dulcolax® Tablets 25 $7

20 Laxative (Bisacodyl) 10mg Suppositories 12 $5 520 Dulcolax® Suppositories 8 $13

21 Stomach Relief Flavored Tablets 30 $3 521 Pepto–Bismol® Tablets 30 $5

22 Stool Softener Capsules 100 $4 522 Colace® Softgels 30 $13

ANTI-INFLAMMATORY

23 Ibuprofen 200mg Liquid Gel Caps 20 $5 523 Advil® Liquid Gel Caps 20 $6

24 Ibuprofen 200mg Tablets 50 $5 524 Advil® Tablets 50 $10

25 Naproxen Sodium 220mg Caplets 50 $8 525 Aleve® Caplets 24 $7

ARTHRITIS MEDICINE

26 Arthritis Pain Relief Tablets 24 $5 N/A Tylenol® Arthritis N/A N/A

27 Hot/Cold Patches 5 $5 527 Icy Hot® Patches 5 $7

BLADDER CONTROL ITEMS

167 Adult Protective Briefs Small/Medium 20 $18 N/A Adult Protective Briefs

Small/Medium N/A N/A



BLADDER CONTROL ITEMS

168 Adult Protective Briefs Large 20 $18 N/A Adult Protective Briefs

Large N/A N/A

169 Adult Protective Briefs XL 20 $20 N/A Adult Protective Briefs

XL N/A N/A

170 Adult Bladder Control Pads 28 $9 N/A Adult Bladder Control

Pads N/A N/A

200 Disposable Bed Underpads 5 $6 N/A Disposable Bed

Underpads N/A N/A

COLD/COUGH/FLU REMEDIES

53 APAP Sinus Congestion 24 $4 553 Tylenol® Sinus Congestion 24 $8

54 Cough/Throat Drops 30 $3 554 Halls® Cough Drops 25 $3

55 Daytime Cold/Flu Relief Caplets 16 $5 555 DayQuil® Caplets 16 $8

56 Daytime Cold/Flu Relief Liquid 4 oz. $5 556 DayQuil® Liquid 8 oz. $8

174 Daytime/Nite-time Cold/Flu Caplets 16 $5 674 DayQuil/NyQuil® caplets 32 $16

57 Mucus Relief DM Tablets 30 $9 557 Mucinex-DM® 20 $15

58 Mucus Relief Tablets 30 $8 558 Mucinex® 20 $15

59 Nasal Decongestion Spray 1 oz. $4 559 Afrin® Nasal Spray 1 oz. $10

60 Nasal Decongestion PE Tablets 36 $4 N/A Sudafed® PE N/A N/A

61 Nite-Time Cold/Flu Relief Caplets 16 $5 561 NyQuil® Caplets 16 $8

62 Nite-Time Cold/Flu Relief Liquid 4 oz. $5 562 NyQuil® Liquid 8 oz. $8

63 Saline Nasal Spray 1.5 oz. $3 563 Ocean® Nasal Spray 1.5 oz. $6

64 Sore Throat Spray 6 oz. $4 N/A Chloraseptic® Sore Throat Spray N/A N/A

65 Tussin DM Syrup SF 4 oz. $4 565 Robitussin® DM Syrup 4 oz. $7

66 Tussin Syrup 4 oz. $4 N/A Robitussin® Syrup N/A N/A

67 Vapor Rub 3.53 oz. $5 N/A Vicks Vaporub® N/A N/A



DENTAL AND DENTURE CARE

69 Denture Adhesive Cream 2.4 oz. $4 569 Fixodent® 2.4 oz. $5

70 Denture Cleaner 40 $4 570 Efferdent® 16 $5

71 Fluoride Toothpaste 6 oz. $2 571 Colgate® 4.6 oz. $4

72 Premium Adult Toothbrush 1 $2 572 Aim® Toothbrush 1 $3

73 Premium Dental Floss 1 $2 573 Aim® Dental Floss 1 $3

75 Sensitive Teeth Toothpaste 4 oz. $3 N/A Sensodyne N/A N/A

76 Toothache Relief Liquid/Gel

0.33 oz. $4 576 Anbesol® Liquid/Gel 0.41

oz. $9

EAR CARE

77 Ear Syringe 1 $3 N/A Ear Syringe N/A N/A

78 Ear Wax Drops 0.5 oz. $6 578 Debrox® Ear Wax Drops 0.5 oz. $8

EYE CARE

79 Artificial Tears 0.5 oz. $4 579 Visine® Tears 0.5 oz. $7

93 Red Eye Relief Drops 0.5 oz. $3 593 Visine® Drops 0.5 oz. $6

FIBER SUPPLEMENTS

94 Fiber Gummies 60 $9 594 Vitafusion® Fiber Well Gummies 90 $18

95 Fibertab Tablets 90 $9 595 FiberCon® Tablets 90 $16

FIRST AID AND MEDICAL SUPPLIES

96 Adhesive First-Aid Tape** 1 $2 N/A Adhesive First-Aid Tape** N/A N/A

189 Aid Ankle Support 1 $8 N/A Aid Ankle Support N/A N/A

191 Aid Elbow Support 1 $8 N/A Aid Elbow Support N/A N/A

192 Aid Hand Support 1 $8 N/A Aid Hand Support N/A N/A

166 Aid Knee Support 1 $8 N/A Aid Knee Support N/A N/A

190 Aid Wrist Support 1 $8 N/A Aid Wrist Support N/A N/A

97 Alcohol Pads** 100 $3 N/A Alcohol Pads** N/A N/A



FIRST AID AND MEDICAL SUPPLIES

162 Anti-Embolism Stockings Extra Large 1 $13 N/A Anti-Embolism Stockings

Extra Large N/A N/A

163 Anti-Embolism Stockings Large 1 $13 N/A Anti-Embolism Stockings

Large N/A N/A

164 Anti-Embolism Stockings Medium 1 $13 N/A Anti-Embolism Stockings

Medium N/A N/A

165 Anti-Embolism Stockings Small 1 $13 N/A Anti-Embolism Stockings

Small N/A N/A

98 Athletic Bandage** 1 $2 N/A Athletic Bandage** N/A N/A

99 Bandages Assorted 100 $3 599 Band-Aids® 100 $7

100 Butterfly Closures** 10 $2 N/A Butterfly Closures** N/A N/A

101 Corn and Callus Remover 0.5 oz. $4 N/A Dr. Scholl’s® Corn and Callus Remover N/A N/A

102 Cotton Balls 100 $2 N/A Cotton Balls N/A N/A

103 Cotton Swabs 150 $3 603 Q-Tips® Cotton Swabs 170 $4

104 First Aid Kit 1 $8 N/A First Aid Kit N/A N/A

105 Flexible Tip Thermometer 1 $10 N/A Flexible Tip Thermometer N/A N/A

106 Ice Bag 1 $4 N/A Ice Bag N/A N/A

107 Liquid Wart Remover 0.5 oz. $6 607 Compound W® Wart Remover 1 $8

108 Oral Digital Thermometer 60 Second 1 $5 N/A Oral Digital Thermometer

60 Second N/A N/A

109 Stretch Gauze Bandage** 1 $2 N/A Stretch Gauze Bandage** N/A N/A

HEADACHE RELIEF

110 Headache Relief Tablets 24 $4 610 Excedrin® Migraine 24 $6

HEMORRHOIDAL PREPARATIONS

111 Hemorrhoid Ointment 2 oz. $7 611 Preparation H® Ointment 2 oz. $16

112 Hemorrhoid Pads 100 $8 612 Tucks® Medicated Pads 100 $10

113 Hemorrhoid Relief Suppositories 12 $5 613 Preparation H®

Suppositories 12 $7



LACTOSE INTOLERANCE

114 Lactase Enzyme 60 $10 614 Lactaid® Tablets 32 $10

MOTION SICKNESS MEDICATION

115 Motion Sickness Tablets 12 $3 615 Dramamine® Motion Sickness 12 $6

PEDICULICIDES (HEAD LICE TREATMENTS)

136 Lice Comb 1 $3 N/A Lice Comb N/A N/A

137 Lice Treatment Shampoo 4 oz. $10 637 Rid® Lice Shampoo 4 oz. $12

SLEEPING AIDS

138 Night Time Sleep Tablets (Diphenhydramine) 24 $4 638 Sominex® Tablets 16 $7

139 Sleep Aid Tablets (Doxylamine) 16 $5 639 Unisom® Tablets 16 $7

SMOKING CESSATION PRODUCTS

196 Nicotine Gum 2mg 20 $10 N/A Nicotine Gum 2mg N/A N/A

197 Nicotine Gum 4mg 20 $10 N/A Nicotine Gum 4mg N/A N/A

TOPICAL OINTMENTS AND CREAMS

140 Anti-Itch Cream 1 oz. $3 640 Benadryl® Cream 1 oz. $6

141 Clotrimazole 1% Cream 1 oz. $5 641 Lotrimin® AF 0.42 oz. $10

142 Cold Sore Treatment 1 $8 N/A Herpecin® N/A N/A

143 Hydrocortisone 1% Cream 1 oz. $3 N/A Cortaid® N/A N/A

144 Muscle Rub Cream 1.25 oz. $3 644 Bengay® 2 oz. $6

145 Petroleum Jelly 4 oz. $3 645 Vaseline® Jelly 3.75 oz. $5

171 SPF 50 Sunblock 4 oz. $6 N/A Coppertone® SPF 50 Sunblock N/A N/A

146 Tolnaftate 1% Cream 1.25 oz. $5 646 Tinactin® Cream 0.5 oz. $10

147 Triple Antibiotic Ointment 1 oz. $4 647 Neosporin® Ointment 0.5 oz. $6




VITAMINS AND MINERALS†

148 Adult Multi-Vitamins 100 $8 N/A Adult Multi-Vitamins N/A N/A

149 Calcium 600 + Vitamin D 60 $6 649 Caltrate® 600 + D Tablets 60 $14

150 Calcium Tablets 60 $5 N/A Calcium Tablets N/A N/A

151 Ferrous Sulfate (Iron) 325mg Tablets 100 $6 N/A Ferrous Sulfate (Iron)

325mg Tablets N/A N/A

152 Folic Acid 400mcg Tablets 100 $4 N/A Folic Acid 400mcg

Tablets N/A N/A

153 Magnesium 250mg Tablets 100 $4 N/A Magnesium 250mg

Tablets N/A N/A

155 Vitamin A 10,000 IU Caplets 100 $4 N/A Vitamin A 10,000 IU

Caplets N/A N/A

156 Vitamin B-12 100 $5 N/A Vitamin B-12 N/A N/A

157 Vitamin B-Complex 100 $5 N/A Vitamin B-Complex N/A N/A

158 Vitamin B-Complex Gummy 70 $8 N/A Vitamin B-Complex

Gummy N/A N/A

159 Vitamin C 500mg Tablets 100 $4 N/A Vitamin C 500mg Tablets N/A N/A

193 Vitamin C Gummy 60 $8 N/A Vitamin C Gummy N/A N/A

160 Vitamin E 100 IU Caplets 100 $7 N/A Vitamin E 100 IU Caplets N/A N/A

161 Zinc 50mg Tablets 100 $5 N/A Zinc 50mg Tablets N/A N/A

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1 Make sure to order your items every month. If you skip a month, the benefits don’t carry over to the next month.

2 Use your monthly dollar amount to stock up on a variety of items by ordering different items every month.

3 If you buy your items at a store, make sure to send us a copy of your itemized receipt and OTC claim form within 90 days so we can reimburse you.

Thanks for being our member!

How Do I Get Reimbursed if I Buy Items From a Store? All we need from you is an OTC claim form and a copy of the itemized receipt from the store where you bought the items. You must send these to us within 90 days of the date on your receipt.

For your convenience, use the blank form on the next page. Need more forms? You can: Call Customer Service Make copies of this blank form Download the form from our website at www.ohanahealthplan.com/medicare under Extra Benefits

Remember: Purchase eligible items only or your request for that item will be denied. Handwritten receipts are not accepted.

Fill out every section, or your claim could be denied for missing information.

We will repay you within 30 days.

To get the most out of your OTC benefit:


Sample Receipt*:

#09396 Green Pharmacy 123 West Road Tampa, FL 33634

08/13/13

Aspirin 325 mg. $10.00

Daytime Cold Relief $10.00

Candy $6.00

SUBTOTAL $26.00

TAX (7%) $1.82

TOTAL $27.82

Complete the claim form on the other side of this page.�

Include a copy of the receipt for the item(s) purchased.�

Your receipt must include the date of purchase and item(s) purchased.�All fields must be completed for reimbursement. Handwritten receipts will not be accepted.

You may fax or mail your claim form and receipt, but faxing provides faster customer service.

FAX your form and receipt to: ‘Ohana OTC DMR Center at 1-877-849-5068

OR MAIL your form and receipt to: ‘Ohana OTC DMR Center • P.O. Box 31396 • Tampa, FL 33631-3396

To get more information or inquire how to get more claim forms, please contact Customer Service at one of the toll-free numbers listed in your OTC benefit information.

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Sample Claim Form:

Purchase Date Merchant Name Merchant ZIP Code Item Name/Description Package Size Total Item Cost

(list URL if an online purchase) (if multiple count of same item, use a line for each count)

(i.e., 6 oz., 36 capsules/tablets)

(include any applicable tax in the total)

8/13/2013 Green Pharmacy 33634 Aspirin 325mg 100 tablets $10.70*

8/13/2013 Green Pharmacy 33634 Daytime Cold Relief 16 oz. $10.70*

Grand Total: $21.40

*To calculate total item cost, multiply cost of item by 7% tax ($10.00 X .07 = $0.70) and add together ($10.00 + $.70 = $10.70).

Remember:

NA026551_WCM_OTC_ENG_HI ©WellCare 2014 NA_06_14HI5DMRFRM60345E 60

345

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (HMO-POS)is a Medicare Advantage organization with a Medicare contract. Enrollment in ‘Ohana (HMO-POS)depends on contract renewal.

Over-the-Counter (OTC) Items Claim Form FAX form and receipt to 1-877-849-5068 OR�

MAIL form and receipt to ‘Ohana OTC DMR Center • P.O. Box 31396 • Tampa, FL 33631-3396�Use this claim form to be reimbursed for eligible over-the-counter items. Please submit one form per member.

Member Name: Member ID: Check here if new address

Address:

City: State: ZIP Code:

Telephone: ( )

Receipts must be submitted within 90 days of receipt date and are processed within 30 days of receipt. Do not send original receipts.

Purchase Date Merchant Name Merchant ZIP Code Item Name/Description Package Size Total Item Cost

(list URL if an online purchase) (if multiple count of same item, use a line for each count)

(i.e., 6 oz., 36 capsules/tablets)

(include any applicable tax in the total)

$

$

$

Grand Total: $

By signing this form, I confirm that the request for reimbursement is for eligible over-the-counter items and is not covered by any other plan or program. (If you have questions regarding eligible items, please refer to your OTC benefit information or call Customer Service at the number listed on the back of your member ID card.) Member’s Signature: Date:

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We’re always just a phone call away! If you’re ready to enroll or have enrollment questions, call 1-877-817-5793,

8 a.m. to 8 p.m., 7 days a week.

If you’re already a member, call the number for your state/plan listed below.

Hours of operation are Monday–Friday, 8 a.m. to 8 p.m.�Between October 1 and February 14, representatives are available Monday–Sunday,�

8 a.m. to 8 p.m., or visit us anytime at www.ohanahealthplan.com/medicare.�

TTY for all of the above .........................................................................................................1-877-247-6272�

Hawai‘i: ‘Ohana Choice or Value (HMO-POS).................................... 1-888-505-1201

Nurse Advice Line .............................................................. 1-800-581-9952 (24 hours, 7 days a week)


‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (HMO-POS) is a Medicare Advantage organization with a Medicare contract. Enrollment in ‘Ohana (HMO-POS) depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments and restrictions may apply. Benefits, premium and/or co-payments/ coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Please contact ‘Ohana for details.

P.O. Box 31389 | Tampa, FL 33631-3389�

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Over-the-Counter (OTC) Catalog - ohanahealthplan.com · Over-the-Counter (OTC) Catalog ... Ibuprofen 200mg Liquid Gel Caps : 20 : $5 : 523 : Advil® Liquid Gel Caps : 20 : $6 : 24