Over-the-Counter Health & Wellness Products

1 over -the-CounterHealth & WellnessProducts2016 Catalog and Order FormY0040_GNHJBPBEN 0815 Your current plan may have an Over-the-Counter benefit that would allowyou to purchase Over-the-Counter (OTC) Health and Wellness productsfrom Humana Humana Pharmacy at 1-855-211-8370 (TTY: 711) if you have questionsabout how to use this benefit at Humana Pharmacy. Customer Carerepresentatives are available Monday Friday, 8 11 andSaturday, 8 6:30 , Eastern this catalog somewhere important. You ll need this to look up thehealth and Wellness Products you want to order each to order:Place your order no later than the 20th of each month to ensure thatHumana Pharmacy is able to process your order within the applicable benefit month.

2 If your total order exceeds your benefit amount limit, please be sure to include a check, money order, or credit card information to paythe remaining amount due. Failure to submit payment in full will lead toa delay in shipment or a cancellation of can place your order: Online: Go to Mail: Fill out the OTC Health and Wellness product Order Form and mailonly the order form pages to:Humana PharmacyPO Box 1197 Cincinnati, OH 45201-1197 Fax: Fill out the OTC Health and Wellness product Order Form and faxonly the order form pages to: 1-800-379-7617.* This order form is for the 2016 benefit year. Please do not submit your first order until after January 1, Over-the-Counter (OTC) Health and Wellness product Order FormGender Male FemaleMMDDYYYY2016 Humana Health and Wellness product Order FormSTEP 1 - COMPLETE YOUR INFORMATION BELOW:STEP 2 - product SELECTION During which month would you like to receive this order?

3 M MPlease note: Orders can only be placed for the current or further month. Humana Pharmacy is not able to backdate an order for a previous ID (found on Humana ID card) Date of Birth / / First Name Last Name MI Street Number Street Name Apt/Suite # City State Zip Code

4 Daytime Phone Evening Phone Please check box if this is a new address: product CodeProduct NameQuantity to order*Price1 OTC2 OTC3 OTC4 OTC5 OTC6 OTC7 OTC8 OTC9 OTC10 OTC*Write in the quantity of the product you would like to receive, not the package size listed in the catalog.

5 Example: 0 4 7 Aspirin 325mg 1 $5 Your total order amount Humana monthly allowance Total remaining amount due If your total order is less than your plan s monthly allowance, you DO NOT need to include payment andyou will receive the items you your order exceeds your plan s monthly allowance, please include your check, money order, or enteryour credit card information below to pay the remaining amount due. Failure to submit payment in full will lead to items being cancelled to bring your order total at or below your monthly benefit allowance. Any unused allowance does not roll over to the next month. YYMMSTEP 3 PAYMENT INFORMATION (if applicable) Please make checks payable to Humana Pharmacy.

6 Please do not send pay by credit card, please complete the following:Credit/Debit Card # Exp. Date / Cardholder First Name Cardholder Last Name Cardholder Signature:Note: A monthly allowance amount is only available if your plan offers the Over-the-Counter (OTC)services as a benefit. Call Humana Pharmacy at 1-855-211-8370 (TTY: 711) if you have questions about yourorder, or about how to use this benefit at Humana Pharmacy, Monday Friday, 8 11 , and Saturday,8 6:30 Eastern time.

7 Orders will be shipped to your home by UPS or the US Postal Service at no extra charge to you. Please allow 10 to 14 business days from the time Humana Pharmacy receives your order to shipment. You ll receive a generic comparable to the name-brand product . Please consult your doctor before using any Over-the-Counter (OTC) product . This product list is subject to change. If a product is unavailable or not in stock, it may be substituted for a similar product at no additional charge. Y0040_GNHJBPBEN 08152016 Humana Health and Wellness product Order FormSTEP 4 - To order by mail, send the completed Humana Health and Wellness product Order Form page along with payment (if applicable) to: Humana Box 1197 Cincinnati, OH 45201-1197$ _____$ _____$ _____Over-the- counter (OTC) Health and Wellness product CatalogNote.

8 You will receive the generic equivalent of all itemsAntacid, Anti-Diarrheals, and LaxativesProduct codeProduct nameCompare toPackage countPrice075 Antacid/Anti-Gas ChewMaalox Plus 1100$ LiquidMaalox 360 ml$ Tablets - Loperamide 2 mgImodium A-D 12$ OintmentPreparation H 60 gm$ Carbonate AntacidTums Extra Strength96$ Carbonate Antacid - Regular StrengthTums Regular Strength150$ Strength Gas Relief TabletsGas-X Extra Strength30$ 20 mgPepcid 20 mg25$ Laxative TabletsFiberCon 90$ Suppositories, AdultFleet Glycerin Suppositories25$ SuppositoriesPreparation H Suppositories12$ 15 mgPrevacid 14$ - Biscodyl 5 mgDulcolax 25$ of Magnesia - Laxative/AntacidPhillips Milk of Magnesia360 ml$ 24 HRNexium 24HR14$ OTC 20 mg14$ Bismuth - Chewable TabletsPepto-Bismol Chewable Tablets30$ Glycol 3350 MiraLAX 238 gm$ Fiber Laxative CapsulesMetamucil 160$ 75 mg Tablets - AntacidZantac 30$ Laxative TabletsSenokot 100$ Softener CapsulesColace 100$ , Cold and AllergyProduct codeProduct nameCompare toPackage countPrice292 Allergy Nasal SprayFlonase.

9 34 fl oz$ HCL 10 mgZyrtec 10 mg30 $ s Allergy Liquid 5 mgChildren s Claritin 4 oz$ and Cold High Blood Pressure TabletsCoricidin HBP Cough and Cold16$ PE TabletsDayQuilTM16$ - Guaifenesin 400 mgMucus Relief 400 mg30$ Itch Relief Eye DropsZaditor .17 fl oz$ 180 mg 24 hourAllegra Allergy30$ Formula ExpectorantRobitussin 120 ml$ Suppressant (sugar free)Robitussin Sugar Free DM118 ml$ suppressant/expectorantRobitussin DM120 ml$ suppressant/nasal decongestant/expectorantRobitussin CF120 ml$ 10 mgClaritin 30$ Chest RubVicks VapoRub 99 gm$ Sore Throat LozengesChloraseptic Lozenges18$ Allergy 24 hour - genericNasacort .57 fl oz$ Decongestant PE Max StrengthSudafed PE Tablets36$ Decongestant SprayAfrin 30 ml$ Anesthetic Sore Throat SprayChloraseptic 180 ml$ Nasal SprayOcean Saline Nasal Spray45 ml$ HClTylenol Sinus24$ ManagementProduct codeProduct nameCompare toPackage countPrice265 Compression Stockings 15-20mmHg Regular Beige Size A (Ankle: 7 - 7 7/8 ; Calf: 10 - 13 )JOBST 1$ Stockings 15-20mmHg Regular Beige Size B (Ankle: 8 - 8 7/8 ; Calf: 12 - 15 )JOBST 1$ Stockings 15-20mmHg Regular Beige Size C (Ankle: 9 - 9 7/8 ; Calf: 14 - 17 )JOBST 1$ Stockings 15-20mmHg Regular Beige Size D (Ankle: 10 - 10 7/8 ; Calf: 16 - 19 )JOBST 1$ Stockings 15-20mmHg Regular Beige Size E (Ankle: 11 - 11 7/8.)

10 Calf: 18 - 21 )JOBST 1$ Stockings 15-20mmHg Regular Beige Size F (Ankle: 12 - 12 7/8 ; Calf: 20 - 23 )JOBST 1$ Stockings 15-20mmHg Regular Beige Size G (Ankle: 13 - 13 7/8 ; Calf: 22 - 26 )JOBST 1$ Skin Relief Foot CreamGold Bond Diabetic Skin Relief Foot Cream96 gm$ TabletsDEX4 Glucose Tablets60$ Strips for UrinalysisDiastix Reagent Strips for Urinalysis50$ ContainerBDTM Home Sharps Container1$ Strips for UrinalysisKetone Test Strips for Urinalysis50$ RelieversProduct codeProduct nameCompare toPackage countPrice294 Acetaminophen 325 mgTylenol Regular Strength100$ 500 mgTylenol Extra Strength100$ 80 mg chewableTylenol Children s Chewable30$ 325 mgBayer 100$ Low Dose 81 mg ECBayer Adult Low Strength EC120$ Aspirin 81 mgBayer 108$ and Hot PatchesIcy Hot Patch5$ Pain ReliefAlka-Seltzer 36$ Aspirin 325 mgEcotrin 100$ Formula - Aspirin/Acetaminophen/CaffeineExcedrin 100$ 200 mgAdvil