r2022.OTC.STS.DPC writable 110821

1 2022. Your Over-the Counter Benefit Service To Seniors (HMO) H0545, Plan 001. Desert Preferred Choice (HMO) H0545, Plan 012. 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. 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. About OTC Products Products on the Order Form are eligible for coverage. These are products you would likely find on the shelf at your local pharmacy or general store.

2 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 benefit. 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.

3 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 confirmed diagnosis of Chronic Heart Failure and or Liver Disease. Items that are not eligible Items that are not eligible for your OTC benefit 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 Inter Valley Health Plan is a not-for-profit HMO with a Medicare contract. Enrollment in Inter Valley Health Plan depends on contract renewal.

4 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 2. 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 fill 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.

5 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: Costco Mail Order Pharmacy 215 Deininger Circle, Corona, CA 92878. $25 Minimum order required $50 Quarterly allowance ORDER FORM. Name DOB. Address Order Date Phone Number Allergies Inter Valley Member Number Grp Number Order Month Received by: 3. Clear All Data Print Save As Product Active Ingredient/Item Detail Package Price Qty Size MISCELLANEOUS ITEMS. Dramamine Motion Sickness Tablet meclizine 25mg 8ct $ Weekly Pill Box Planner Each compartment holds 22 aspirin tablets 1ct $ ALLERGY. 4-Hour Allergy Tablet chlorpheniramine 4mg 100ct $ Allergy Relief Nasal Spray fluticasone propionate 50mcg $ 50mcg/Act 144 sprays Banophen 25mg Capsule diphenhydramine 25mg 24ct $ Cetirizine 10mg Tablet cetirizine 10mg 30ct $ Coricidin HBP Cough & Cold Tablet chlorpheniramine maleate 4mg 16ct $ dextromethorphan hydrobromide 30mg Cromolyn Sodium Nasal Spray cromolyn sodium per spray 26ml $ LDR Allergy Relief 180mg Tablet fexofenadine 180mg 15ct $ Loratadine 10mg Tablet loratadine 10mg 30ct $ Saline Mist Nose Spray sodium chloride 44ml $ ANTACIDS.

6 Acid Gone Antacid aluminum hydroxide 95mg, 355ml $ magnesium carbonate 358mg Bismatrol 262mg/15ml bismatrol 262mg/15ml 236ml $ Bismatrol 262mg Chewable bismatrol 262mg chewable 30ct $ Calcium Antacid 500mg calcium carbonate chew 500mg 150ct $ Heartburn Relief 10mg Tablet famotidine 10mg 30ct $ Omeprazole 20mg Tablet omeprazole 20mg 14ct $ Simethicone Chew 125mg simethicone 125mg 60ct $ CANDIDAL. Clotrimazole 1% Cream clotrimazole 1% 45gm $ Miconazole 3 miconazole Nitrate (200mg in each suppository); 1ct $ miconazole nitrate 2% (external cream). Monistat 1 Day tioconazole 300mg ( ) per applicator $ ANTIDIARRHEAL & LAXATIVE. Enema, Disposable sodium phosphate 133ml $ Ex-Lax 15mg Tablet sennosides 15mg 8ct $ Fleet Glycerin Suppositories glycerin 2 g 24ct $ GERI-KOT sennosides 100ct $ Loperamide 2mg Tablet loperamide 2mg 12ct $ 4. Product Active Ingredient/Item Detail Package Price Qty Size ANTIDIARRHEAL & LAXATIVE (CONTINUED).

7 Senna Plus Tablet sennosides sodium 50mg 60ct $ SM Bisacodyl Gentle Laxative Tablet bisacodyl 5mg 25ct $ Stool Softener 250mg Softgel docusate sodium 250mg 100ct $ BRACES AND SUPPORT. Ace Elbow Support Sizing: 9 11 in ( cm) 1ct $ Ace Wrist Support Adjustable size 1ct $ Ankle Stabilizer Adjustable size 1ct $ Fut Sport Knee Support Sizing: in ( cm) 1ct $ Sport Aid 2 inch Elastic Bandage** latex free 1ct $ COUGH/COLD. All-Night Cold Flu Relief Liquid dextromethorphan 15mg/acetaminophen 237ml $ 325mg/doxylamine per 15mL. Halls Cough Drops menthol 30ct $ Halls Cough Drops Triple Soothing menthol 30ct $ Action-Honey Lemon Halls Cough Drops Sugar Free menthol 5mg 25ct $ Mucinex DM Tablet dextromethorphan HBr 30mg 20ct $ guaifenesin 600mg Mucus & Chest Congestion guaifenesin 100mg/5mL 118ml $ Mucus Relief 400mg Tablet guaifenesin 400mg 60ct $ Oxymetazoline Spray (Nasal) oxymetazoline 30ml $ Robafen CF guaifenesin 100mg/ dextromethorphan 10mg / 118ml $ phenylephrine 5mg per 5mL.

8 Guaifenesin 100mg/ dextromethorphan 118ml $ Robafen DM Cough Clear 10mg per 5mL. Siltussin DM Cough Syrup guaifenesin 100mg/ dextromethorphan 118ml $ 10mg per 5mL. Sore Throat Spray phenol 177ml $ Tylenol Cold Flu Severe acetaminophen 325mg/ dextromethorphan HBr 240ml $ 10mg /guaifenesin 200mg/phenylephrine HCI. 5mg per 15 mL. Vicks Vaporub camphor oil 100gm $ DENTAL. Colgate Plus Toothbrush Soft 1ct $ 5. Product Active Ingredient/Item Detail Package Price Qty Size DENTAL (CONTINUED). Colgate Plus Toothbrush Medium 1ct $ Dental Floss 55 yards 1ct $ Fixodent 68gm $ Floss Pick 90ct $ Orajel benzocaine 10% 7ml $ Pepsodent Complete Care sodium fluoride 156gm $ Polident Overnight Whitening 40ct $ Sensodyne potassium nitrate 5%/sodium fluoride 113gm $ (w/v fluoride ion). DIAGNOSTICS. Floor Scale Digital Audio Display 550lbs** Single purchase item per year 1ct $ Infrared Thermometer** Single purchase item per year 1ct $ Omron 3 Series Blood Pressure Monitor** Single purchase item per year 1ct $ Pulse Oximeter 1ct $ DIGESTIVE HEALTH.

9 Beano Food Enzyme Tablet alpha-galactosidase enzyme 30ct $ 300 per 2 tablets Lactase lactase 3000 units per caplet 60ct $ EAR CARE. Ear Syringe (2oz capacity) latex free 1ct $ EYE CARE. Alaway Eye Itch Relief ketotifen (equivalent to Ketotifen 10ml $ fumarate ). Artificial Tears peg 400/hypromellose/glycerine 1 15ml $ B&L Eye Wash purified water 118ml $ Bausch & Lomb Soothe glycerin ; propylene glycol 28ct $ Single use droppettes Clear Eyes Redness Relief glycerin ; naphazoline 15ml $ hydrochloride Healthy Eyes vitamin C 250mg, vitamin E 200IU, zinc 40mg, 120ct $ Supervision 2 capsules copper 1mg, lutein 5mg , zeaxanthin 1mg Ketotifen Fum Eye Drops ketotifen (equivalent to Ketotifen 5ml $ fumarate ). Lubricating Plus Drops carboxymethylcellulose sodium 30ct $ Single use droppettes 6. Product Active Ingredient/Item Detail Package Price Qty Size EYE CARE (CONTINUED).

10 Preservision AREDS 2 Softgel vitamin C 250mg, vitamin E 200IU, zinc 40mg, 60ct $ copper 1mg, lutein 5mg, zeaxanthin 1mg Preservision AREDS 2 Chewable vitamin C 250mg, vitamin E 200IU, zinc 40mg, 60ct $ Mixed Berry flavor copper 1mg, lutein 5mg, zeaxanthin 1mg Refresh Tears Drops carboxymethylcellulose sodium 15ml $ Stye Ointment mineral oil ; white petrolatum $ Systane Eye Drops polyethylene glycol 400 ; 15ml $ propylene glycol Thera Tears Dry Eye Drops sodium carboxymethylcellulose 30ml $ Thera Tears Liquid Gel Single Use Vials sodium carboxymethylcellulose 1% 30ct $ FIBER SUPPLEMENTS. Citrucel Fiber Powder S/F methylcellulose 2g (a non-allergic fiber) 479gm $ per heaping tablespoon calcium polycarbophil 625mg equivalent Fiber Laxative Capsule 625mg to 500mg polycarbophil per caplet 90ct $ Fiber Powder methylcellulose 2g (a non-allergic fiber) 454gm $ per heaping tablespoon Metamucil Sugar Free Brand psyllium fiber supplement 425gm $ Phillips Fiber Gummies inulin 4g 90ct $ FIRST AID.