Page 1 of 4. order up to plan. All available OTC. items are listed on this. price. plan s website at. and. order. your. page.
|
|
- Myles Cain
- 7 years ago
- Views:
Transcription
1 Over-the-Counter Pharmacy Order Form If you have chosen the Over-the-Counter Merchandise option from PHP (HMO SNP) s Health and Wellness Benefit, you may order up to $200 worth of over-the-counterr (OTC) pharmacy items for the plan year. You may order items in whatever increment you d like up to $200 total for the plan year. A plan year is January 1 through December 31. OTC items are fulfilled by AHF Pharmacy. All available OTC items are listed on this form. There is no cost to you for your order or its delivery. The price shown for each item on this form is approximate and is subject to change. The price listed should be used as a guide in helping you select the items you want and figuring the approximate cost of your order. The actual price of your order will likely differ and will be shown on the receipt you gett with your items. AHF Pharmacy reserves the right to substitute brand name items with like items when necessary. This OTC item list is effect August 1, The list of available OTC items and/or pricing may change during the year. To seee the most current list of OTC items available andd pricing, go to the plan s website at To place your order, complete Part I and Part II of the form, thenn go to Part III and select the items and quantities you want. In Part IV, compute the total value of the order. Pleasee allow seven (7) days for delivery of your order. You may place your order through any AHF Pharmacy in person or by mail, phone or fax. See the insertt page for the directory of AHF Pharmacies in Los Angeles County. If you need help finding an AHF Pharmacy, please call Member Services at (800) (TTY 711), 8:00 a.m. to 8:00 p..m., seven days a week. If you run out of order forms or need help, please call Member Services at ( 800) (TTY 711), 8:00 a.m. to 8: 00 p.m., seven days a week, to request more forms. You can also download and print forms from the plan s website at Part I Your Information. Please print legibly. Orders cannot be deliveredd to post office boxes. First and Last Name Date of Birth (MM/DD/YY) Memberr ID Number (from ID card) Home Phone Alternate Phone Date of Orderr Signature Part II Indicate how you want to receive your order. Orders cannot be delivered to post office boxes. Pick up at pharmacy. Specify whichh pharmacy. Refer to thee insert page for pharmacy locations: Deliver to: Street Address (No PO Boxes) Apt. City Effective January 1, 2015 State Page 1 of 4 Zip H5852_ Approvedd
2 Part III Select the items you want to order by placing a quantity number desired in the Qty. Ordered column. Multiply Qty. Ordered by Item to get the of the item(s) you want and fill in the column. Remember, you can order up to $200 worth of items for the plan year. Qty./ Size Item Qty. Ordered Allergy Prevention and Treatment/Antihistamines Claritin Loratadine 10 mg Tablets 10 $0.80 X = Claritin Loratadine 10 mg Tablets 30 $1.75 X = Benadryl Tablets Diphenhydramine 25 mg Caplets 24 $4.55 X = Benadryl Elixir Diphenhydramine Liquid -- Alcohol Free 4 oz $3.75 X = Sudafed PE Phenylephrine HCL 10mg Tablets 18 $1.60 X = Analgesics/Antipyretics/NSAIDS Bayer Aspirin Aspirin 325 mg Tablets 100 $0.95 X = Bayer EC Aspirin (Adult Regimen) Aspirin EC 81 mg Tablets 100 $4.25 X = Bengay Muscle Rub 3 oz $7.30 X = Capsaicin Capsaicin 0.025% cream 60 gm $18.80 X Ecotrin Maximum Strength Tablets EC Aspirin Maximum Strength Tablets 100 $2.65 X = Advil Tablets Ibuprofen 200 mg FC Tablets 50 $3.00 X = Aleve Caplets Naproxen Sodium 220 mg Caplets 50 $4.90 X = Excedrin Acetaminophen, Aspirin, Caffeine Tablet 100 $6.30 X = Antacids and Acid Reducers Mylicon Simethicone 80 mg 100 $15.85 X = Prilosec (Limit two per month) Omeprazole 20 mg 14 $12.80 X = Tums Tablets Antacid Chewable Tablets 150 $3.60 X = Zantac Tablets Ranitidine HCL 75 mg Tablets 30 $3.60 X = Anti-Arthritis Glucosamine/ Chondroitin Glucosamine/Chondroitin 100 mg Tablets 60 $5.90 X = Antibiotics (Topical) Neosporin Ointment Triple Antibiotic Ointment 1 oz $7.20 X = Anticandidals (Yeast) / Antifungals Clotrimazole Vaginal 1% Cream Gyne-Lotrimin Cream Application 45 gm $7.30 X = Tinactin Cream Tolnaftate 1% Cream 1 oz $5.00 X = Antidiarrheals and Laxatives Colace Softgels Dos 100 mg SG Caplets 100 $7.00 X = Dulcolax Suppositories Reliable Gentle Laxative Suppositories 12 $15.50 X = Page 2 of 4
3 Qty./ Item Qty. Size Ordered Dulcolax Tablets Reliable Gentle Laxative Tablets 25 $5.90 X = Imodium Caplets Anti-Diarrheal 2 mg Caplets 12 $5.20 X = Pepto-Bismol Liquid Pink Bismuth Liquid 8 oz $2.60 X = 1 Miralax Polyethylene Glycol 3350, 17 g/capful Bottle $10.25 X = Anti-Itch Lotions and Cream Calamine Lotion Calamine Lotion 6 oz $2.00 X = Aveeno Anti-Itch Lotion Colloidal Oatmeal Lotion 4 oz $5.75 X = Cold Remedies Mucinex Guaifenesin 30 $6.10 X = 1 Afrin Nasal Spray Nasal Decongestant Spray 30 ml Bottle $4.45 X = Chloraseptic Throat Lozenges Cherry 1 Bag $2.95 X = Robitussin Syrup Guaifenesin 100mg/tsp 4 oz $2.10 X = Camphor 4.8%, Eucalyptus oil 1.76 Vicks 1.2%,Menthol 2.6% Ointment oz $4.35 X = Dental Care Anbesol Anbesol 0.3 oz $5.60 X = Toothbrush Toothbrush 1 $2.50 X = Toothpaste Toothpaste 6.4 oz $2.90 X = Waxed Dental Floss Waxed Dental Floss 100 yd $2.00 X = Ear Care Ear Syringe Ear Syringe 3 oz $4.60 X = Debrox Ear Wax Removal Drops Carbamide Peroxide 0.5 oz $2.55 X = Eye Care Dry Eye Drops Artificial Tears 0.5 oz $4.40 X = Visine Drops Sterile Eye Drops Irritation Relief 0.5 oz $2.10 X = Fiber Supplements Metamucil Fiber Capsules 100 $6.40 X = First Aid/Medical Supplies Ace Bandage Athletic Bandage 1 $3.40 X = Adhesive Tape Adhesive Tape 1inch x 5 Yards 1 $2.00 X = Alcohol Swabs * Alcohol Swabs 100 $1.80 X = Band-Aids Adhesive Bandage 50 $1.90 X = Cotton Balls Cotton Balls 100 $1.45 X = Cotton Swabs Cotton Swabs 170 $1.45 X = Ice Bag Ice Bag 1 $6.50 X = Page 3 of 4
4 Qty./ Size Item Qty. Ordered Johnson & Johnson Gauze * Stretch Gauze Bandage 2 Inches x 2 Yards 1 $1.25 X = Oral Thermometer Oral Thermometer 1 $2.45 X = Healing Ointments Aquaphor Skin Healing Ointment Aquaphor ointment 1.75 oz $4.30 X = Hemorrhoidal Preparations Preparation H Prompt Relief Hemorrhoid Ointment 2 oz $6.00 X = Lactose Intolerance Lactaid Dairy Relief Capsule 60 $13.60 X = Pediculosis RID Extra Strength Shampoo Lice Treatment Maximum Strength Cream 4 oz $6.90 X = Sun Protection Coppertone Sport Sunblock Lotion SPF 30 Sunblock SPF 30 8 oz $10.00 X = Topical Steroids Cortaid Cream Hydrocortisone 1% Maximum Strength Cream 1 oz $3.35 X = Vitamins and Minerals (If pregnant or in reproductive years, check with your PCP before using any supplements) B-Complex with B-12 Tablets B-Complex/B-12 Tablets 100 $6.30 X = Stuart Prenatal Tablets Prenatal -S Tablets 100 $6.20 X = Magnesium Magnesium 400mg 120 $18.35 Vitamin C Tablets C Chewable 500 mg Tablets 100 $5.50 X = Vitamin E Softgels E DL Alpha 400 IU SG Caplets 100 $5.65 X = Vitamin A 10,000 IU Vitamin A 10,000 IU 100 $3.05 X = Caltrate 600 Calcium 600 D Tablets 120 $3.20 X = Therapeutic M. High Potency Multivitamin w/minerals 100 $7.40 X = * These items are covered under your Part D benefit if you are insulin-dependent (diabetic). Part IV Add the price from each item together to total your order. Remember you may order up to $200 worth of items per year in as many increments as you like. Order Total $ PHP is an HMO plan with a Medicare contract. Enrollment in PHP depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of every year. Page 4 of 4
5 You may place and pick up your orderr at any of the Los Angeles County AHF Pharmacies listed below. To place your order, take your completed order form to thee pharmacy of your choice. You can also call your order into the pharmacy of your choice, or mail or fax it. AHF Pharmacy - Downtown Los Angeles S. Grand Ave., Ste. 801 Los Angeles, CA Phone: (213) Fax: (213) AHF Pharmacy - Hollywood N. Vermont Ave. Los Angeles, CA Phone: (323) Fax: (323) AHF Pharmacy - Long Beach Pacific Coast Hwy Long Beach, CA Phone: (562) Fax: (562) AHFF Pharmacy - Studio City Lankershim Blvd. North Hollywood, CA Phone: (818) , ext Fax: (818) AHFF Pharmacy - San Fernando Valley Van Nuys Blvd. Suitee 200 Sherman Oaks, CA Phone: (818) Fax: (818) AHF Pharmacy - Sunset 6210 W. Sunset Blvd. Los Angeles, CA Phone: (323) Fax: (323) AHF Pharmacy - West Hollywood Santa Monica Blvd. West Hollywood, CA Phone: (323) Fax: (323) AHF Pharmacy - Westside 99 N. La Cienega Blvd., Ste. 200 Beverly Hills, CA Phone: (310) Fax: (310) OTC Order Form Insert H5852_ Approvedd
How to Order: Keep this catalog. You will need this to look up the Health and Wellness products you want to order each month.
Did you know that depending on your current Humana plan, you may be able to purchase Health and Wellness products from the RightSource mail-order pharmacy? Call RightSource at 1-855-211-8370 (TTY: 711)
More informationOver-the-Counter Health & Wellness Products
Over-the-Counter Health & Wellness s 2015 Catalog and Order Form Y0040_GNHHXUEEN 2015 Over-the-Counter (OTC) Health and Wellness Order Form Your current plan may have an over-the-counter benefit that would
More informationAETNA BETTER HEALTH Over the counter (OTC) product list
TOPICAL ANTIBACTERIAL/ANTIFUNAL OTC DRUGS OTC bacitracin topical ointment OTC clotrimazole (vaginal use) OTC clotrimazole (topical use) OTC miconazole 2% ointment OTC miconazole vaginal suppositories,
More informationGeorgia s health care choice. Member. Handbook
Georgia s health care choice Member Handbook 2011-2013 WELCOME TO WELLCARE We are glad you joined our family! WellCare is the health care plan that really puts you in control. You can choose from a large
More informationproduct list Put our quality and service behind your brand. 200 Hicks Street, Westbury, NY 11590 +1.516.986.1700
product list We are committed to high quality and expedited service, bringing leading and exclusive products to our customers. Our private label products include a broad range of pharmaceutical categories.
More information2016 OVER-THE-COUNTER (OTC) BENEFIT CATALOG
2016 OVER-THE-COUNTER (OTC) BENEFIT CATALOG Special Health Plan Benefit Get Over-the-Counter Products Every Quarter As a member of Ultimate Health Plans, you have an Over-the-Counter (OTC) benefit every
More informationWellCare means better care. Member Handbook
WellCare means better care. Member Handbook WELCOME TO WELLCARE We are glad you joined our family! WellCare is the health care plan that really puts you in control. You can choose from a large network
More informationOver-the-Counter (OTC) Catalog Get the OTC items you need.
2015 Over-the-Counter (OTC) Catalog Get the OTC items you need. Medicare Advantage Plans H5087_CA027266_WCM_OTC_ENG CMS Accepted 08302014 WellCare 2014 CA_07_14_EC EC5OTCCAT60343E The Benefits of Easy
More informationKnow What s in the Medicine You Take:
1 Know What s in the Medicine You Take: Active Ingredients in OTC Pain Relievers, Antihistamines, Decongestants and Cough Medicines Single Ingredient Brand Names Pain relievers Acetaminophen Tylenol:,
More informationOver-the-Counter Health & Wellness Products
Over-the-Counter Health & Wellness Products 2016 Catalog and Order Form Y0040_GNHJBPBEN 0815 2016 Over-the-Counter (OTC) Health and Wellness Product Order Form Your current plan may have an over-the-er
More informationSTAYWELL MEMBER HANDBOOK
STAYWELL MEMBER HANDBOOK Table of Contents Getting Started... 3 Member Information... 5 Enrollment in Staywell... 5 Your Identification (ID) Card... 5 Your Doctor... 6 How to Get Medical Services... 7
More informationFlexible Spending Account Overview
Flexible Spending Account Overview Medical Reimbursement Accounts Dependent Care Reimbursement Accounts Transforming Employee Benefits What is a Flexible? A Flexible is offered through your employer and
More informationNote: Unless we have parental authorization, we CANNOT administer ANY medications.
Appendix B: Cleveland State University Youth Program/Camp Parent/Guardian Authorization, Waiver and Consent for Over-the-Counter Medication Form PROGRAM/CAMP INFORMATION Program/Camp Name: (hereafter Program
More informationFlexible Spending Account (FSA) Enrollment Kit. Significant savings 24/7 web access Fast, efficient, convenient The benefit that benefits everyone
Flexible Spending Account (FSA) Enrollment Kit Significant savings 24/7 web access Fast, efficient, convenient The benefit that benefits everyone The FSA Plan A Flexible Spending Account (FSA) is an employee
More informationFlexible Spending Arrangements
IRC Section 125 Flexible Spending Arrangements Enrollment Information Save 25-40% on your eligible expenses! Save money on your common medical and day care expenses and put more money in your pocket!!!
More informationHealth Reform Changes Affecting Over-the-counter Expenses in 2011
Expenses Guide This guide provides important information about your CONEXIS flexible spending account () and includes detailed lists of expenses generally reimbursable under your. The various lists contain
More information2016 Over-the-Counter (OTC) Benefit Catalog
2016 Over-the-Counter (OTC) Benefit Catalog As a member of Care1st Health Plan, you have an Over-the-Counter (OTC) benefit every quarter. This benefit allows you to get OTC products you may need such as
More informationLEVEL II FAK YOUTUBE : USNERDOC
LEVEL II FAK A Level II FAK in a medical roll configuration that provides a deep level of medical capability for groups in a remote austere environment YOUTUBE : USNERDOC MARCH 2010 LEVEL II FAK CONTENTS
More informationFlexible Spending Account Convenience Card
How to Use Your Flexible Spending Account Convenience Card Your Flexible Spending Accounts allow you to be reimbursed for eligible health care and dependent care expenses with tax-free dollars. Overview
More informationFSA Plan. City of Seattle. Administered by Flex-Plan Services, Inc. Plan Year starting 1/1/2013 and ending 12/31/2013
FSA Plan Administered by Flex-Plan Services, Inc. City of Seattle Plan Year starting 1/1/2013 and ending 12/31/2013 www.flex-plan.com Flex-Plan Services, Inc General FSA Overview An FSA plan is a pre-tax
More informationOver-The-Counter Medications Approved For Pregnancy & Nursing
Screenings During Pregnancy Ultrasound Screenings An ultrasound is a procedure that uses high frequency sound waves to create a picture. Not only are these scans routine, but they are also fun for you
More informationFlexible Spending Accounts
IRC Section 125 Flexible Spending Accounts Enrollment Information Save 25-40% on your eligible expenses! Save money on your common medical and day care expenses and put more money in your pocket!!! SAVE
More informationFSA Eligible Expenses Crosby Benefit Systems www.crosbybenefits.com v09122014
FSA Expenses All over-the-counter (OTC) medications and drugs must be prescribed by a physician to be eligible for reimbursement. This change was effective January 1, 2011, regardless of your plan year.
More informationFSA Eligible Expenses Crosby Benefit Systems www.crosbybenefits.com v04072014
FSA Expenses All over-the-counter (OTC) medications and drugs must be prescribed by a physician to be eligible for reimbursement. This change was effective January 1, 2011, regardless of your plan year.
More informationFSA Eligible Expenses Crosby Benefit Systems, Inc. www.crosbybenefits.com Version: 04/19/2011
FSA Expenses www.crosbybenefits.com Version: 04/19/2011 Please Note: Effective January 1, 2011, all over-the-counter (OTC) medications and drugs must be prescribed by a physician to be eligible for reimbursement.
More informationOhio Medicaid Fee-For-Service Cough and Cold Drug List Effective October 1, 2013 $ 2 Co-Pay May Apply
NDC ANALGESICS Label Name Generic Drug Name Drug Strength Dosage Form 00713011801 ACEPHEN 120 MG SUPPOSITORY ACETAMINOPHEN 120 MG SUPP.RECT 45802073233 ACETAMINOPHEN 120 MG SUPPOSITORY ACETAMINOPHEN 120
More informationMedical Reimbursement Account. How to Use Your Medical Reimbursement Account. San Francisco City Option Updated April 2016 www.sfcityoption.
Medical Reimbursement Account How to Use Your Medical Reimbursement Account San Francisco City Option Updated April 2016 www.sfcityoption.org Contents About this Handbook...1 What is a Medical Reimbursement
More informationPARTIAL LISTING OF OVER-THE-COUNTER DRUGS
A Abreva Actifed Cold & Allergy Actifed Cold & Sinus Caplets Actron Advil Advil Cold and Sinus Advil Flu & Body Ache Caplets Advil Migraine Liquigels Afrin 12 Hour Afrin Nasal Decongestant Children's Aleve
More informationHealth Flexible Spending Account Frequently Asked Questions
Health Flexible Spending Account Frequently Asked Questions What is a health flexible spending account? A health flexible spending account (FSA) is part of your benefits package. This plan lets you use
More informationWelcome. What s Inside. Have questions? A Guide to Your Flexible Spending Account (FSA) As you start the new plan year, remember that:
Welcome A Guide to Your Flexible Spending Account (FSA) As you start the new plan year, remember that: ``You are saving tax dollars. You won t pay taxes when you use your money for eligible health and/or
More informationPATIENT INSTRUCTIONS PRIOR TO MOHS SURGERY
Columbia University Medical Center New York Presbyterian Hospital Director Unit for Dermatologic Surgery and Cutaneous Oncology Mohs Micrographic Surgery Laser Surgery Site: Lesion: Size: For an appointment
More informationCall for ap p oi ntm e nts 804.288.4084
1 This Journal Belongs to: Name: Address: City: State: Zip: Home #: Cell #: Emergency Contact: Emergency Phone #: Important Virginia Women s Center Phone Numbers Doctor: Nurse Practitioner: Nurse: Nights/Weekends
More informationUT FLEX Plan Year: 9/1/2009 8/31/2010. Flexible Spending Account
UT FLEX Plan Year: 9/1/2009 8/31/2010 Flexible Spending Account What will be covered? UT FLEX Flexible Spending Account (FSA) Eligible / Ineligible Healthcare Expenses UT FLEX Card (optional) Grace Period
More informationELIGIBLE EXPENSES. FSA Eligible & Ineligible Expenses MEDICAL/PRESCRIPTIONS DENTAL VISION
ELIGIBLE EXPENSES MEDICAL/PRESCRIPTIONS Acupuncture - if to treat a medical condition Ambulance Expenses Artificial Limbs/Prosthetics Breast Reconstruction Surgery - following a mastectomy to ameliorate
More informationOver-the-Counter Drug List
Over-the-Counter Drug List This list includes some of the over-the-counter drugs covered by Passport Health Plan. To get these covered, you must have a prescription from your doctor. NOTE: Generic is always
More informationFlexible Spending Account (FSA) Enrollment Kit
Flexible Spending Account (FSA) Enrollment Kit Significant Savings 24/7 Web access Fast, Efficient, Convenient The benefit that benefits everyone With the EBS Flex Card An FSA means more money in your
More informationHealth Savings Accounts (HSAs)
Health Savings Accounts (HSAs) What does the Beniversal HSA provide? Tax-free savings on eligible medical expenses for today and tomorrow. A savings opportunity! You own the account. Funds carry over from
More informationCHOTA COMMUNITY HEALTH SERVICES - SCHOOL-BASED HEALTH CLINIC
CHOTA COMMUNITY HEALTH SERVICES - SCHOOL-BASED HEALTH CLINIC STUDENT Health History Annual Update 2015-2016 Student's Name: Date of Birth: Phone Number: Grade: Primary Care Doctor: Dr's Phone Number: Pharmacy:
More informationIMPORTANT INFORMATION FOR FSA PLANS AND HEALTH CARE REFORM
IMPORTANT INFORMATION FOR FSA PLANS AND HEALTH CARE REFORM The recent enactment of the health care reform legislation represents some impact to health care FSA plans. ADP wants to ensure that you have
More informationFlexible Spending Accounts
Flexible Spending Accounts FLEX Your Check Get More Muscle from Your Pay Oakland University Flexible Spending Account Flexible Spending Accounts let you set aside money from your paycheck before federal,
More informationCAMPER HEALTH HISTORY FORM 1
CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Dates will attend camp: from to
More informationHow To Pay For Medical Expenses
The Medical Flexible Spending Account is used for tax-deductible health care expenses not paid by insurance for yourself, your spouse and anyone you claim as a dependent on your federal income tax return.
More informationGeneral Information for Prospective Seminarians Fall 2015
General Information for Prospective Seminarians Fall 2015 New seminarians are to arrive for the Fall semester on Saturday, August 15, 2015 by 1:00 PM. Should you need to arrive before or after August 15,
More informationMass Group Marketing, Inc.
Guide to Eligible Health and Dependent Care Flexible Spending Account Expenses Mass Group Marketing, Inc. A Section 125 Cafeteria Plan offered by Mass Group Marketing, Inc. A Section 125 Plan is a part
More informationCITY OF NEW BERN. A Guide To Your Flexible Spending Account
CITY OF NEW BERN A Guide To Your Flexible Spending Account FSA Reminders for City of New Bern Group number: 212 Plan year: 07/01/15-06/30/16 FSA Reimbursement checks: Claims are processed weekly. Healthcare
More informationFlexible Spending Account (FSA) Enrollment Kit
Flexible Spending Account (FSA) Enrollment Kit Significant Savings 24/7 Web access Fast, Efficient, Convenient The benefit that benefits everyone With the EBS RMSCO Debit Card B 3384 An FSA means more
More informationAxiom Resource Management, Inc.
Axiom Resource Management, Inc. A Guide to Your Flexible Spending Account A Balanced Approach To Saving Time And Money Flexible Spending Accounts Making the most of your money. What if you could make your
More informationIMPORTANT INFORMATION FOR FSA PLANS AND HEALTH CARE REFORM
IMPORTANT INFORMATION FOR FSA PLANS AND HEALTH CARE REFORM The recent enactment of the health care reform legislation represents some impact to health care FSA plans. ADP wants to ensure that you have
More informationMedicines Containing Acetaminophen
Medicines Containing Acetaminophen A ABENOL ACET 120 ACET 160 ACET 325 ACET 650 ACET CODEINE 30 TAB ACET CODEINE 60 TAB ACETAMINOPHEN ACETAMINOPHEN 300 MG WITH 15 MG CAFFEINE AND 8 MG CODEINE PHOSPHATE
More informationELIGIBLE FLEXIBLE EXPENSES
ELIGIBLE FLEXIBLE EXPENSES The following is not a comprehensive list of items, but it should cover the majority of eligible expenses that can typically be processed through flexible spending accounts.
More informationHow To Set Up A Flexible Spending Account Plan
SPRING ARBOR UNIVERSITY FLEXIBLE SPENDING ACCOUNT PLAN SUMMARY FOR 2015 HOW IT WORKS Your flexible spending account (FSA) allows you to redirect a portion of your salary into two specific types of expenses:
More informationSelf Care: Over The Counter (OTC) Drug Therapy. William Beaumont Army Medical Center Self Care Program
Self Care: Over The Counter (OTC) Drug Therapy William Beaumont Army Medical Center Self Care Program Objective of the Self-Care Course Encourage and provide the Fort Bliss community with information to
More information900 N Kingsbury Road, Ste 130N, Chicago IL, 60610. phone: 312-775-1100 MEDICATION LISTS
900 N Kingsbury Road, Ste 130N, Chicago IL, 60610. phone: 312-775-1100 MEDICATION LISTS The following is a comprehensive list of medications and their safety during pregnancy. As a rule, you make safely
More informationFSA. Flexible Spending Account Overview Medical Reimbursement Accounts Dependent Care Reimbursement Accounts. Business Solutions
FSA Flexible Spending Account Overview Medical Reimbursement Accounts Dependent Care Reimbursement Accounts Business Solutions What is a Flexible Spending Account? A Flexible Spending Account is offered
More informationCONEXIS Benefit Card Frequently Asked Questions
CONEXIS Benefit Card Frequently Asked Questions What is the CONEXIS Benefit Card? The CONEXIS Benefit Card is a stored-value card that simplifies the process of paying for qualified health flexible spending
More informationPrescription Drug Rider
Prescription Drug Rider This Rider is part of the Evidence of Coverage and is effective on the date Your group is effective or renews its coverage with Southern Health Services, Inc. Benefits are available
More informationEligible Expenses. Your plan may have additional restrictions and entire categories of eligible items may not qualify for reimbursement.
Eligible Expenses The following are examples of IRS allowable and disallowed healthcare expenses for a Healthcare Flexible Spending Account (FSA) or Personal Care Account (PCA). Note: This is only a list
More informationEligible Health Care Expenses
Eligible Health Care Expenses IMPORTANT INFORMATION FOR FSA PLANS AND HEALTH CARE REFORM The recent enactment of the health care reform legislation represents some impact to health care FSA plans. ADP
More informationFormulario de Medicamentos OTC
Formulario de Medicamentos OTC 2011 H4004 PMC Medicare Choice, Inc. Y0049_2011 1009 0008 2 File & Use 08312010 Qué es el Formulario de Medicamentos OTC? Es un formulario que contiene una guía de referencia
More informationMedical FSA and HSA Expense Eligibility List (IRS Code Section 213 (d) Eligible Expenses)
The following is a summary of common expenses claimed against Medical Flexible Spending Accounts (FSAs) and Health Savings Accounts (HSAs). Due to frequent updates to the regulations governing FSAs and
More informationRosemount-Apple Valley-Eagan School District #196 Flexible Spending Account (FSA) Benefit Guide 2014-2015
Rosemount-Apple Valley-Eagan School District #196 Flexible Spending Account (FSA) Benefit Guide 2014-2015 Plan Outline Administrator: Corporate Health Systems, Inc. Local Phone: (952) 939-0911 Toll Free
More informationSample eligible expenses Personal Care Account (PCA), Health Savings Account (HSA) and Flexible Spending Account (FSA)
Prescription drugs: Prescription drugs or insulin Medicines and drugs from other countries Illegal drugs Cosmetic prescriptions Medical equipment: Artificial limbs Blood pressure monitoring devices Breast
More informationFlexible benefits plan (Section 125)
C Flexible benefits plan (Section 125) Dedicated to the educational community At Horace Mann, we believe educators are taking care of our children s future, and we need to take care of theirs. While other
More informationThe Coverage Gap in Medicare Part D. How to delay or avoid the Gap and save money with over-the-counter medications
The Coverage Gap in Medicare Part D How to delay or avoid the Gap and save money with over-the-counter medications MEDICARE PART D COVERAGE THE COVERAGE GAP Understanding the Coverage Gap in Medicare Part
More informationcrc - Over The Counter Medicine List
Chicago Rabbinical Council 2701 W Howard Street Chicago, IL 60645-1303 PH: 773.465.3900 Fax: 773.465.6632 Rabbi Sholem Fishbane Kashruth Administrator The following are general guidelines for the consumption
More informationFlexible Spending Accounts
Creating Healthier Benefits sm Flexible Spending Accounts Information & Enrollment Packet Post Office Box 19108, Raleigh, NC 27619-5621 Departure Drive, Suite 117, Raleigh, NC 27616 Phone: (919) 877-9933
More informationMANAGING CHRONIC CONSTIPATION A PATIENT G U IDE
MANAGING CHRONIC CONSTIPATION A PATIENT G U IDE Do you have Fewer than three bowel movements per week? The need to strain during bowel movements at least 25 percent of the time? A feeling of not being
More informationDepartment of Human Services
Department of Human Services Proposed PDL for IOWA Medicaid Program Listing Covered OTC Drugs: Effective Date: 10/13/2015 Note: Not all s may be represented and the status of those listed are subject to
More informationShip to: Payment: Item# Lot# 1.60 1.2 % Menthol 2.6 %; topical ointment Acetaminophen Susp.160mg/5mL, Bott/100mL 0000000100 3BK0215
97 060-B Lorimar Drive Mississauga ON LS R8 PHONE:(90) 670-990 FAX:(90) 670-78 ShipDate: 0// Shipper# PTP97- Chest Rub Ointment, Jar/00g 000000008 0/0/ VI-JON INC JAR/00G,7,7-Trimethylbicyclo[..]heptan--one.8
More information2015 Plan Guide ALLEGIAN ADVANTAGE (HMO) H8554_013-2015 Accepted
2015 Plan Guide ALLEGIAN ADVANTAGE (HMO) H8554_013-2015 Accepted Allegian Advantage is an HMO plan. We proudly serve Texas residents in Cameron, Hidalgo and Willacy counties, offering doctor, hospital
More informationHBW. % 10 off PROFIT OPPORTUNITIES ALLERGY & SUN CARE MARCH 2015. Health, Beauty & Wellness. This month s featured categories. off 357-0926 255-0838
HBW Health, Beauty & Wellness PROFIT OPPORTUNITIES 396-9359 471-8334 5 % NEW ITEM off 10 off % 10 off % NEW ITEM 357-0926 This month s featured categories ALLERGY & SUN CARE 255-0838 MARCH 2015 OUTPERFORMS
More informationMedication Management: A Family Caregiver s Guide
Family Caregiver Guide Medication Management: A Family Caregiver s Guide Types of Medications You should make sure all of your family member s doctors and the home care nurse know all the overthe-counter
More informationAPPROVED MEDICATION LIST FOR OBSTETRICAL PATIENTS
APPROVED MEDICATION LIST FOR OBSTETRICAL PATIENTS The following list of medications are approved by Dr. Martinez M.D., and Jennifer Stauss, CNP. These are all over the counter medications, and it is very
More informationSafety Point: Preparing Your First Aid Kit
Safety Point: Preparing Your First Aid Kit We all have things in our home that keep us safe, healthy, and happy: Lots of food and water Clothes that keep us warm and dry Comfortable bed and pillow Toothbrush
More informationSISC Flex Plan HEALTH CARE AND DEPENDENT CARE EXPENSES
SISC Flex Plan HEALTH CARE AND DEPENDENT CARE EXPENSES *Please note, all "potentially eligible expenses" require a Certification of Medical Necessity form completed by your medical practitioner in order
More informationQUESTION: ARE THE SALES OF TAXPAYER S HOMEOPATHIC REMEDIES (LISTED AND DESCRIBED IN EXHIBIT A) SUBJECT TO FLORIDA S SALES TAX?
Executive Director Marshall Stranburg QUESTION: ARE THE SALES OF TAXPAYER S HOMEOPATHIC REMEDIES (LISTED AND DESCRIBED IN EXHIBIT A) SUBJECT TO FLORIDA S SALES TAX? ANSWER: THE SALE OF TAXPAYER S HOMEOPATHIC
More informationThe Brain Injury Rehabilitation Center Brain Injury Rehabilitation Services for the Whole Person
The Brain Injury Rehabilitation Center Brain Injury Rehabilitation Services for the Whole Person The Brain Injury Rehabilitation Center Application for Brain Injury Rehabilitation INF-2 Return information
More informationPharmacy Policy (General)
WORKSAFE VICTORIA Pharmacy Policy (General) WorkSafe can pay the reasonable costs of medications and other pharmacy items required as a result of a work-related injury or illness in accordance with Victorian
More informationFirst Name: Last Name: Home Address: City: State: Zip: Gender: Male Female Date of Birth / / / Age: Grade in Sept. 2016:
Please complete the entire form. Incomplete forms will not be processed. Please include a 50 NONREFUNDABLE DEPOSIT. Please complete a separate form for each camper. Please Print CAMPER INFORMATION For
More informationHealth and Wellness Preference Data Segments Arts & Entertainment > Reading > Health Baby Health & Safety Beauty, Health & Fitness > Cosmetics &
Health and Wellness Preference Data Segments Arts & Entertainment > Reading > Health Baby Health & Safety Beauty, Health & Fitness > Cosmetics & Beauty Products Beauty, Health & Fitness > Fitness & Exercise
More informationDRUG INTERACTIONS: WHAT YOU SHOULD KNOW. Council on Family Health
DRUG INTERACTIONS: WHAT YOU SHOULD KNOW Council on Family Health Drug Interactions There are more opportunities today than ever before to learn about your health and to take better care of yourself. It
More informationCamper Name: Male Female DOB: Custodial parent(s)/guardian(s)name phone: cell # email. 2. Physician Name Telephone: Exam Date: Weight: lbs.
To be Completed by Physician or Licensed Medical Personnel Camper Name: Male Female DOB: Custodial parent(s)/guardian(s)name phone: cell # email Page 1 2. Physician Name Telephone: Exam Date: Weight: lbs.
More information(Host) Freedom Health 2014 Video Script - H5427_14SalesVideo_CMS Approved
Thank you for joining us for this special presentation on Freedom Health s Medicare Advantage Plans. Today we will explain the tremendous value of a Freedom Health plan which offers benefits and savings
More informationNationalONE VEBA Overview. (includes comparison to NationalONE 200-25 plan)
NationalONE VEBA Overview (includes comparison to NationalONE 200-25 plan) July 2014 June 2015 The VEBA Trust The VEBA Plan is short for Voluntary Employee s Beneficiary Association Plan. This plan allows
More informationSISC Flex Plan HEALTH CARE AND DEPENDENT CARE EXPENSES
SISC Flex Plan HEALTH CARE AND DEPENDENT CARE EPENSES *Please note, all "potentially eligible expenses" require a Certification of Medical Necessity form completed by your medical practitioner in order
More informationPost-operative Instructions Following Rhinoplasty
Post-operative Instructions Following Rhinoplasty Early healing of the nose depends upon how well you take care of yourself after surgery. Please review the following instructions before surgery and ask
More informationHealthcare and Dependent Care Flexible Spending Accounts. City & County of San Francisco Employees. Short Plan Year Resource Guide
Healthcare and Dependent Care Flexible Spending Accounts City & County of San Francisco Employees Short Plan Year Resource Guide 2 City & County of San Francisco Table of Contents 3 Flexible Spending Accounts
More informationFSA Health Care Eligible & Ineligible Expense Items. FSA Eligible Health Care Expenses
FSA Eligible Health Care Expenses Acupuncture Alcoholism Treatment Ambulance Artificial Limb Autoette/Wheelchair Bandages Braille Books and Magazines Breast Pumps and Lactation Supplies Chiropractor Christian
More informationSelf Care & Over the Counter (OTC) Medication Program. Department of Preventive Medicine Bayne-Jones Army Community Hospital Fort Polk, LA
Self Care & Over the Counter (OTC) Medication Program Department of Preventive Medicine Bayne-Jones Army Community Hospital Fort Polk, LA 1 OBJECTIVES Provide information to our Fort Polk community which
More informationQUALIFIED FSA EXPENSES (For Health Care Flexible Spending Accounts)
QUALIFIED FSA EXPENSES (For Health Care Flexible Spending Accounts) * This list is by no means exhaustive. Please consult IRS 213 for additional information, or contact MGIS directly (flexinfo@mgis.com).
More informationOF INSURANCE, MEDICAID, OR MEDICARE CARDS IN THE BOXES BELOW.
MEDICAL INFORMATION PAGE CAMP LOYALTOWN 2016 INDIVIDUAL S NAME: Dear Parents and Guardians, Please submit this form with the required information attached, signed and dated. If the medical forms will cover
More informationOxford Centre for Head and Neck Oncology. Sore Mouth or Throat (Mucositis) Dry Mouth (Xerostomia) Oral Thrush (Candida) Information for patients
Oxford Centre for Head and Neck Oncology Sore Mouth or Throat (Mucositis) Dry Mouth (Xerostomia) Oral Thrush (Candida) Information for patients This leaflet gives you some suggested remedies which previous
More informationIMPORTANT INFO Read all pages of the enrollment form before signing
Start here - Tear and separate pages along the perforated edge before completing Kaiser Permanente Senior Advantage (HMO) or Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) Individual
More informationNO-COST PREVENTIVE CARE DRUGS
NO-COST PREVENTIVE CARE DRUGS INFORMATION FOR NON-GRANDFATHERED ASO GROUPS The Affordable Care Act (ACA) requires that certain preventive care drugs and drug categories be covered at no cost to health
More informationLeading the Consumer Health Products Market in Canada (1)
Executive Summary Updating Tax Policy to Support Responsible Self-Care The vast majority of Canadians treat their minor ailments through self-care with consumer health products, including over-the-counter
More informationFlexible Spending Account Enrollment Packet
Flexible Spending Account Enrollment Packet The following forms are included in this enrollment packet: Enrollment Form In order to participate in a cafeteria plan you must complete the enrollment form
More informationCIDNY FACT SHEET. Elderly Pharmaceutical Insurance Coverage (EPIC) Information below is from the website: https://www.health.ny.gov/health_care/epic/
Information below is from the website: https://www.health.ny.gov/health_care/epic/ What is EPIC: The program is a New York State program for seniors administered by the Department of Health. It helps more
More informationYOU RE GOING TO NEED A BIGGER BANK. BASIC FLEX
YOU RE GOING TO NEED A BIGGER BANK. BASIC FLEX GET MORE OUT OF YOUR PAYCHECK. Do you pay medical expenses? How about insurance premiums? Child care? If you answered yes to any of these questions then keep
More informationWarfarin. (Coumadin, Jantoven ) Taking your medication safely
Warfarin (Coumadin, Jantoven ) Taking your medication safely Welcome This booklet is designed to provide you with important information about warfarin to help you take this medication safely and effectively.
More informationExpense Eligibility List Medical FSAs and HSAs
Expense Eligibility List Medical FSAs and HSAs The following is a summary of common expenses claimed against Medical Flexible Spending Account (FSAs) and Health Savings Accounts (HSAs). Due to frequent
More information