2016 Over-the-Counter Health Products Catalog 1344430 55116MUMENMUB_005 AGP 2016 OTC Catalog Cover
Amerigroup Over-the-Counter Health Products Catalog We are pleased to provide our Amerigroup members with an Over-the-Counter How to place an order or Evidence of Coverage 1. Order online: www.myamerigroup.com/medicare 2. Order by phone: 1-866-805-4589 711 3. Order by mail: print 4. Order by fax: 1-847-258-1913 Y0114_16_ 24640_U_023 CMS Accepted 10/01/2015 53977MUMENMUB_023 TX 1306139 53977MUMENMUB_023 AGP TX 2016 OTC Catalog
Over-the-Counter Health Products Catalog How to use the OTC Health Products Catalog Eligible: Dual Purpose: NOTE: Frequently asked questions and answers about the OTC benefit How do I get more order forms? can call Customer Service at 1-866-805-4589 711
Over-the-Counter Health Products Catalog How do I return items? 1-866-805-4589 711 1-866-805-4589 711
Over-the-Counter Health Products Catalog NOTE: Product details used in this catalog came from the makers of the products. We provide them to make it easier for you to know what over-the-counter items to order. But, Amerigroup does not verify the ask your doctor for advice about your own health needs. Your doctor may choose to have you use items not listed in this catalog. 1-866-805-4589 711 número gratuito del Servicio a Miembros al 1-866-805-4589 de TTY deben llamar al 711 Amerivantage is a D-SNP with a Medicare contract and a contract with
Acne Treatment BENZOYL PEROXIDE GEL 10% 45 GM. 5060520 $3.35 CLEAN & CLEAR ADVANTAGE ACNE SPOT TREATMENT 0.75 OZ. 3541471 $8.50 NEUTROGENA OIL-FREE ACNE WASH 6 OZ. 1663582 $7.98 NEUTROGENA CLEAR PORE OIL-ELIMINATING ASTRINGENT 8 OZ. 2756567 $6.25 Antifungals ATHLETE S ANTIFUNGAL FOOT CREAM 0.5 OZ. 4081683 $10.39 CLOTRIMAZOLE 1% CREAM 0.5 OZ. 2073484 $5.25 5
LIQUID 0.31 OZ. Over-the-Counter Health Products Catalog 1156603 $9.57 COMPOUND W GEL 0.25 OZ. 1047471 $9.66 LAMISIL AT ATHLETE S FOOT CREAM 12 GM. 2856060 $11.31 LOTRIMIN AF CREAM 24 GM. 1887819 $14.25 LOTRIMIN AF LIQUID SPRAY 4.6 OZ. 4889614 $9.00 LOTRIMIN AF POWDER SPRAY 4.6 OZ. 3636883 $9.00 MICONAZOLE 7 VAGINAL SUPPOSITORIES 7 CT. 3379666 $5.75 6
MONISTAT-3 CREAM PREFILLED APPLICATOR 3 CT. 4738936 $18.38 MYCOCIDE NS ANTIMICROBIAL SOLUTION 1 OZ. 1119841 $15.75 TOLNAFTATE 1% CREAM 0.5 OZ. 2164044 $3.99 TOLNAFTATE 1% POWDER 1.5 OZ. 1026525 $4.30 Anti-infectives BACITRACIN ZINC OINTMENT 1 OZ. 2149250 $5.99 BACTINE LIQUID 4 OZ. 1028760 $5.59 NEOSPORIN ORIGINAL ANTIBIOTIC OINTMENT 1 OZ. 1026434 $9.85 7
Over-the-Counter Health Products Catalog NEOSPORIN PLUS OINTMENT MAXIMUM STRENGTH 1 OZ. 1203504 $11.33 TRIPLE ANTIBIOTIC OINTMENT 1 OZ. 4762878 $7.15 Anti-itch BENADRYL REGULAR STRENGTH ITCH RELIEF 1% CREAM 1 OZ. 2529709 $5.38 CALAMINE LOTION 6 OZ. 4835450 $4.00 CORTIZONE 10 CREME 1 OZ. 1598960 $6.49 CORTIZONE 10 INTENSIVE HEALING FORMULA ANTI-ITCH CREME 1 OZ. 4029112 $6.25 8
DIPHENHYDRAMINE CREAM 2% 1 OZ. 2372134 $4.50 GOLD BOND MEDICATED BODY POWDER 10 OZ. 1542059 $7.91 HYDROCORTISONE 1% ANTI-ITCH CREAM 1 OZ. 1021872 $4.72 HYDROCORTISONE 1% OINTMENT 1 OZ. 2187003 $5.42 Cough and Cold AFRIN NASAL SPRAY ORIGINAL 0.5 OZ. 1200021 $7.31 ALKA-SELTZER PLUS COLD FORMULA EFFERVESCENT TABLETS ORIGINAL 36 CT. 4240206 $9.58 ALL NIGHT COLD ORIGINAL LIQUID 8 OZ. 4807822 $5.50 9
Over-the-Counter Health Products Catalog ALLEGRA OTC 180 MG. TABLETS 24-HOUR 15 CT. 4330601 $18.71 ALLEGRA OTC 60 MG. TABLETS 12-HOUR 12 CT. 4330668 $13.48 CHLORASEPTIC SORE THROAT SPRAY CHERRY 6 OZ. 1380476 $6.57 CLARITIN ALLERGY 24-HOUR 10 MG. 30 CT. 5037759 $31.05 DIPHENHYDRAMINE 25 MG. CAPSULES 100 CT. 2152874 $4.50 HALLS COUGH DROPS HONEY LEMON 30 CT. 2971000 $2.80 10
HALLS DEFENSE COUGH DROPS STRAWBERRY 30 CT. 2971141 $3.20 HALLS DEFENSE VITAMIN C DROPS SUGAR FREE ASSORTED CITRUS 25 CT. 3662343 $3.20 HALLS DEFENSE ZINC DROPS HARVEST CHERRY 25 CT. 2971125 $3.20 LORATADINE 10 MG. TABLETS 30 CT. 4242327 $3.50 MUCINEX EXTENDED RELEASE TABLETS 20 CT. 3459377 $13.76 NASAL SPRAY 1 OZ. 3595196 $6.58 11
Over-the-Counter Health Products Catalog OCEAN NASAL SPRAY 1.5 OZ. 4764163 $4.69 ROBITUSSIN DM SUGAR-FREE PEAK COLD COUGH/CONGESTION 4 OZ. 4485868 $7.17 ROBITUSSIN PEAK COLD MAX MULTI-SYMPTOM LIQUID 4 OZ. 4485769 $8.57 SUCRETS REGULAR LOZENGES WILD CHERRY 18 CT. 3413754 $3.88 SUDOGEST PE TABLETS 10 MG. 36 CT. 3653219 $5.99 VICKS DAYQUIL LIQUID CAPSULES 24 CT. 4420766 $11.72 VICKS NYQUIL LIQUID 8 OZ. 4410890 $9.97 12
Dental VICKS VAPORUB 6 OZ. 1274505 $15.43 ACT TOTAL CARE ANTICAVITY FLUORIDE RINSE FRESH MINT 18 OZ. 4164711 $6.48 AIM ANTI-TARTAR GEL TOOTHPASTE 6 OZ. 1435478 $1.45 COLGATE CAVITY PROTECTION TOOTHPASTE 1.3 OZ. 4071858 COLGATE PLUS ADULT TOOTHBRUSH SOFT 1212349 $1.27 $1.78 DENTAL FLOSS MINT 115 YD. 9900440 $2.99 EFFERDENT DENTURE CLEANSER TABLETS 40 CT. 1359454 $3.58 13
Over-the-Counter Health Products Catalog EFFERDENT PLUS MINT TABLETS 78 CT. 2356327 $7.00 FIXODENT CONTROL DENTURE ADHESIVE CREAM 2 OZ. 3586401 $6.87 FIXODENT FRESH 2.5 OZ. 1831072 $6.87 ORAJEL MAXIMUM-STRENGTH GEL 0.42 OZ. 1335645 $7.56 ORAL B DENTURE BRUSH 1498435 $3.50 POLIDENT 3-MINUTE TABLETS 120 CT. 4575304 $9.86 SEA-BOND DENTURE ADHESIVE LOWERS ORIGINAL 15 EA. 1138809 $4.03 14
SEA-BOND DENTURE ADHESIVE UPPERS ORIGINAL 15 EA. 1138932 $4.03 SEA-BOND DENTURE BATH 1220896 $1.73 SENSODYNE TOOTHPASTE ORIGINAL FLAVOR 4 OZ. 1089689 $7.42 SUPER POLIGRIP DENTURE ADHESIVE CREAM ZINC-FREE FORMULA 2.4 OZ 4300133 TOOTHBRUSH FULL HEAD SOFT 1123272 $7.32 $1.50 CREST TOOTHPASTE LARGE 4.6 OZ. 1185313 $3.49 Devices OPTICHAMBER DIAMOND-VALVED HOLDING CHAMBER 4742292 $15.67 15
Diabetes Care DEX4 GLUCOSE TABLETS RASPBERRY 50 CT. 16 Over-the-Counter Health Products Catalog 1752831 $7.00 DIABETIC HEALING SKIN CREAM 4 OZ. 2871168 $11.00 DIABETIDERM FOOT REJUVENATING CREAM 4 OZ. 4969085 $13.03 GOLD BOND ULTIMATE DIABETIC DRY SKIN RELIEF FOOT CREAM 3.4 OZ. 4738894 $7.57
TRIDERMA MD DIABETIC FOOT HEALING CREAM 4.2 OZ. 4740015 $10.00 Dual Purpose Diagnostics BLOOD PRESSURE MONITOR DIGITAL, TALKING 4758140 $54.90 CARA HEATING PAD ECONO DRY 11.5 X 14 1681592 $20.31 CARA HEATING PAD MOIST/DRY WITH SELECT TEMP 3658770 $32.92 OMRON BLOOD PRESSURE CUFF LARGE - CUFF ONLY 1946896 $22.50 17
OMRON MANUAL BLOOD PRESSURE MONITOR Over-the-Counter Health Products Catalog 3258860 $35.83 Dual Purpose Hormone Replacements ESTROVEN MAXIMUM-STRENGTH CAPLETS 28 CT. 3905916 $25.74 ESTROVEN REGULAR STRENGTH CAPLETS 30 CT. 2965713 $15.98 Dual Purpose Minerals FISH OIL 1000 MG. SOFTGELS 100 CT. 2305928 $7.50 18
CARAMEL + D 60 CT. 4898375 $9.60 VIACTIV CALCIUM CHEW MILK CHOCOLATE + D 60 CT. 4898383 $9.60 Dual Purpose Vitamins CALCIUM CARBONATE 600 MG. + D TABLETS 60 CT. 2200285 $5.42 CENTRUM SILVER 50+ MEN S 100 CT. 4163507 $15.13 CENTRUM SILVER 50+ WOMEN S 100 CT. 4967014 $15.13 CEROVITE SENIOR TABLETS 60 CT. 1121797 $4.44 FERROUS SULFATE TABLETS 325 MG. 100 CT. 1430503 $5.89 19
Over-the-Counter Health Products Catalog OYST-CAL + D 500 MG. 60 CT. 2461689 $3.50 VITAMIN D TABLETS 400 IU 100 CT. 1715473 $5.05 VITAMIN E 400 IU SOFTGELS 100 CT. 2162998 $13.31 WINDMILL CALCIUM CHEWABLE 500 MG. TABLETS 60 CT. 3123239 $6.40 WINDMILL FOLIC ACID 400 MG. TABLETS 180 CT. 3069549 $6.40 WINDMILL VITAMIN A 10,000 IU SOFTGELS 100 CT. 3123247 $5.48 WINDMILL VITAMIN B COMPLEX WITH VITAMIN C + IRON 100 CT. 3108404 $8.23 WINDMILL VITAMIN C 500 MG. TABLETS 100 CT. 4079521 $6.98 20
Ear Care DEBROX DROPS EARWAX REMOVAL AID 0.5 OZ. 4811857 $6.99 MURINE EAR WAX REMOVAL SYSTEM 0.5 OZ. 3599669 $7.76 Eye Care ARTIFICIAL TEARS 0.5 OZ. 1287648 $5.99 BAUSCH & LOMB RENU MULTI- PURPOSE SOLUTION 12 OZ. 1444298 $12.35 BAUSCH & LOMB RENU MULTI- PURPOSE NO RUB 4 OZ. 2608123 $5.39 21
Over-the-Counter Health Products Catalog CLEAR EYES ITCHY EYE RELIEF DROPS 0.5 OZ. 3599412 $4.82 CLEAR EYES MAXIMUM REDNESS RELIEF DROPS 0.5 OZ. 4005377 $4.93 EYE DROPS 0.5 OZ. 2260040 $2.77 OPTI-FREE NO-RUB EXPRESS SOLUTION 4 OZ. 3003019 $6.41 OPTI-FREE REPLENISH MULTI-PURPOSE SOLUTION 10 OZ. 3668480 $13.17 SYSTANE LUBRICANT EYE DROPS 15 ML. 3458122 $14.50 VISINE AC EYE DROPS 0.5 OZ. 1398544 $5.95 22
Fiber Supplements FIBER LAXATIVE CAPLETS 100 CT. 9900364 $10.48 First Aid Supplies ACE BANDAGE VELCRO 2-INCH 1669886 $4.90 ACE BANDAGE VELCRO 3-INCH 1669878 $7.79 ACE REUSABLE COLD COMPRESS 1363159 $6.73 ACE SELF-ADHERING BANDAGE 2-INCH 1393503 $4.60 23
Over-the-Counter Health Products Catalog ALCOHOL PREP PADS 100 CT. 4763371 $3.00 24 BAND-AID COMFORT-FLEX PLASTIC ALL ONE SIZE 60 CT. 1094507 $2.51 BAND-AID COMFORT-FLEX SHEER ASSORTED 60 CT. 1675024 $3.50 BAND-AID SHEER ASSORTED 40 CT. 1675032 $3.25 BASIC DIGITAL THERMOMETER 4543138 $4.91 BD ALCOHOL SWABS 100 CT. 1237551 $3.50
BD HOME SHARPS CONTAINER 2295285 $3.38 EPSOM SALT 16 OZ. 2810653 $4.35 FIRST AID KIT/GENERIC 42 PIECES 4974846 $1.69 HYDROGEN PEROXIDE 3% 8 OZ. 2369429 $3.50 JOHNSON & JOHNSON FIRST AID KIT 125 ITEMS 5076377 $13.50 JOHNSON & JOHNSON WATERPROOF TAPE ½ IN. X 10 YD. 5006192 $5.22 25
NEW-SKIN LIQUID BANDAGE 1 OZ. 2167104 $6.22 PURELL HAND SANITIZER 8 OZ. 3659315 $4.15 RUBBING ALCOHOL 70% 16 OZ. 2369411 $4.00 SOLARCAINE BURN RELIEF ALOE EXTRA SPRAY 4.5 OZ. 1477223 $8.10 VICKS COMFORTFLEX THERMOMETER 2867786 $15.70 Foot Care DR SCHOLL S CORN CUSHION REGULAR 9 CT. 1038108 $3.50 26
Gastrointestinals ALKA-SELTZER ORIGINAL 24 CT. 1189422 ANTACID ASSORTED TABLETS 150 CT. 1783489 $4.89 $4.22 ANTACID CHEWABLE EXTRA STRENGTH 96 CT. 2311934 $3.45 ANTACID LIQUID DS 12 OZ. 2164309 $4.50 ANTIDIARRHEAL CAPLETS 2 MG. 12 CT. 1363068 $3.48 BISACODYL TABLETS 25 CT. 2362408 $4.04 DULCOLAX TABLETS 5 MG. 100 CT. 3323680 $25.28 DULCOLAX TABLETS 5 MG. 25 CT. 3323664 $8.07 27
EX-LAX TABLETS REGULAR STRENGTH 30 CT. Over-the-Counter Health Products Catalog 2617033 FAMOTIDINE TABLETS 10 MG. 30 CT. 4153862 $7.40 $6.05 FLEET GLYCERIN SUPPOSITORY 24 CT. 1025972 $3.69 GAS RELIEF CHEWABLE 125 MG. TABLETS 60 CT. 5018593 $5.59 GAS RELIEF SOFTGEL EXTRA STRENGTH 30 CT. 2967776 $6.00 GAS-X EXTRA-STRENGTH SOFTGELS 10 CT. 2435568 $3.40 KAOPECTATE LIQUID REGULAR FLAVOR 8 OZ. 4605168 $5.93 LACTAID FAST ACT CAPLETS 32 CT. 3637964 $10.88 28
METAMUCIL CAPSULES 100 CT. 4590543 $19.58 METAMUCIL FIBER WAFERS CINNAMON 24 CT. 4408878 $9.08 MILK OF MAGNESIA SUSPENSION 16 OZ. 3519808 $5.29 MIRALAX POWDER 7 DOSES 4.1 OZ. 3919909 $8.31 NATURAL LAXATIVE PLUS STOOL SOFTENER TABLETS 60 CT. 3550779 $5.15 PEPCID AC TABLETS ORIGINAL STRENGTH 30 CT. 3434321 $13.11 29
Over-the-Counter Health Products Catalog PEPTO-BISMOL CAPLETS ORIGINAL 40 CT. 2189959 $9.42 PEPTO-BISMOL LIQUID ORIGINAL 8 OZ. 1099829 $5.25 PINK BISMUTH TABLETS - CHEWABLE 30 CT. 2572691 $3.83 PREPARATION H OINTMENT 2 OZ. 1156835 $15.18 PREPARATION H SUPPOSITORIES 24 CT. 1156850 $17.65 PRILOSEC OTC TABLETS 42 CT. 3508314 $32.00 30
RANITIDINE 75 MG. TABLETS 30 CT. 4938775 $4.89 SENNA TABLETS 100 CT. 3580743 $6.29 SENOKOT-S TABLETS 30 CT. 1003565 $21.06 STOOL SOFTENER SOFTGELS 100 CT. 1470475 $4.50 TUCKS MEDICATED PADS 100 CT. 1101237 $10.13 TUMS EXTRA-STRENGTH SMOOTHIES TABLETS ASSORTED FRUIT 60 CT. 3710092 $6.53 TUMS TABLETS REGULAR ASSORTED FRUIT 150 CT. 1336700 $6.53 31
32 Over-the-Counter Health Products Catalog Incontinence A&D OINTMENT 4 OZ. 1219070 $5.85 BALMEX CLEAR PROTECTION OINTMENT 3.5 OZ. 3545092 $5.99 BALMEX DIAPER RASH CREAM WITH ZINC OXIDE 4 OZ. 2320794 $5.53 DESITIN ORIGINAL OINTMENT 4 OZ. 1171883 $7.63 FITTED BRIEFS - EXTRA LARGE (DIAPERS) 15 CT. 4740585 $14.95 FITTED BRIEFS - LARGE (DIAPERS) 18 CT. 4740536 $14.95 FITTED BRIEFS - MEDIUM (DIAPERS) 16 CT. 4740551 $14.95
IN BETWEEN PERINEAL SPRAY SKIN CLEANSER 8 OZ. 3306826 $6.95 PERFIT PROTECTIVE UNDERWEAR - EXTRA LARGE 14 CT. 4157053 $15.00 PERFIT PROTECTIVE UNDERWEAR - LARGE 18 CT. 4157012 $15.00 PERFIT PROTECTIVE UNDERWEAR - MEDIUM 20 CT. 4157004 $15.00 PREVAIL BLADDER CONTROL PADS - MODERATE 20 CT. 3012762 $15.00 PREVAIL UNDERPAD (BED LINERS) 30 in. x 36 in. 25 CT. 4742458 $25.00 33
Pain Relievers ACETAMINOPHEN 325 MG. TABLETS 100 CT. Over-the-Counter Health Products Catalog 2525855 $4.50 ACETAMINOPHEN EXTRA- STRENGTH 500 MG. TABLETS 100 CT. 2525871 $5.00 ADVIL 200 MG. CAPLETS 100 CT. 1110543 $14.61 ADVIL 200 MG. LIQUI-GELS 80 CT. 2764959 $16.16 ADVIL 200 MG. MIGRAINE LIQUID- FILLED CAPSULES 20 CT. 2947406 $5.65 ADVIL CHILD SUSPENSION FRUIT 4 OZ. 2488237 $7.20 ADVIL PM CAPLETS 40 CT. 3725611 $10.42 34
GELCAPS 40 CT. EASY OPEN 4212783 $9.40 ALEVE 220 MG. ARTHRITIS LIQUID GELS 80 CT. EASY OPEN 4118147 $18.86 ALEVE 220 MG. CAPLETS 100 CT. 2190874 $15.13 ALEVE 220 MG. LIQUID GELS 40 CT. 3807260 $11.77 ASPIRIN 325 MG. TABLETS 100 CT. 2749588 $3.50 ASPIRIN ADULT ENTERIC-COATED 81 MG. 120 CT. 3998192 $4.49 ASPIRIN CHILD CHEWS 81 MG. 36 CT. 1498807 $1.99 35
Over-the-Counter Health Products Catalog BAYER 325 TABLETS 100 CT. 4212866 $9.43 BAYER ADULT 81 MG. ENTERIC- COATED LOW-DOSE ASPIRIN 120 CT. 4212809 $10.00 HEADACHE RELIEF ADDED- STRENGTH TABLETS 100 CT. 2164226 $5.31 IBUPROFEN 200 MG. CAPLETS 100 CT. 2291243 $6.09 MIDOL MAXIMUM-STRENGTH MENSTRUAL FORMULA CAPLETS 24 CT. 2612778 $6.73 MIGRAINE RELIEF FORMULA CAPLETS 24 CT. 3312154 $4.01 36
NAPROXEN SODIUM CAPLET 100 CT. 4970471 $9.58 PAIN RELIEVER PM EXTRA- STRENGTH CAPLETS 50 CT. 4760310 $3.89 PAMPRIN MULTI-SYMPTOM CAPLETS 20 CT. 2364834 $4.89 ST. JOSEPH ADULT ASPIRIN 81 MG. CHEW TABLETS 36 CT. 4379871 $3.45 Sunscreen BANANA BOAT SPORT SUNBLOCK SPF 30 8 OZ. 4251906 $10.50 SUNSCREEN LOTION/GENERIC SPF 30 8 OZ. 4246781 $7.67 SUNSCREEN LOTION/GENERIC SPF 50 8 OZ. 4247011 $7.79 37
Support Items FUTURO ANKLE SUPPORT WRAP AROUND MEDIUM Over-the-Counter Health Products Catalog 3936366 $10.53 FUTURO ANKLE SUPPORT WRAP AROUND LARGE 3936374 $10.53 FUTURO KNEE SUPPORT STABILIZING LARGE 3498516 $15.40 FUTURO KNEE SUPPORT STABILIZING MEDIUM 3498508 $15.40 38
FUTURO WRIST STABILIZER DELUXE LEFT LARGE/X-LARGE 2887214 $27.31 FUTURO WRIST STABILIZER DELUXE LEFT SMALL/MEDIUM 2887206 $27.31 FUTURO WRIST STABILIZER DELUXE RIGHT LARGE/X-LARGE 2887198 $27.31 FUTURO WRIST STABILIZER DELUXE RIGHT SMALL/MEDIUM 2887180 $27.31 39
Over-the-Counter Health Products Catalog JOBST WOMEN S SHEER KNEE HIGH 8-15 MM HG. MEDIUM SILKY BEIGE 2952414 $13.15 JOBST WOMEN S SHEER KNEE HIGH 8-15 MM HG. SMALL SILKY BEIGE 2952406 $13.15 Topicals ABREVA COLD SORE CREAM 2 GM. 2986651 $24.55 ACTIVON ULTRA-STRENGTH ARTHRITIS TOPICAL ANALGESIC 2 OZ. 3878014 $11.68 ASPERCREME HEAT PAIN RELIEVING GEL 2.5 OZ. 4020004 $6.46 ASPERCREME PAIN-RELIEVING RUB 3 OZ. 1241249 $6.99 40
AVEENO SOOTHING OATMEAL BATH TREATMENT 8 PK. 1115500 $8.00 BENGAY PAIN-RELIEVING CREAM ULTRA STRENGTH 4 OZ. 2308591 $9.88 BENGAY ULTRA-STRENGTH PAIN- RELIEVING PATCH REG SIZE 5 CT. 3577418 $9.25 BLISTEX MEDICATED LIP OINTMENT 0.21 OZ. 1540467 $2.29 41
Over-the-Counter Health Products Catalog CAPZASIN TOPICAL ANALGESIC LIQUID NO-MESS APPLICATOR 1 OZ. 3934254 $9.99 CARMEX JAR 0.25 OZ. 3674942 $1.79 CARMEX EASY-ON APPLICATOR 0.35 OZ. 1067503 HERPECIN L LIP PROTECTANT SPF 30 0.1 OZ. 1216787 $1.79 $5.99 ICY HOT CREAM 1.25 OZ. 1141878 $4.89 ICY HOT MEDICATED PATCHES EXTRA STRENGTH LARGE (BACK) 5 CT. 3485984 $8.33 42
ICY HOT SLEEVE LARGE KNEE, ANKLE AND ELBOW 3 CT. 3549649 $7.73 MEDERMA GEL 50 GM. 2539245 $38.71 CRYODERM (WAS STOPAIN) SX 10% MSM PAIN RELIEF SPRAY 4 OZ. 4878468 $11.72 THERMACARE HEATWRAPS 8-HOUR LOWER BACK AND HIP 2 CT. 3296340 $9.50 THERMACARE HEATWRAPS 8-HOUR NECK, SHOULDER AND WRIST 3 CT. 3296365 $9.50 43
MENSTRUAL 3 CT. Over-the-Counter Health Products Catalog 4264628 $9.50 TIGER BALM EXTRA-STRENGTH OINTMENT 0.63 OZ. 3278058 $6.78 44
Over-the-Counter (OTC) Catalog Order Form perf line - does not print There are four ways to order your OTC products through the Amerigroup OTC benefit: 1. Order by mail: Please fill out the boxes below when placing an order through the mail. Include the item number, description and price. At the bottom of the table, please add the total price for all items. 2. Order by phone: Call 1-866-805-4589 (TTY: 711) from 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14; Monday to Friday (except holidays) from February 15 through September 30. 3. Order by fax: Fax the completed order form to 1-847-258-1913 anytime. 4. Order online: Log on to the member site at www.myamerigroup.com/medicare. Note: Due to the nature of some of the items, quantities may be limited. Item No. Item Description Price Example: 053652 Bactine First Aid Squeeze $5.59 Total Sum Y0114_16_24637_I_013 07/16/2015 53974MUMENMUB_013 AGP
Amerigroup Over-the-Counter Order Form Clearly write your Amerigroup member ID, date of birth, name, address and telephone number. Your shipping address must be the same as the address in your member record. We cannot fill your order if your address is not the same. Member ID: Date of birth: Date: Name: Shipping address: City: State: ZIP code: Telephone number (including area code): Use the pre-addressed envelope included with this catalog, or mail your order form to: OTC Orders, P.O. Box 1366, Elk Grove Village, IL 60009-1366. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. Amerigroup is an HMO plan with a Medicare contract. For Dual-Eligible Special Needs Plans: Amerigroup is a D-SNP plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in Amerigroup depends on contract renewal. 1306332 53974MUMENMUB 2016 OTC Catalog order form template
When you need health care solutions, we re here to help. Y0114_16_25231_U_005 CMS Accepted 10/01/2015 55116MUMENMUB_005 TX