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2019 CHRISTUS Health Plan Generations Plus (HMO) B:11.25” 8-15-2018 4:13 PM APPROVED | APPROVED 18-CHS-0241_Medicare_Collateral_BenefitsCvrNewMexico_8-5x11.indd | w/CHANGE Path: CREATIVE:CHRISTUS:Health Plans...l_BenefitsCvrNewMexico_8-5x11.indd ___________ | ___________ CREATIVE Normal • 1 of 1 Contact: Carley King 214.550.5552 ....................................................................................................................................................... ___________ | ___________ COPYWRITER ............................................................................ Colors: 4-Color • Cyan, Magenta, Yellow, Black ___________ | ___________ ACCOUNT SERVICE Mech Live: 8” x 10.5” Images: grandpa_kid_offset_comp_591382_CMYK.jpg (CMYK; 880 ppi; 34.06%), S_CLR(vlo)_CHP.eps Mech Trim: 8.5” x 11” (86.98%) ___________ | ___________ COPY EDITING Mech Bleed: 8.75” x 11.25” ............................................................................ Fonts: Brix Slab (Regular, Medium, Bold) Built At: 100% • Print Scale: None ___________ | ___________ PRODUCTION MAC-41 • Troy Burger / Troy Burger ___________ | ___________ STUDIO B:8.75” T:8.5” S:8” 2019 CHRISTUS Health Plan Generations Plus (HMO) B:11.25” Over the Counter S:10.5” Formulary T:11” New Mexico CHRISTUS Health Plan Generations covers members in the following counties: Los Alamos Rio Arriba Santa Fe San Miguel 8-15-2018 4:13 PM APPROVED | APPROVED 18-CHS-0241_Medicare_Collateral_BenefitsCvrNewMexico_8-5x11.indd | w/CHANGE Path: CREATIVE:CHRISTUS:Health Plans...l_BenefitsCvrNewMexico_8-5x11.indd ___________ | ___________ CREATIVE Normal • 1 of 1 Contact: Carley King 214.550.5552 ....................................................................................................................................................... ___________ | ___________ COPYWRITER ............................................................................ Colors: 4-Color • Cyan, Magenta, Yellow, Black ___________ | ___________ ACCOUNT SERVICE Mech Live: 8” x 10.5” Images: S_C_CHS_HP_CMYK.eps (50.96%) Mech Trim: 8.5” x 11” Fonts: Brix Slab (Medium, Light, Regular, Bold) ___________ | ___________ COPY EDITING ............................................................................Mech Bleed: 8.75” x 11.25” Built At: 100% • Print Scale: None ___________ | ___________ PRODUCTION MAC-41 • Troy Burger / Troy Burger ___________ | ___________ STUDIO B:8.75” T:8.5” S:8” CHRISTUS Health Plan Generations Plus (HMO) METHOD MEMBER SERVICES – CONTACT INFORMATION CALL 844.282.3026 Calls to this number are free. The CHRISTUS Health Plan Member Services department is available to assist you seven days a week, 8 a.m. to 8 p.m., local time, from Oct. 1 – Mar. 31; and Mon - Fri, 8 a.m. to 8 p.m., local time, from Apr. 1 – Sept. 30. A voice response system is available after hours. Messages left will be responded to within one business day. Member Services also has free language interpreter services available for non-English speakers. TTY 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Available to assist you seven days a week, 8 a.m. to 8 p.m., local time, from Oct. 1 – Mar. 31; and Mon - Fri, 8 a.m. to 8 p.m., local time, from Apr. 1 – Sept. 30. FAX 469.282.3013 WRITE CHRISTUS Health Plan Generations Attention: Member Services P.O. Box 169001 B:11.25” S:10.5” Irving, TX 75016 T:11” WEBSITE CHRISTUShealthplan.org THE NEW MEXICO AGING AND LONG-TERM SERVICES DEPARTMENT The New Mexico Aging and Long-Term Services Department is a state program that gets money from the federal government to give free local health insurance counseling to people with Medicare. METHOD CONTACT INFORMATION CALL 800.432.2080 or 505.476.4799 Calls to these numbers are free. TTY 505.476.4937 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. WRITE New Mexico Aging and Long-Term Services Department P.O. Box 27118 Santa Fe, NM 87502-7118 WEBSITE nmaging.state.nm.us 844.282.3026, TTY 711 Oct. 1 – Mar. 31, 7 days a week, 8 a.m. – 8 p.m., local time Apr. 1 – Sept. 30, Mon – Fri, 8 a.m. – 8 p.m., local time CHRISTUShealthplan.org We are glad you have chosen CHRISTUS Health Plan Generations Plus! CHRISTUS Health Plan Generations Plus offers an over the counter pharmacy benefit in addition to the Part D benefits described in the Evidence of Coverage. This benefit allows for reimbursement of up to $100 every 3 months for over-the-counter drugs included in this document, the CHRISTUS Health Plan Generations Plus Over-the-Counter Formulary, without a prescription. To obtain reimbursement, you must submit receipts for qualified over-the-counter drugs in the manner below no later than 30 days after the end of the quarter. 1.) Collect receipts for qualified drugs, included in the Over-the-Counter Formulary. 2.) Complete the CHRISTUS Health Plan Generations Plus OTC Member Reimbursement Form. This form is included in the back of this Over-the-Counter Formulary or can be found on-line at christushealthplan.org. 3.) Mail original receipts and complete CHRISTUS Health Plan Generations Plus OTC Member Reimbursement Form to: CHRISTUS Health Plan Generations Plus Attention: Claims, Member Reimbursement 919 Hidden Ridge Drive Irving, TX 75038 Time Period Submission Deadline Limit Quarter 1 January – March 2019 April 30, 2019 $100 Quarter 2 April – June 2019 July 30, 2019 $100 Quarter 3 July – September 2019 October 30, 2019 $100 Quarter 4 October – December 2019 January 30, 2020 $100 Questions? We are here to help. Call the CHRISTUS Health Plan Generations Plus Member Service at 844.282.3026. H1189_MC822_C 09/21/2018 1 CHRISTUS HEALTH PLAN GENERATIONS PLUS (HMO) Over-the-Counter Listing FORM CHAPTER GENERIC NAME BRAND NAME ANTIDIARRHEALS BANANA FLAKES/T-GALACTOOLIGOS. BANATROL PLUS BISMUTH SUBSALICYLATE BISMATROL BISMUTH MAXIMUM STRENGTH DIOTAME STOMACH RELIEF LOPERAMIDE HCL LOPERAMIDE ANTIHISTAMINES CETIRIZINE HCL 24HOUR ALLERGY FEXOFENADINE HCL ALLEGRA ALLERGY LORATADINE ALLERGY RELIEF LORADAMED LORATADINE NON-DROWSY ALLERGY ANTITUSSIVE COMBINATIONS DEXTROMETHORPHAN HBR ROBAFEN COUGH ROBITUSSIN SCOT-TUSSIN VICKS DAYQUIL COUGH DEXTROMETHORPHAN/PHENYLEPHRINE TRIAMINIC DAYTIME COLD-COUGH DM/PSEUDOEPHED/ACETAMINOPHEN DAY-TIME NON-ASPIRIN FLU D-METHORPHAN/PE/ACETAMINOPHEN ALKA-SELTZER PLUS DAY DAYTIME COLD MULTI-SYMPTOM DAYTIME COLD-FLU FLU-SEVERE COLD MAPAP COLD FORMULA SUDAFED PE PRESSURE+PAIN+COUGH THERAFLU EXPRESSMAX COLD DAY THERAFLU EXPRESSMAX COLD- COUGH VICKS DAYQUIL EUCALYPTUS OIL/MENTHOL CHERRY MENTHOL GUAIFEN/DEXTROMETHORPHAN/K CIT SORBUTUSS ADLT WAL-TUSSIN COUGH-COLD GUAIFEN/DEXTROMETHORPHAN/PE CF ADULT TUSSIN MULTI-SYMP COLD DESGEN DM DESPEC DM DURAVENT DM GILTUSS TR G-TUSICOF NIVANEX DMX PRES GEN 2 CHRISTUS HEALTH PLAN GENERATIONS PLUS (HMO) Over-the-Counter Listing FORM CHAPTER GENERIC NAME BRAND NAME RELHIST DMX ROBITUSSIN COUGH & COLD CF TUSICOF TUSSI-PRES VANACOF DM ADULT TUSSIN COUGH CONGEST GUAIFENESIN/DEXTROMETHORPHAN DM ADULT TUSSIN DM ADULT WAL-TUSSIN DM ADULT WAL-TUSSIN DM MAX COUGH GUAIASORB DM GUAIFENESIN-DM ER G-ZYNCOF MUCINEX COUGH MUCINEX DM MUCINEX FAST-MAX DM MAX MUCUS DM MUCUS RELIEF DM PECGEN DMX REFENESEN DM RI-TUSSIN DM ROBAFEN DM COUGH ROBAFEN DM COUGH-CHEST CONGEST ROBAFEN-DM ROBITUSSIN COUGH-CHEST-CONG DM SAFETUSSIN DM SCOT-TUSSIN SENIOR SILTUSSIN DM SILTUSSIN DM DAS COUGH FORMULA SORBUGEN NR SUPRESS DM TRISPEC DMX TUSNEL DIABETIC TUSSIN DM COUGH & CHEST TUSSIN DM MAX VICKS DAYQUIL MUCUS CONTROL GUAIFENESIN/DM/PSEUDOEPHEDRINE MAXIFED DM PECGEN PSE POLY-VENT DM 3 CHRISTUS HEALTH PLAN GENERATIONS PLUS (HMO) Over-the-Counter Listing FORM CHAPTER GENERIC NAME BRAND NAME TRISPEC PSE TUSNEL PSEUDOEPH/DM/GUAIFEN/ACETAMIN DURAFLU ANTIVERTIGO & ANTIEMETIC AGENTS DIMENHYDRINATE DIMENHYDRINATE DRIMINATE MECLIZINE HCL BONINE MEDI-MECLIZINE MOTION RELIEF MOTION SICKNESS II MOTION SICKNESS RELIEF MOTION-TIME TRAVEL SICKNESS PHOSPORATED CARB(DEXT-FRUCTOS) FORMULA EM NAUSEA CONTROL BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES URINE ACETONE TEST,STRIPS CHEMSTRIP K KETONE CARE KETOSTIX REAGENT URINE GLUCOSE TEST STRIP DIASTIX REAGENT URINE GLUCOSE-ACET TEST STRIP KETO-DIASTIX REAGENT URINE MULTIPLE TEST STRIPS CHEMSTRIP 10 WITH SG CHEMSTRIP 2 GP LABSTIX REAGENT BOWEL EVACUANTS POLYETHYLENE GLYCOL 3350 GAVILAX GENTLELAX MIRALAX PEG3350 DECONGESTANT / ANTIHISTAMINES CETIRIZINE HCL/PSEUDOEPHEDRINE ALL DAY ALLERGY-D ALLERGY COMPLETE-D FEXOFENADINE/PSEUDOEPHEDRINE ALLEGRA-D 12 HOUR FEXOFENADINE-PSE ER NAPROXEN SODIUM/PSEUDOEPHEDRIN ALEVE COLD AND SINUS ALEVE-D SINUS AND COLD PHENYLEPHRINE HCL MEDI-PHENYL SINUS DECONGESTANT SUDAFED PE SUDOGEST PE PHENYLEPHRINE HCL/ACETAMINOPHN CONTAC COLD-FLU DAY SINUS PAIN & PRESSURE VICKS SINEX DAYTIME 4 CHRISTUS HEALTH PLAN GENERATIONS PLUS (HMO) Over-the-Counter Listing FORM CHAPTER GENERIC NAME BRAND NAME PSEUDOEPHEDRINE HCL NASAL DECONGESTANT PSEUDOEPHEDRINE HCL SINUS 12-HOUR SUDAFED 12 HOUR SUDAFED 12-HOUR SUDAFED 24-HOUR SUDOGEST SUPHEDRIN PSEUDOEPHEDRINE/ACETAMINOPHEN NEXAFED SINUS PRESSURE-PAIN EXPECTORANT COMBINATIONS GUAIFEN/PHENYLEPH/ACETAMINOPHN PRESSURE-PAIN PE PLUS MUCUS TYLENOL COLD HEAD CONGEST SEVR GUAIFENESIN ADULT WAL-TUSSIN ALLFEN CHEST CONGESTION RELIEF FENESIN IR MUCUS RELIEF CHEST REFENESEN RI-TUSSIN SILTUSSIN SA TAB TUSSIN TUSSIN HONEY TUSSIN MUCUS-CHEST CONGESTION GUAIFENESIN/EPHEDRINE HCL PRIMATENE ASTHMA GUAIFENESIN/PHENYLEPHRINE HCL GILPHEX TR MUCUS RELIEF PE REFENESEN PE RELCOF IR RESCON-GG SUPRESS-PE GUAIFENESIN/PSEUDOEPHEDRNE HCL POLY-VENT
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