2021 Your Over-the-Counter Benefit You’re eligible as an You do not need a prescription to receive products in this program. Inter Valley Health Plan Vitality Plus (HMO) You are allowed one (1) order per month. plan member, to get Each order you place must have a over-the-counter minimum total of $25, and you may items delivered spend up to $30 per month. Unused balances DO NOT carry over to the to your home next month. at no cost. 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. 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. 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. 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 遵守适用的联邦民权法律规定，不因种族、肤色、民族血统、年龄、残障或性别而歧视任何人 H0545_FUY2021_009_VP_C 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 ID Card Your mailing address and phone number The items you want to order and total cost Your credit card. This will be used only if your order exceeds the allowance provided What month would you like this order to be applied to? To place your Over the Counter order call Costco 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 [email protected] Costco Mail Order Pharmacy 215 Deininger Circle, Corona, CA 92880-9911 $25 Minimum order required $30 Monthly allowance ORDER FORM Name DOB Address Order Date Phone Number Allergies Inter Valley Member Number Grp Number Order Month Received by: Product Active Ingredient/Item Detail Package Price Qty Size MISCELLANEOUS ITEMS Dramamine Motion Sickness Tablet meclizine 25mg 8ct $8.00 Weekly Pill Box Planner 1ct $4.00 ALLERGY Banophen 25mg Capsule diphenhydramine 25mg 24ct $6.00 Cetirizine 10mg Tablet cetirizine 10mg 30ct $6.00 chlorpheniramine maleate 4mg Coricidin HBP Cough & Cold Tablet dextromethorphan hydrobromide 30mg 16ct $10.00 Cromolyn Sodium Nasal Spray cromolyn sodium 5.2mg per spray 26ml $11.00 LDR Allergy Relief 180mg Tablet fexofenadine 180mg 15ct $10.00 Loratadine 10mg Tablet loratadine 10mg 30ct $6.00 Saline Mist 0.65% Nose Spray sodium chloride 0.65% 44ml $3.00 SM Allergy Relief Nasal Spray fluticasone propionate 50mcg 50mcg $13.00 50mcg/Act 120 sprays Sun Mark 4-Hour Allergy 4mg Tablet chlorpheniramine 4mg 100ct $6.00 ANTACIDS aluminum hydroxide 95mg, Acid Gone Antacid magnesium carbonate 358mg 355ml $9.00 Bismatrol 262mg/15ml bismatrol 262mg/15ml 236ml $7.00 Bismatrol 262mg Chewable bismatrol 262mg chewable 30ct $4.00 Calcium Antacid 500mg calcium carbonate chew 500mg 150ct $7.00 Heartburn Relief 10mg Tablet famotidine 10mg 30ct $7.00 Milk of Magnesia Suspension magnesium hydroxide 1200mg per 15mL 355ml $4.00 Omeprazole 20mg Tablet omeprazole 20mg 14ct $10.00 Simethicone Chew 125mg simethicone 125mg 60ct $7.00 CANDIDAL Clotrimazole 1% Cream clotrimazole 1% 45gm $6.00 miconazole Nitrate (200mg in each suppository); 1ct $10.00 Miconazole 3 miconazole nitrate 2% (external cream) Monistat 1 Day tioconazole 300mg (6.5%) per applicator 4.6gm $18.00 Product Active Ingredient/Item Detail Package Price Qty Size ANTIDIARRHEAL & LAXATIVE Enema, Disposable sodium phosphate 133ml $6.00 Ex-Lax 15mg Tablet sennosides 8.6mg 8ct $4.00 Fleet Glycerin Suppositories glycerin 2 g 12ct $6.00 GERI-KOT sennosides 8.6mg 100ct $6.00 Loperamide 2mg Tablet loperamide 2mg 12ct $5.00 Senna Plus 8.6-50mg Tablet sennosides 8.6mg/docusate sodium 50mg 60ct $3.00 SM Bisacodyl Gentle Laxative Tablet bisacodyl 5mg 25ct $4.00 SM Stool Softener 100mg Softgel docusate sodium 100mg 100ct $5.00 Stool Softener 250mg Softgel docusate sodium 250mg 100ct $8.00 BRACES AND SUPPORT Ace Elbow Support Sizing: 9 – 11 in (8 – 27.9 cm) 1ct $10.00 Ace Wrist Support Adjustable size 1ct $12.00 Ankle Stabilizer Adjustable size 1ct $10.00 Fut Sport Knee Support Sizing: 13.0 – 17.5 in (33.0 – 14.4 cm) 1ct $13.00 Sport Aid 2 inch Elastic Bandage** latex free 1ct $5.00 COUGH/COLD dextromethorphan 15mg/acetaminophen All-Night Cold Flu Relief Liquid 325mg/doxylamine 6.25 per 15mL 237ml $5.00 Halls Cough Drops menthol 7.5mg 25ct $4.00 Halls Cough Drops Triple Soothing menthol 7.5mg 30ct $6.00 Action Honey - Lemon Halls Cough Drops Sugar Free menthol 5mg 25ct $4.00 Mucinex DM Tablet dextromethorphan HBr 30mg guaifenesin 600mg 20ct $14.00 Mucus & Chest Congestion guaifenesin 100mg/5mL 118ml $6.00 Mucus Relief 400mg Tablet guaifenesin 400mg 60ct $7.00 Oxymetazoline 0.05% Spray (Nasal) oxymetazoline 0.05% 30ml $6.00 guaifenesin 100mg/dextromethorphan 10mg/ Robafen CF phenylephrine 5mg per 5mL 118ml $7.00 guaifenesin 100mg/dextromethorphan 118ml $7.00 Robafen DM Cough Clear 10mg per 5mL Product Active Ingredient/Item Detail Package Price Qty Size COUGH/COLD continued guaifenesin 100mg/dextromethorphan Siltussin DM Cough Syrup 10mg per 5mL 118ml $9.00 Sore Throat Spray phenol 1.4% 177ml $6.00 Sudogest PE 10mg Tablet phenylephrine 10mg 36ct $6.00 acetaminophen 325mg/dextromethorphan HBr 10mg/guaifenesin 200mg/phenylephrine HCI Tylenol Cold Flu Severe 5mg per 15 mL 240ml $10.00 camphor 4.8%/eucalyptus oil Vicks Vaporub 1.2%/menthol 2.6% 100gm $11.00 DENTAL Colgate Plus Toothbrush Soft 1ct $4.00 Colgate Plus Toothbrush Medium 1ct $4.00 Dental Floss (55 yards) mint flavor 1ct $4.00 Fixodent 68gm $6.00 Floss Pick 90ct $6.00 Orajel benzocaine 10% 7gm $9.00 Pepsodent Complete Care sodium fluoride 0.24% 156gm $6.00 Polident Overnight Whitening 40ct $5.00 potassium nitrate 5%/sodium fluoride 0.25% Sensodyne (w/v fluoride ion) 113gm $8.00 DIAGNOSTICS Floor Scale Digital Audio Display 550lbs*** 1ct $30.00 Infrared Thermometer*** 1ct $30.00 Omron 3 Series Blood Pressure Monitor*** 1ct $30.00 DIGESTIVE HEALTH alpha-galactosidase enzyme Beano Food Enzyme Tablet 300 per 2 tablets 30ct $8.00 Lactase lactase 3000 units per caplet 60ct $10.00 EAR CARE Ear Syringe latex free 1ct $5.00 Murine Ear Drops 6.5% carbamide peroxide 6.5% 15ml $6.00 Product Active Ingredient/Item Detail Package Price Qty Size EYE CARE ketotifen 0.025% (equivalent to Ketotifen Alaway Eye Itch Relief 0.025% fumarate 0.035%) 10ml $13.00 Artificial Tears 15ml $8.00 B&L Eye Wash purified water 99.05% 118ml $8.00 Bausch & Lomb Soothe glycerin 0.6%; propylene glycol 0.6% 28ct $12.00 Bausch & Lomb Sensitive Eyes Plus 355ml $5.00 glycerin 0.25%; naphazoline Clear Eyes Redness Relief 0.012% hydrochloride 0.012% 15ml $5.00 ketotifen 0.025% (equivalent to Ketotifen Ketotifen Fum 0.025% Eye Drops fumarate 0.035%) 5ml $11.00 Lubricating Plus Drops 0.5% carboxymethylcellulose sodium 0.5% 30ct $7.00 Preservision AREDS 2 Softgel vitamin C 250mg, vitamin E 200iu zinc 40mg, copper 1mg, lutein 5mg 60ct $18.00 Refresh Tears 0.5% Drops carboxymethylcellulose sodium 0.5% 15ml $10.00 polyethylene glycol 400 0.4%; Systane Eye Drops propylene glycol 0.3% 15ml $14.00 Stye Ointment mineral oil 31.9%; white petrolatum 57.7% 3.5gm $9.00 Thera Tears Liquid Gel Single Use Vials sodium carboxymethylcellulose 1% 30ct $13.00 FIBER SUPPLEMENTS methylcellulose 2g (a non-allergic fiber) Citrucel Fiber Powder per heaping tablespoon