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[Pages:2]NAME (NOMBRE) ______________________________________________________________________ ADDRESS (DIRECCI?N) ________________________________________________________________ ___________________________________________________________________________________ MEMBER ID ( N?MERO DE MEMBRES?A) ______________ PHONE (TEL?FONO) ______________________

Item

Antacids / Digestion / Laxatives (Anti?cidos / Digesti?n / Laxantes)

Qty

Brand Price

Marca Precio

A1 EFFERVESCENT PAIN RELIEF 36CT ALKA-SELTZER 4.49

A2 DAIRY RELIEF FAST ACTING CHEWABLE 60CT

12.49

A7 RANITIDINE 75MG 30CT ZANTAC 7.99

L6 GLYCERIN SUPPOSITORIES ADULT 25CT

3.49

L11 COLON CLEANSER 120CT FDC 7.99

Q3 PINK BISMUTH CHEWABLE TABS 30CT PEPTO-BISMOL 3.99

Q9 GRIPE WATER COLIC 4OZ

8.49

Pain Relievers (Analg?sicos)

P6 ACETAMINOPHEN 500MG TABS 100CT

6.99

P9 HEADACHE RELIEF COATED TABLETS 24CT

1.99

P14 HOT / COLD PATCHES 5CT ICY HOT 6.99

P17 HEADACHE RELIEF COATED TABLETS 100CT EXCEDRIN 7.49

P44 MUSCLE THERAPEUTIC BLUE GEL 8OZ

7.49

P45 ACETAMINOPHEN NIGHTTIME PAIN RELIEF 24ct TYLENOL PM 3.99

Item

First

Primeros

Aid / Personal

Auxilios / Cuidado

Care

Personal

Qty

Brand Price

Marca Precio

F1 ELASTIC BANDAGE 1CT

3.99

F2

MUSCLE RUB

3OZ BEN-GAY 5.99

F3 ANTIBAC HEAVY DUTY FABRIC BANDAGE 20CT

3.49

F4 CALAMINE LOTION 6OZ CALADRYL 2.99

F9 CLEAR BANDAGES 45CT

3.99

F10 DIAPER RASH OINTMENT 2OZ DESITIN 3.99

F12 SHEER BANDAGES 40CT

2.49

F21

IODINE

1OZ

2.49

F22

MERTHIOLATE

2OZ

3.99

F24

FIRST-AID KIT

EACH

6.99

F29 ITCH RELIEF GEL MAX STRENGTH 4OZ

4.99

F34 HOT/COLD MULTI-COMPRESS 1CT

8.49

F61 BACITRACIN OINTMENT 1OZ

5.99

Miscellaneous / Sunscreen Lotion (Miscel?neo / Loci?n Protectora Del Sol)

F35 LIQUID CORN & CALLUS REMOVER .5OZ

3.99

M1 SUNBLOCK SPF 45

3OZ NEUTROGENA 6.99

M3

LIP BALM

.15OZ

1.99

M9 COTTON SWABS DOUBLE TIPPED PLASTIC STICK 375CT

2.49

M11 BABY POWDER WITH CORN STARCH 4OZ J&J 1.99

M12

BABY WIPES

20CT

1.99

M23 HAND SANITIZER

2OZ

.99

M39

UNISEX FOAM INSOLES

EACH

2.49

M43

TWEEZERS

EACH

1.99

M44

NAIL CLIPPER

EACH

2.49

M46 AZO URINARY RELIEF 12CT AZO STANDARD 4.99

M48

OIL OF BEAUTY

6OZ OLAY 6.99

M51 7 DAY WEEKLY PILL PLANNER EACH

2.49

M55 HEARING AID BATTERIES 312 8CT

6.99

M57 VINYL DISPOSABLE GLOVES 50CT

7.49

X18

VITAMIN E CREAM

4OZ

4.99

X74 BLADDER CONTROL PADS* 20CT POISE 5.99

X75 WOMEN S/M UNDERWEAR XTRA 20ct

12.99

X76 MEN L/XL UNDERWEAR MAX 16ct

12.99

X77 MEN S/M UNDERWEAR MAX 18ct

12.99

X80

MAXI PADS REGULAR

48ct STAYFREE 5.49

X82

TAMPON PLASTIC

20ct TAMPAX 4.49

F62

FIRST AID TAPE

EACH

1.99

F66 LIQUID BANDAGE

.3OZ

4.99

M52 BENZOCAINE TOPICAL .33OZ ANBESOL 5.99

M53

GAUZE

1CT

1.99

M56 GENTLE TAPE 2 PK EACH

5.99

X72 *BLOOD PRESSURE MONITOR MANUAL EACH

17.99

Dental (Dental)

M2

TOOTHBRUSH

1CT

0.99

M4 SENSATIVE TOOTHPASTE EXTRA WHITENING 4OZ

4.49

M35 DENTAL FLOSS WAXED 100YD

2.49

X2

DENTURE TABS

84CT

5.49

X5 DENTURE CLEANSER TABLETS 40CT

2.99

X6 DENTURE ADHESIVE REGULAR 2.4OZ FIXODENT 3.99

Cough / Cold / Allergy (Tos / Catarros / Alergia)

C7 MEDICATED CHEST RUB 3.53OZ VICK'S VAPORUB 5.99

C8 THERMOMETER DIGITAL EACH

4.99

C11 SORE THROAT LOZENGES 18CT

3.99

C57 SORE THROAT SPRAY 6OZ CHLORASEPTIC 4.49

Aetna Better Health of Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. Limitations, copays, and restrictions may apply. For more information, call Aetna Better Health of Ohio Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week

or read the Aetna Better Health of Ohio Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year."

YOU WILL RECEIVE THE GENERIC EQUIVALENT OF ALL ITEMS. USTED RECIBIR? EL GEN?RICO EQUIVALENTE DE TODOS LOS PRODUCTOS.

FOR QUESTIONS, CALL AETNA BETTER HEALTH OF OHIO AT 1-855-364-0974 (TTY: 711) 24 HOURS A DAY, 7 DAYS A WEEK. YOU CAN GET THIS INFORMATION FOR FREE IN OTHER LANGUAGES. CALL 1-855-364-0974 AND TTY: 711; 24 HOURS A DAY, 7 DAYS A WEEK. THE CALL IS FREE.

Puede obtener esta informaci?n en otros idiomas de manera gratuita. Llame al 1-855-364-0974 (TTY: 711), 24 horas al dia, siete dias de la semana. Esta llamada es gratuita. This information is available for free in other languages and formats like Braille or audio CD.

*LIMIT (1) PER ORDER ? *L?MITE DE (1) POR ORDER

Vitamins / Minerals (Vitaminas / Minerales)

V10 GLUCOSAMIN/CHONDROITIN 50 CT NATURE'S BOUNTY 10.99 V45 PROBIOTIC ADULT 20 BILLION 15CT

V14 A 10,000 IU NATURAL 100 CT NATURE'S BOUNTY 4.99 V49 MELATONIN GUMMIES 5MG 60CT

V22 COLLAGEN 500MG 100 CT BOTANIC CHOICE 8.49 V50 L-LYSINE 500MG VITAMIN 100CT

V33

B-12 1000 MCG

100CT

8.99 V51 TURMERIC 400MG 1O0CT

Participant must consult with Primary Care Physician prior to ordering a dual-purpose item. Debe consultar con su m?dico de cabecera antes de ordenar un producto de doble prop?sito.

13.49 9.49 5.49 10.49

Over-the-Counter Drug Catalog Program $20 Monthly Benefit

Aetna Better Health Ohio

Aetna Better Health Ohio is pleased to provide its members with the Over-the-Counter (OTC) Drug Catalog. This is a convenient way to get OTC drugs and supplies by mail through your Aetna Better Health Ohio OTC benefit.

HOW TO ORDER BY MAIL:

1. Clearly write your name, address, telephone number and member ID in the space at the top of the form. 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.

2. Check () items you want on the order form that add up to $20 or less. Your benefit limit is $20 every month. If you order more than $20, you will receive the first $20 of items on your order.

3. Fold and insert completed form in envelope, place first class postage and mail to: OTC Health Solutions

9400 NW 104 Street ? Medley, FL 33178

ORDER BY PHONE: To place your order by phone, call 1-888-628-2770 from 9 a.m. to 5 p.m. E.S.T. Monday through Friday. ORDER BY FAX: Fax the completed order form to 1-866-682-6733 any time. ORDER ONLINE: aetnaoh.

Programa de Cat?logo de Medicamentos sin Receta Beneficio de $20 Mensual Aetna Better Health Ohio

Aetna Better Health Ohio se complace en proveer a sus miembros el Cat?logo de Medicamentos Sin Receta. Esta es una forma conveniente de recibir por correo sus medicamentos y suministros sin receta medica a trav?s de su beneficio de Aetna Better Health Ohio.

COMO ORDENAR POR CORREO:

1. Escriba claramente su nombre, direcci?n, numero de tel?fono y numero de socio en el espacio indicado. Su direcci?n de envio debe coincidir con la direcci?n que tenemos en su archivo de afiliaci?n. No se completar?n las solicitudes en los casos en que no coincidan las direcci?nes.

2. Seleccione art?culos que sumen hasta $20 o menos. Su beneficio tiene un limite de $20 cada mes. Si excede este limite, recibir? autom?ticamente s?lo los primeros art?culos que sumen un total de $20.

3. Coloque este formulario dentro de un sobre con una estampilla de Primera Clase y envienosla a: OTC Health Solutions

9400 NW 104 Street ? Medley, FL 33178

POR TELEFONO: Para colocar su orden llame al 1-888-628-2770 de 9 a.m. a 5 p.m., Hora del Este Lunes a Viernes. POR FAX: Envie su forma por fax al 1-866-682-6733 a cualquier hora. Por internet: aetnaoh.

Name: _______________________________________________

Place

Address: _____________________________________________

Stamp Here

City: _____________________ State: __________ Zip: ________

OTC Health Solutions 9400 NW 104 Street Medley, FL 33178

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