OTC Benefit Catalog - Members - Benefits
Over-the-Counter (OTC) Benefit Catalog As a member of Keystone VIP Choice, you have an over-the-counter (OTC) benefit of $40.00 every quarter. This benefit allows you to order OTC products you may need, such as bandages, cold and allergy medicines, pain relievers, and vitamins, at no cost to you. Benefit amounts do not roll over, so be sure to use them before the end of every quarter. Ordering is easy. Simply call the toll-free number or fill out and mail the order form provided. Your order will be shipped directly to your door. You can order OTC products without having to talk with your doctor, but we always recommend that you talk with your doctor before starting a new product regimen. Before ordering any of the items, you should talk with your doctor. Keystone VIP Choice is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in Keystone VIP Choice depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the state and Medicare. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Benefits may change on January 1 of each year. Y0093_CAT_1507_ACCEPTED_03032015 PRODUCT PRODUCT NUMBER ACNE TREATMENT Acne gel 10% benzoyl peroxide 1076 ALLERGY, COLD, FLU DECONGESTANT AND SINUS All-day allergy tablets 1090 All-night cold/flu 1361 PACKAGING OTC PRODUCT STRENGTH PRICING 1.5 oz 0.1 $10.00 14 tabs 4 oz $10.00 $10.00 Chlorpheniramine maleate Cough & Cold for High Blood Pressure Diphenhist (antihistamine) Diphenhydramine HCL (antihistamine) Multi-symptom cold formula Nasal saline spray Nasal decongestant spray 12 hour Sudogest PE 10 mg ANTACIDS AND ACID REDUCERS Chewable antacid Famotidine Antacid/anti-gas liquid Omeprazole *D ANTI-ARTHRITIC Arthritis pain reliever Capsaicin Glucosamine/chondroitin ANTICANDIAL (YEAST) Clotrimazole vaginal cream with applicator Micanozole 3-day treatment ANTIDIARRHEAL AND LAXATIVES Bismatrol (Bismuth Subsalicylate) 1008 1166 1308 1009 1357 1052 1091 1352 100 tablets 16 tabs 100 tabs 24 capsules 24 tabs 1.5 oz 1 oz 36 tabs 10 mg 30-1212.5650 mg 4 mg — 25 mg 25 mg — 0.0065 0.0005 10 mg 1346 1108 1006 1110 150 tabs 30 tabs 12 oz 28 caps 500 mg 10 mg — 20 mg $10.00 $10.00 $10.00 $30.00 1311 1367 1003 100 tabs 2 oz 60 caps 650 mg 0.025 mg 250-200 mg $16.00 $11.00 $14.00 1115 1117 45 gm 1 kit 1% 2% $11.00 $18.00 1045 30 tablets 262 mg $10.00 Docusate sodium Glycerin suppository Loperamide HCL *D Milk of magnesia Natural vegetable laxative Pink bismuth Polycarbophil Senna Plus ANTIFUNGAL Clotrim antifungal cream *D Terbinafine HCL tube Tolnaftate cream 1126 1125 1133 1011 1340 1318 1012 1130 100 capsules 25 suppositories 12 tabs 12 oz 13 oz 8 oz 90 tabs 60 tabs 100 mg 2.1 gm 2 mg 400 mg — 262 mg 625 mg 50 mg $7.00 $10.00 $9.00 $10.00 $14.00 $11.00 $14.00 $10.00 1047 1046 1064 1 oz 0.5 oz 0.5 oz 0.01 1% 1% $10.00 $11.00 $10.00 $9.00 $10.00 $10.00 $5.00 $10.00 $9.00 $9.00 $9.00 PRODUCT PRODUCT NUMBER PACKAGING OTC PRODUCT STRENGTH PRICING ANTI-ITCH LOTIONS AND CREAMS Diphenhydramine HCL/Zinc 1140 1 oz — ANTI-ITCH LOTIONS AND CREAMS (CONTINUED) Hydrocortisone 1074 1 oz 1% COLD SORE, FEVER BLISTER AND OTHER MEDICATED LIP PRODUCTS Abreva 1152 2 gm 10% Herpecin-L lip balm 1153 0.1 oz 1% CONTACT LENS SUPPLIES Multi-purpose contact lens solution 1468 120 ml — COUGH SUPPRESSANTS OR EXPECTORANTS Cough drop cherry 1056 30 lozenges 17 mg Guaifenesin cough 1180 60 tabs 200 mg Cough syrup expectorant 1054 4 oz 100 mg Mucus relief DM 1178 30 tabs — Sugar-free cough drop cherry 1182 25 lozenges 5 gm DENTAL/DENTURE CARE Denture cleaning tablets 1032 40 tablets — Fixodent 1187 0.75 oz — Oral pain relief 1286 0.5 oz 0.2 Toothbrush – Colgate – clean adult soft 1413 1 — Toothbrush – Tek Pro – straight soft 1412 1 — Toothpaste – Pepsodent 1414 6 oz — DIAGNOSTIC SUPPLIES Blood pressure cuff medium 1504 1 — Desktop talking blood pressure monitor 1503 1 — DIGESTIVE HEALTH Lactase 1067 60 caps 90001 cc units EAR CARE Ear drop 1190 15 ml 0.065 Ear wax removal system 1363 15 ml — EYE CARE Clear Eyes 1199 0.20 oz — Eye drops (redness relief) 1061 15 ml 0.05% Artificial tears drops 1192 0.5 oz — Artificial tears ointment 1194 3.5 gm — FIRST AID AND MEDICAL SUPPLIES Alcohol pads *D 1200 Box/100 70% Ankle support 1225 1 — Bandages 1344 60 assorted — Digital ear thermometer 1285 1 — $9.00 $4.00 $30.00 $13.00 $11.00 $9.00 $11.00 $10.00 $11.00 $9.00 $10.00 $10.00 $8.00 $9.00 $9.00 $9.00 $23.00 $37.00 $14.00 $10.00 $10.00 $11.00 $10.00 $10.00 $11.00 $9.00 $13.00 $10.00 $28.00 PRODUCT PRODUCT NUMBER FIRST AID AND MEDICAL SUPPLIES CONTINUED Elastic bandage 2” *B 1207 Elastic bandage 3” *B 1209 Elastic bandage 4” 1211 Elastic bandage 6” *B 1213 First aid kit 1215 Hot/cold pack 1062 Hydrogen peroxide Isopropyl alcohol Neosporin Plus Tape, paper surgical 1” *B Thermometer (digital) HEMORRHOIDAL PREPARATIONS Hemorrhoidal ointment Pre-moist hemorrhoidal pads MIGRAINE RELIEF Migraine relief MOTION SICKNESS Driminate PAIN RELIEVERS AND FEVER REDUCERS Acetaminophen Aspirin 325mg Aspirin 325mg enteric-coated Aspirin 81mg Acetaminophen 500mg Ibuprofen Naproxen Pain reliever PM extra strength Pain relieving muscle rub PEDICULICIDE Lice treatment shampoo PERSONAL CARE Aloe vera cream Ammonium lactate Hand sanitizer Sunscreen lotion SPF 15 Sunscreen lotion SPF 30 PACKAGING OTC PRODUCT STRENGTH PRICING — — — — — — $9.00 $9.00 $9.00 $9.00 $13.00 $10.00 1228 1229 1326 1217 1063 1 1 1 1 48 piece Pack 1 small and 1 large 8 oz 16 oz 0.5 oz 1 1 0.03 70% — — — $5.00 $10.00 $14.00 $9.00 $8.00 1066 1364 2 oz 100 pads — — $10.00 $11.00 1365 100 tabs 250/250/ 65 mg $11.00 1263 12 tabs 50 mg $9.00 100 tablets 325 mg 100 tabs 325 mg 100 tabs 325 mg 120 tabs 81 mg 50 tabs 500 mg 100 tabs 200 mg 100 tabs 220 mg 100 tabs 25 mg – 100 mg 2 oz 2.50% $9.00 $9.00 $10.00 $5.00 $9.00 $6.00 $14.00 $11.00 $8.00 1001 1095 1096 1002 1105 1004 1097 1332 1475 1271 4 oz — $10.00 1070 1368 1065 1283 1284 240 ml 8 oz 8 oz 4 oz 3.5 oz — 0.12 62% — — $7.00 $14.00 $9.00 $9.00 $9.00 PRODUCT SLEEP AIDS Nasal strips large Nasal strips medium Sleep tabs SMOKING CESSATION Nicorelief gum SUPPORT ITEMS Men’s compression socks blk lg *B Men’s compression socks wht med *B Men’s compression socks wht lg *B Women’s compression socks blk sm *B Women’s compression socks blk med *B Women’s compression socks blk lg *B Women’s compression socks nude sm *B Women’s compression socks nude med *B Women’s compression socks nude lg *B TOPICAL ANTIBIOTICS Bacitracin ointment Triple antibiotic ointment VITAMINS/MINERALS Calcium and Vitamin D 400 u Calcium carbonate Daily multiple vitamins w/ minerals Ferrous sulfate Vit One a day Magnesium oxide Vitamin A Vitamin B complex Vitamin B-1 Vitamin B-12 Vitamin B-12 Vitamin B-6 Vitamin C Vitamin D Vitamin D Vitamin E WART REMOVER Wart remover (liquid) OTC PRODUCT STRENGTH PRICING PRODUCT NUMBER PACKAGING 1725 1724 1276 30 30 50 tabs — — 25 mg $16.00 $16.00 $10.00 1372 Box 50 4 mg $23.00 1399 1400 1401 1409 1410 1411 1406 1407 1408 Pair Pair Pair Pair Pair Pair Pair Pair Pair — — — — — — — — — $20.00 $20.00 $20.00 $13.00 $13.00 $13.00 $13.00 $13.00 $13.00 1020 1014 1 oz 1 oz 500 U/gm — $7.00 $6.00 1373 1291 1385 1376 1393 1377 1379 1382 1016 1381 1389 1380 1017 1390 1383 1384 60 tabs 60 tabs 100 tabs 100 tabs 100 tabs 100 tabs 100 tabs 100 tabs 100 tablets 100 tabs 100 tabs 100 tabs 100 tablets 100 tabs 100 tabs 100 tabs 600 mg/400 u 600 mg — 325 mg — 250 mg 10 mu — 100 mg 1000 mcg 500 mcg 50 mg 500 mg 1000 iu 400 iu 400 iu $9.00 $10.00 $10.00 $9.00 $10.00 $11.00 $10.00 $10.00 $10.00 $13.00 $10.00 $10.00 $10.00 $10.00 $10.00 $13.00 1075 0.5 oz 17% $11.00 Helpful Information • Your quarterly benefit amount is $40.00. Once your order is received, please allow 7 – 10 business days for delivery. Returns are not accepted. • OTC items are available through mail order only. Products may not be purchased at a local retail pharmacy or through any other source other than the Keystone VIP Choice OTC Benefit Catalog. • If you disenroll from Keystone VIP Choice, your OTC benefit will automatically terminate. • Orders may only be placed by the member, an authorized representative verbally approved by the member at the time of order, or the member’s power of attorney representative on file. • OTC products are intended for members’ use only. Keystone VIP Choice prohibits the purchase of OTC items for family members and friends. • We encourage you to use your full quarterly benefit amount in one order. This benefit amount does not roll over from quarter to quarter. • If you place your order using an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29, but we receive it on July 1, your order total will be applied to your July (or third-quarter) benefit, not your June (or second-quarter) benefit. • If you’re getting close to the end of the quarter and you do not think your order form will be received in time, please call in your order. Our OTC advocates are available to take your order from Monday – Friday from 8:00 a.m. – 8:00 p.m. EST at 1-800-580-7187 (TTY: 711). • Your quarterly order total may not exceed the quarterly benefit amount. You may not use cash, checks, money orders or any other form of personal payment to purchase items under this OTC benefit. • Items in the OTC Benefit Catalog may change throughout the year. A copy of this catalog is also available on the Keystone VIP Choice website at www.keystonevipchoice.com. For up-to-date information, please call our OTC advocates from Monday – Friday from 8:00 a.m. – 8:00 p.m. EST at 1-800-580-7187 (TTY 711). KVIPCPA-1422-59 Over-the-Counter (OTC) Benefit Catalog If you have questions or would like to place an order over the phone, OTC advocates are available Monday – Friday from 8:00 a.m. to 8:00 p.m. Eastern Time at 1-800-580-7187 (TTY: 711). COMPLETE YOUR INFORMATION BELOW Date of birth Member ID (found on health ID card) Last name First name MI Street name Street number Apartment/suite number State City ZIP code Please check this box if this is a new address: □ Email Daytime phone PRODUCT SELECTION Your quarterly order total may not exceed the quarterly benefit amount. Cash, checks, money orders or any other form of personal payment to purchase items are not accepted under this OTC benefit. Item number Product name Quantity Price Total order $ If you place your order using an order form, your order total will be applied to the quarter in which we receive your form. For example, if you mail your order form on June 29, but we receive it on July 1, your order total will be applied to your July (or third-quarter) benefit, not your June (or second-quarter) benefit. See the other side of this panel for your Keystone VIP Choice Over-the-Counter (OTC) Benefit Order Form. Information on how to place your OTC order can be found on the back cover.
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