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.