horizon blue cross blue shield of new jersey 2019 health ... · • otc products are intended for...

Horizon Blue Cross Blue Shield of New Jersey

2019 Health Products Benefit Catalog

New items available for 2019 !

$245 per

quarter

Get over-the-counter products every quarterSpecial health plan benefit with no cost to you.As a member of Horizon NJ TotalCare (HMO SNP), you are able to purchase certain over-the-counter health and wellness products through this catalog. This quarterly benefit helps lower your out-of-pocket costs for these items. Be sure to use your benefit amounts before the end of of every quarter (March, June, September and December). There are 3 ways you can order: online at HorizonBlueOTC.com, over the phone through our toll-free number OR fill out and mail one of the order forms provided. Your order will be shipped directly to your door.

Remember to Keep this Catalog.You will want to reference this catalog each time you place your order.

Y0090_H8298_EC001302_C HorizonBlue.com/Medicare

http://HorizonBlue.com/Medicare

HorizonBlueOTC.com

2 2019 Health Products Benefit Catalog HorizonBlueOTC.com

ORDER GUIDELINES

ORDER ONLINE

You may place your order online at HorizonBlueOTC.com. Remember to save your username and password to order again during your next benefit period.

ORDER BY MAIL

You may place your order by mailing in the order form at the end of your catalog. If the end of the benefit period is approaching and you do not think your order form will be received in time, you may order online or call in your order.

ORDER BY PHONE

If you have questions or would like to place an order over the phone, OTC Advocates are available Monday – Friday from 8 a.m. to 11 p.m., ET at 1-855-345-4759 (TTY 711).

• For delivery, please allow 7 - 10 business days from the time your order is placed.

• Your order total may not exceed your benefit amount. Cash, checks, credit cards or money orders are not accepted under this OTC benefit.

•

and friends.

Your order total will be applied to the benefit period in which the order is received.

• OTC products are intended for member use only to help with a health or medical need. Horizon NJ TotalCare (HMO SNP) prohibits the use of this benefit to order OTC items for family members

• Due to the personal nature of these products, returns are not accepted.

• Items in the 2019 OTC catalog may change throughout the year. Images are for illustration purposes only. For the most up-to-date listing of OTC products available, go to HorizonBlue.com/Medicare.

• OTC items are available through home delivery only. Products may not be purchased at a local retail pharmacy or through any source other than the Horizon NJ TotalCare (HMO SNP) OTC benefit channels listed above.

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-543-5656 (TTY 711). This document is also available in other languages, as well as other formats, such as large print and Braille.

http://HorizonBlueOTC.com

http://HorizonBlue.com/Medicare

3Product details available online or by phone – See Page 2 * ‡ § – See 2

Allergy, Cold, Flu,Decongestant & Sinus

Personal Steam InhalerItem #: 1792Packaging: 1 ctStrength: -

$45.00

Dental & Denture Care

Dental Travel KitItem #: 1749Packaging: 1 ctStrength: -

$10.00

Denture BrushItem #: 1747Packaging: 1 ctStrength: -

$6.00

Denture Cleaning TabletsItem #: 1032Packaging: 40 ctStrength: -

$7.00

Efferdent Plus Mint TabletsItem #: 1653Packaging: 36 ctStrength: -

$11.00

Effergrip Denture Cream Adhesive

Item #: 1842Packaging: 1.5 ozStrength: -

$8.00

Effergrip Denture Cream Adhesive


$10.00


Dental & Denture Care (Continued)

Fingertip Tooth & Gum Massager

Item #: 1745Packaging: 1 ctStrength: -

$9.00

FixodentItem #: 1187Packaging: .75 ozStrength: -

$7.00

Interdental FlossupsItem #: 1751Packaging: 90 ctStrength: -

$7.00

Interdental Gum BrushesItem #: 1748Packaging: 8 ctStrength: -

$8.00

Oral Care System KitItem #: 1750Packaging: 1 ctStrength: -

$14.00

Polident Denture CreamItem #: 1324Packaging: 3.9 ozStrength: -

$9.50

Polident OvernightItem #: 1892Packaging: 84 ctStrength: -

$12.00

Reach Waxed Dental Floss - Cinnamon

Item #: 1901Packaging: 55 ydStrength: -

$5.00

5Product details available online or by phone – See Page 2 * ‡ § – See Page 32


Reach Waxed Dental Floss - Mint


$5.00

Reach Waxed Dental Floss - Unflavored


$5.00

Tongue CleanerItem #: 1746Packaging: 1 ctStrength: -

$8.00

Toothbrush, Colgate, Adult Medium


$3.00

Toothbrush, Colgate, Adult Soft


$3.00

Toothbrush, Professional Care Electronic


$80.00

Toothbrush, RechargeableItem #: 1450Packaging: 1 ctStrength: -

$37.00

Toothbrush, Soft 2-packItem #: 1948Packaging: 2 ctStrength: -

$6.00



Toothbrush, Tek Pro, Angled Soft


$3.00

Toothpaste, ColgateItem #: 1831Packaging: 4 ozStrength: -

$6.00

Toothpaste, Crest Sensi-ReliefItem #: 1838Packaging: 4.1 ozStrength: -

$9.00

Toothpaste, FluorideItem #: 1914Packaging: 6.4 ozStrength: -

$5.00

Toothpaste, PepsodentItem #: 1414Packaging: 5.5 ozStrength: -

$6.00

Toothpaste, Sensitive TeethItem #: 1903Packaging: 4.3 ozStrength: -

$6.00

Toothpaste, Ultrabrite Advanced Whitening

Item #: 1716Packaging: 6 ozStrength: -

$6.00

Water JetItem #: 1744Packaging: 1 ctStrength: -

$39.00



Water Jet Replacement TipsItem #: 1743Packaging: 5 ctStrength: -

$18.00

Diabetes

Diabetic Skin Relief Foot Cream


$16.00

Diabetic Socks, Black, Medium 3-pack

Item #: 1956Packaging: 3 pairStrength: -

$9.00

Diabetic Socks, Black, Large 3-pack


$9.00

Diabetic Socks, Black, X-Large 3-pack


$9.00

Diabetic Socks, White, Medium 3-pack


$9.00

Diabetic Socks, White, Large 3-pack


$9.00


Diabetes (Continued)

Diabetic Socks, White, X-Large 3-pack


$9.00

Ultra Soft Padded Diabetic Sock, Black, Medium 2-pack


$11.00

Ultra Soft Padded Diabetic Sock, Black, Large 2-pack


$11.00

Ultra Soft Padded Diabetic Sock, Black, X-Large 2-pack


$11.00

Ultra Soft Padded Diabetic Sock, White, Medium 2-pack


$11.00

Ultra Soft Padded Diabetic Sock, White, Large 2-pack


$11.00

Ultra Soft Padded Diabetic Sock, White, X-Large 2-pack


$11.00


Ear Care

Cotton Tipped SwabsItem #: 1742Packaging: 300 ctStrength: -

$5.00

Eye Care

Stye Eye CompressItem #: 1905Packaging: 1 ctStrength: -

$13.00

Stye Eye OintmentItem #: 1906Packaging: 3.5 gmStrength: -

$13.00

First Aid & Medical Supplies

Adjustable Transfer BenchItem #: 1764Packaging: 1 ctStrength: -

$65.00

Anti-Slip Safety Tread AidsItem #: 1793Packaging: 1 rollStrength: -

$13.00

Bath Bench with BackItem #: 1728Packaging: 1 ctStrength: -

$65.00

Bath Bench without BackItem #: 1727Packaging: 1 ctStrength: -

$50.00


First Aid & Medical Supplies (continued)

Bath Mat, Non-SkidItem #: 1459Packaging: 1 ctStrength: -

$18.00

Bath Tub Safety RailItem #: 1730Packaging: 1 ctStrength: -

$38.00

Cotton BallsItem #: 1763Packaging: 200 ctStrength: -

$5.50

Cotton Tipped Applicator - 6”Item #: 1669Packaging: 1000 ctStrength: -

$12.00

CPAP Pillow Fiber FilledItem #: 1836Packaging: 1 ctStrength: -

$60.00

CPAP Pillow Memory FoamItem #: 1837Packaging: 1 ctStrength: -

$105.00

Cushion, Foam RingItem #: 1732Packaging: 1 ctStrength: -

$22.00

Cushion, Gel / Foam SeatItem #: 1466Packaging: 1 ctStrength: -

$27.00



Cushion, LumbarItem #: 1731Packaging: 1 ctStrength: -

$27.00

Elastic Bandage - 2” x 4.5 yd *Item #: 1207Packaging: 1 ctStrength: -

$6.00

Elastic Bandage - 3” x 5 yd *Item #: 1209Packaging: 1 ctStrength: -

$6.00


$7.00


$7.00

Fever Strip ThermometerItem #: 1794Packaging: 1 ctStrength: -

$8.00

First Aid Kit, 20 pieceItem #: 1947Packaging: 1 ctStrength: -

$7.00

First Aid Kit, 75 PiecesItem #: 1215Packaging: 1 ctStrength: -

$11.00




$18.00


$17.00


$20.00

Folding Cane Ergonomic Handle *


$21.00

Hot/Cold Pack, 1 small & 1 large


$8.00

Ice Bag - 9”Item #: 1761Packaging: 1 ctStrength: -

$10.00

Insect Repellant Spray - DeetItem #: 1867Packaging: 2 ozStrength: 30%

$10.00


$14.00




$18.00

Knurled Chrome Grab Bar - 12”


$20.00

Knurled Chrome Grab Bar - 24”


$24.00

Medical ID Bracelet - BlankItem #: 1875Packaging: 1 ctStrength: -

$17.00

Medical ID Bracelet - DiabeticItem #: 1877Packaging: 1 ctStrength: -

$17.00

Medical ID Bracelet - HeartItem #: 1876Packaging: 1 ctStrength: -

$17.00

Nitrile Exam GlovesItem #: 1840Packaging: 100 ctStrength: -

$12.00

Pain Relief MaskItem #: 1762Packaging: 1 ctStrength: -

$9.00



Pill Crusher with StorageItem #: 1933Packaging: 1 ctStrength: -

$10.00

Pill Cutter with Safety ShieldItem #: 1932Packaging: 1 ctStrength: -

$10.00

Procedural Face Masks with Earloops


$16.00

Quad Cane, Small Base *Item #: 1777Packaging: 1 ctStrength: -

$26.00

Quad Cane, Large Base *Item #: 1776Packaging: 1 ctStrength: -

$27.00

Raised Toilet SeatItem #: 1729Packaging: 1 ctStrength: -

$36.00

Raised toilet seat with armsItem #: 1950Packaging: 1 ctStrength: -

$65.00

Sharps Container, 1 gallonItem #: 1799Packaging: 1 ctStrength: -

$11.00



Shower Mat, Non-SkidItem #: 1460Packaging: 1 ctStrength: -

$16.00

Tape, Paper Surgical - 1” x 10 yd *


$6.00

Tape, Paper Surgical - 2” x 10 yd *


$7.00

Tape, Silk Surgical - 1” x 10 yd *


$7.00

Tape, Silk Surgical - 2” x 10 yd *


$8.00

Tape, Transparent Surgical - 1” x 10 yd *


$6.00

Tape, Transparent Surgical - 2” x 10 yd *


$7.00

Thermometer Probe CoversItem #: 1752Packaging: 30 ctStrength: -

$8.00



Thermometer, Digital 60 seconds


$7.50

Thermometer, Digital EarItem #: 1285Packaging: 1 ctStrength: -

$24.00

Thermometer, Flexible Tip, Digital 10 seconds


$12.00

Thermometer, Talking Ear and Forehead


$45.00

Toilet Safety RailsItem #: 1779Packaging: 1 setStrength: -

$39.00

Tub & Stair Safety TreadsItem #: 1780Packaging: 1 packStrength: -

$12.00

Warm or Cold Water Bottle, Rubber Latex


$11.00

Weekly AM/PM Pill CaseItem #: 1934Packaging: 1 ctStrength: -

$10.00


Foot Care

Bunion GuardItem #: 1784Packaging: 1 ctStrength: -

$13.00

Hammer Toe CrestItem #: 1785Packaging: 1 ctStrength: -

$14.00

Lamb’s Wool PaddingItem #: 1786Packaging: 1 ctStrength: -

$11.00

Moleskin Sheets PlusItem #: 1782Packaging: 4 ctStrength: -

$10.00

Toe Protector, SmallItem #: 1788Packaging: 1 ctStrength: -

$13.00

Toe Protector, LargeItem #: 1787Packaging: 1 ctStrength: -

$13.00

Toe SeparatorItem #: 1783Packaging: 6 ctStrength: -

$11.00


Incontinence Supplies

Adult Briefs, Medium - 32” to 44” *


$15.00

Adult Briefs, Large - 45” to 58” *


$16.00

Adult Briefs, X-Large - 59” to 64” *


$16.00

Attends Discreet Men’s GuardItem #: 1811Packaging: 20 ctStrength: -

$14.00

Attends Discreet Men’s ShieldItem #: 1810Packaging: 20 ctStrength: -

$15.00

Attends Discreet Women’s Moderate Bladder Control Pad


$18.00

Attends Discreet Women’s Maximum Bladder Control Pad


$20.00

Attends Discreet Women’s Ultimate Bladder Control Pad


$20.00


Incontinence Supplies (continued)

Attends Discreet Women’s Panty Liner


$14.00

Attends Discreet Women’s Ultrathin Pad


$14.00

Bladder Control Shaped Pad, Moderate Absorbency *


$15.00

Bladder Control Shaped Pad, Heavy Absorbency *


$15.00

Bladder Control Shaped Pad, Maximum Absorbency *


$17.00

Disposable Underwear, Medium - 34” to 44” *


$17.00

Disposable Underwear, Large - 44” to 58” *


$17.00

Disposable Underwear, X-Large - 58” to 68” *


$17.00


Incontinence Supplies (continued)

Flushable WipesItem #: 1928Packaging: 24 ctStrength: -

$7.50

No-Rinse Body WashItem #: 1884Packaging: 8 ozStrength: -

$14.00

Underpad, Disposable - 23” x 24” *


$14.00



$14.00



$13.00

Washcloth with LanolinItem #: 1348Packaging: 64 ctStrength: -

$9.00

In-Home Diagonostics

Activity TrackerItem #: 1982Packaging: 1 ctStrength: -

$52.00


In-Home Diagonostics (continued)

Bathroom Scale ‡§Item #: 1935Packaging: 1 ctStrength: -

$35.00

Blood Pressure Monitor, Desktop Automatic ‡


$35.00

Blood Pressure Monitor, Desktop Talking ‡


$34.00

Desktop Blood Pressure Monitor Replacement Cuff ‡


$23.00

Blood Pressure Monitor, Wrist ‡


$22.00

Blood Pressure Monitor, Wrist Talking ‡


$30.00

EZ Detect Colon Cancer Test Kit ‡


$14.00

Finger Pulse Oximeter ‡Item #: 1505Packaging: 1 ctStrength: -

$31.00


In-Home Diagonostics (continued)

Heart Rate Monitor Watch ‡Item #: 1771Packaging: 1 ctStrength: -

$30.00

Home Access Cholesterol Test ‡

Item #: 1251Packaging: 1 kitStrength: -

$25.00

Pain Relievers & Fever Reducers

Heating Pad, 12” X 15” *Item #: 1861Packaging: 1 ctStrength: -

$26.00

Heating Pad, X-Large, 12” x 24” *


$35.00

Heating Pad Wrap For Shoulder, Neck, and Back, 25” x 26” *


$55.00

HeatWraps - Back & HipItem #: 1859Packaging: 2 ctStrength: -

$12.00

HeatWraps - Neck, Shoulder, & Wrist


$12.00


Pain Relievers & Fever Reducers (continued)

Thermacare Lower Back & HipItem #: 1912Packaging: 2 ctStrength: -

$15.00

Thermacare Menstrual ReliefItem #: 1913Packaging: 3 ctStrength: -

$15.00

Personal Care

Elastic Mattress Cover - 80” x 36” x 6”


$11.00

Sleep Aids

Nasal Strips, MediumItem #: 1724Packaging: 30 ctStrength: -

$14.00

Nasal Strips, LargeItem #: 1725Packaging: 30 ctStrength: -

$14.00

Supportive Items

Ankle SupportItem #: 1225Packaging: 1 ctStrength: -

$10.00


Supportive Items (continued)

Arthritis Gloves, SmallItem #: 1767Packaging: 1 pairStrength: -

$28.00

Arthritis Gloves, MediumItem #: 1766Packaging: 1 pairStrength: -

$28.00

Arthritis Gloves, LargeItem #: 1765Packaging: 1 pairStrength: -

$28.00

Back Support Elastic - 24” to 46”


$17.00

Back Support Elastic with Lumbar


$27.00

Carpal Tunnel Brace, SmallItem #: 1770Packaging: 1 ctStrength: -

$24.00

Carpal Tunnel Brace, MediumItem #: 1769Packaging: 1 ctStrength: -

$24.00

Carpal Tunnel Brace, LargeItem #: 1768Packaging: 1 ctStrength: -

$24.00



Compression Knee High Socks, Men’s Black, Medium (Shoe Size 8 - 10) ‡

Item #: 1398Packaging: 1 pairStrength: 15 - 20 mmHg

$21.00

Compression Knee High Socks, Men’s Black, Large (Shoe Size 10.5 - 12) ‡


$21.00

Compression Knee High Socks, Men’s White, Medium (Shoe Size 8 - 10) ‡


$20.00

Compression Knee High Socks, Men’s White, Large (Shoe Size 10.5 - 12) ‡


$20.00

Compression Knee High Socks, Women’s Black, Small (Shoe Size 4-5)


$13.00

Compression Knee High Socks, Women’s Black, Medium (Shoe Size 5.5 - 7.5)


$13.00

Compression Knee High Socks, Women’s Black, Large (Shoe Size 8 - 10.5)


$13.00

Compression Knee High Socks, Women’s Nude, Small (Shoe Size 4 - 5)


$13.00



Compression Knee High Socks, Women’s Nude, Medium (Shoe Size 5.5 - 7.5)


$13.00

Compression Knee High Socks, Women’s Nude, Large (Shoe Size 8 - 10.5)


$13.00

Deluxe Criss Cross Back Support, Small - 28” to 32”


$22.00

Deluxe Criss Cross Back Support, Medium - 33” to 37”


$22.00

Deluxe Criss Cross Back Support, Large - 38” to 42”


$22.00

Elbow SupportItem #: 1224Packaging: 1 ctStrength: -

$15.00

Gait Belt - 60”Item #: 1790Packaging: 1 ctStrength: -

$14.00

Gait Belt - 72”Item #: 1791Packaging: 1 ctStrength: -

$15.00



Heel & Elbow Protector, SmallItem #: 1774Packaging: 1 ctStrength: -

$15.00

Heel & Elbow Protector, Medium


$15.00

Heel & Elbow Protector, LargeItem #: 1772Packaging: 1 ctStrength: -

$15.00

Heel & Elbow Protector, X-Large


$15.00

Hip Protector, SmallItem #: 1862Packaging: 1 ctStrength: -

$50.00

Hip Protector, MediumItem #: 1863Packaging: 1 ctStrength: -

$50.00

Hip Protector, LargeItem #: 1864Packaging: 1 ctStrength: -

$50.00

Hip Protector, X-LargeItem #: 1865Packaging: 1 ctStrength: -

$50.00



Knee StabilizerItem #: 1465Packaging: 1 ctStrength: -

$23.00

Knee Support, Elastic, SmallItem #: 1481Packaging: 1 ctStrength: -

$10.00

Knee Support, Elastic, MediumItem #: 1482Packaging: 1 ctStrength: -

$10.00

Knee Support, Elastic, LargeItem #: 1483Packaging: 1 ctStrength: -

$10.00

Knee Support, Elastic, Small with Stays


$18.00

Knee Support, Elastic, Medium with Stays


$18.00

Knee Support, Elastic, Large with Stays


$18.00

Night Wrist Support Smart Glove


$27.00



Protective Arm Sleeve - SmallItem #: 1897Packaging: 1 pairStrength: -

$30.00

Protective Arm Sleeve - LargeItem #: 1898Packaging: 1 pairStrength: -

$32.00

Protective Arm Sleeve - X-Large


$35.00

Rib Belt - Female (one size fits most)


$20.00

Rib Belt - Male (one size fits most)


$20.00

Thumb BraceItem #: 1778Packaging: 1 ctStrength: -

$21.00

Wrist Compression - SmallItem #: 1918Packaging: 1 ctStrength: -

$17.00

Wrist Compression - MediumItem #: 1919Packaging: 1 ctStrength: -

$17.00



Wrist Compression - LargeItem #: 1920Packaging: 1 ctStrength: -

$17.00

Wrist Compression - X-LargeItem #: 1921Packaging: 1 ctStrength: -

$17.00

Wrist SplintItem #: 1230Packaging: 1 ctStrength: -

$18.00

Wrist SupportItem #: 1227Packaging: 1 ctStrength: -

$12.00

Therapeutic Skin & Sun Care

Sunscreen Lotion SPF 30Item #: 1908Packaging: 1.5 ozStrength: -

$5.00

Sunscreen Lotion SPF 30Item #: 1284Packaging: 3.5 ozStrength: -

$7.00

Vitamins & Minerals

Glucosamine / Chondroitin ‡Item #: 1003Packaging: 60 ctStrength: 250 mg, 200 mg

$12.00


Vitamins & Minerals (continued)

Glucosamine Joint / Muscle ‡Item #: 1114Packaging: 60 ctStrength: 500 mg

$10.00

Leg Cramps Pain Relief Caplets ‡


$14.00

Leg Cramps Pain Relief Caplets ‡


$17.00

Stress Formula Tablets with Zinc ‡


$12.00

Weight Loss

Kitchen Scale Dial ‡Item #: 1756Packaging: 1 ctStrength: -

$12.00


NOTICES

• If you disenroll from Horizon NJ TotalCare (HMO SNP), your OTC benefit will automatically terminate.

• Horizon NJ TotalCare (HMO SNP) is a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) with a Medicare contract. Enrollment in Horizon NJ TotalCare (HMO SNP) depends on contract renewal.

• This information is available for free in other languages. Please call our customer service number Monday - Friday from 8 a.m. to 11 p.m., ET at 1-855-345-4759 (TTY 711).

• The health information provided in the catalog is general in nature and is not medical advice or a substitute for professional health care.

* Part B/D - Under certain circumstances some items may be covered under either Part B or Part D. When you are eligible to receive these items under Part B or Part D you may not purchase these items through your Part C supplemental OTC benefit. For your convenience, we’ve marked these items with an (*)

‡ Dual-purpose items are medicines and products that can be used for either a medical condition or for general health and well-being. In order to purchase these items under your plan, your personal physician must recommend them to you for a specific diagnosed condition. Please speak to your physician before ordering these items.

§ Scales are only available to members with congestive heart failure or liver disease in order to monitor weight changes. Scales are not allowable for other conditions or diseases. Please discuss with your healthcare provider before ordering.

If you disenroll from Horizon NJ TotalCare (HMO SNP), your OTC benefit will automatically terminate. Horizon NJ TotalCare (HMO SNP) is an HMO Medicare Advantage Dual Special Needs plan with a Medicare contract and a contract with the State of New Jersey Medicaid Program. Enrollment in Horizon NJ TotalCare (HMO SNP) depends on contract renewal. Products are provided by HHNJ and Horizon Blue Cross Blue Shield of New Jersey, both of which are independent licensees of the Blue Cross and Blue Shield Association. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies.

The Blue Cross® and Blue Shield® names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon® name and symbols are registered marks of Horizon Blue Cross Blue Shield of New Jersey. © 2018 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.

Horizon NJ TotalCare (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.Spanish (Español): Para ayuda en español, llame al 1-800-543-5656 (TTY 711).Chinese (中文): 如需中文協助請致電 1-800-543-5656 (TTY 711)°

2019 HEALTH PRODUCTS BENEFIT

ORDER FORM

STEP 1 - COMPLETE YOUR INFORMATION BELOW

Member ID (found on plan member ID card) Date of Birth

First Name Last Name MI

Street Number Street Name Apt/Suite #

City State Zip Code

Daytime Phone Email (Optional) Please check box if this is a new address

@

STEP 2 - PRODUCT SELECTION

Cash, checks, credit cards or money orders are not accepted under this OTC benefit.

Item # Product Quantity Unit Price TOTAL

1

2

3

4

5

$ . $ .

$ . $ .

$ . $ .

$ . $ .

$ . $ .

Subtotal from Other Side $ .

Total Order $ .

Please mail the completed form back in the postage-paid envelope provided.

If you place your order using an order form, your order total will be applied to the month 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 benefit, not your June benefit.

STEP 2 - PRODUCT SELECTION (Continued)

Cash, checks, credit cards or money orders are not accepted under this OTC benefit.

Item # Product Quantity Unit Price TOTAL

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.$ .$

.Subtotal $

To order additional products, please see reverse. Please mail the completed form back in the postage-paid envelope provided.

If you place your order using an order form, your order total will be applied to the month 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 benefit, not your June benefit.

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