del Plan de necesidades especiales de Community Health ... · Clean & Clear Advantage Acne Spot Treatment 0.75Oz 148-2967 9.65 Clean & Clear Essential Foam Facial Cleanser 8Oz 410-6050

2019

La información sobre cómo hacersu pedido de productos de OTC se

puede encontrar en el reverso de este Catálogo de productos de OTC.

Recuerde guardar este catálogo. Podrá consultarlo cada vez que

haga su pedido.

Como miembro de Community Health Plan of Washington Medicare Advantage, usted cuenta con una bonificación del beneficio de productos de venta libre (OTC, por sus siglas en inglés) de $50 cada trimestre. Este beneficio le permite obtener los productos de OTC que pueda necesitar. Asegúrese de utilizar los montos de su beneficio antes de finalizar cada trimestre. Simplemente haga su pedido en línea en http://shopping.drugsourceinc.com/chpw, llame al 1-877-603-0402 (TTY: 711) o envíe por correo el formulario de pedido completo. El pedido se enviará directamente a su hogar.

H5826_MK_456_2019_SNP_OTC_Product_Catalog_C SPA Última actualización: 12/2018

Catálogo de productos de venta libre (OTC) del Plan de necesidades especiales de

Community Health Plan of Washington Medicare Advantage

MEDICARE ADVANTAGE

COMMUNITY HEALTH PLANof WashingtonTM

2http://shopping.drugsourceinc.com/chpw

Su Plan de necesidades especiales de Community Health Plan of Washington (CHPW) Medicare Advantage Medicare incluye una bonificación de $50 cada trimestre para comprar cualquier producto de venta libre (OTC) que se encuentre en este catálogo. Los artículos que pida se enviarán a su hogar por correo.

Cómo hacer un pedidoPedido en línea: ingrese en http://shopping.drugsourceinc.com/chpw. Tenga a mano su tarjetade identificación de miembro de CHPW Medicare Advantage y su fecha de nacimiento. Necesitará esta información para iniciar sesión en el sitio de compras de OTC.

Pedido por teléfono: llame al Servicio al cliente al 1-877-603-0402 (TTY: marque 711) de lunes a viernes, de 8:30 a. m. a 10:00 p. m., hora del centro. Tenga a mano su tarjeta de identificación de miembro de CHPW Medicare Advantage y su fecha de nacimiento. Necesitará esta información para hacer su pedido.

Pedido por correo: complete el formulario de pedido que figura en el reverso de este catálogo. Siga las instrucciones que se encuentran en el formulario de pedido.

Pedido por fax: envíe por fax el formulario de pedido completo al 1-847-258-1913.

Tenga en cuenta que la dirección de envío debe ser la misma que su dirección de miembro de CHPW Medicare Advantage. Si la dirección no coincide, comuníquese con el Servicio al cliente de CHPW Medicare Advantage al 1-800-942-0241 (TTY: marque 711), de 8:00 a. m. a 8:00 p. m., los 7 días de la semana para actualizar su dirección.

Para el envío, espere entre 7 y 10 días hábiles desde el momento en que hace su pedido.

Debe utilizar su bonificación de $50 antes de finalizar cada trimestre. Los pedidos tienen un límite de uno por mes.

El total de su pedido no puede superar el monto del beneficio trimestral. Según este beneficio para productos de OTC, no se aceptan giros postales, tarjetas de crédito, cheques ni dinero en efectivo.

El total de su pedido se aplicará al período de beneficio en el que se recibe el pedido.

Los productos de OTC están destinados para el uso exclusivo del miembro a fin de ayudarlo ante una necesidad de salud o médica. CHPW Medicare Advantage prohíbe el uso de este beneficio para pedir artículos de OTC destinados a familiares o amigos..

Debido a la naturaleza propia de estos productos, no se aceptan devoluciones.

Los artículos de OTC perdidos o robados no son reembolsables y no se reemplazarán.

Los artículos que se encuentran en el Catálogo de beneficios de OTC 2019 pueden cambiar durante el año. Para obtener la lista más actualizada de artículos de OTC disponibles, ingrese en http://shopping.drugsourceinc.com/chpw.

Los artículos de OTC se encuentran disponibles exclusivamente a través del envío a domicilio. Los productos no se pueden comprar en una farmacia minorista local ni por otro medio que no sea el proveedor de pedidos por correo de productos de OTC de CHPW Medicare Advantage.

Catálogo de productos de venta libre de CHPW Medicare Advantage

Community Health Plan of Washington es un plan HMO que tiene un contrato con Medicare y uncontrato con el programa Medicaid del estado de Washington. La inscripción en Community Health Plan

of Washington depende de la renovación del contrato.

3 Catálogo de productos de venta libre (OTC) 2019

Nombre del producto Código de artículo (SKU) Precio

Tratamiento para el acnéBenzoyl Peroxide Gel 10% 45Gm 540-8570 3.60Clean & Clear Advantage Acne Spot Treatment 0.75Oz 148-2967 9.65Clean & Clear Essential Foam Facial Cleanser 8Oz 410-6050 6.15Neutrogena Acne Wash Oil-Free 6Oz 645-1330 8.85Neutrogena Clear Pore Oil-Eliminating Astringent 8Oz 113-3560 6.95Oxy Daily Cleansing Pads Maximum 90 Ct 464-7004 6.75

Medicamentos contra la artritisGlucosamine Chondroitin 500/400Mg 60 Capsules 141-1743 12.35

AntimicóticosAthletes Anti-Fungal Foot Cream 0.5Oz 221-5952 12.10Clotrimazole 1% Cream 1Oz 148-1258 7.20Clotrimazole 1% Cream 0.5Oz 904-1955 5.65Compound W Fast-Acting Liquid 0.31Oz 608-0477 10.90Compound W Gel 0.25Oz 608-0485 10.90Fungi Nail Tincture 30Ml 316-0017 19.50Lamisil At Athletes Foot Cream 12Gm 102-3407 12.35Lotrimin Af Cream 0.5Oz 550-3818 11.60Lotrimin Af Cream 30Gm 19150 18.70Miconazole Nitrate Cream 2% 30Gm 099-1265 6.70Mycocide Ns Antimicrobial Solution 1Oz 820-1295 22.15Tolnaftate 1% Cream 1Oz 105-4352 6.00Tolnaftate 1% Cream 0.5Oz 354-0051 4.10Tolnaftate 1% Powder 1.5Oz 536-3387 4.65

Cremas y ungüentos antisépticosBacitracin Ointment 1Oz 103-3448 6.20Bactine Liquid 4Oz 472-0132 5.65Neosporin Original Antibiotic Ointment 1Oz 735-6389 10.55Neosporin Plus Maximum Strength Ointment 0.5Oz 735-6405 7.80Neosporin Plus Ointment Maximum Strength 1Oz 735-6413 12.65Triple Antibiotic Ointment 1Oz 155-2405 7.75Triple Antibiotic Plus Ointment 1Oz 155-2397 6.08

MEDICARE ADVANTAGE COMMUNITY HEALTH PLANof WashingtonTM

The power of community



Cremas y ungüentos para aliviar la picazónAfter Bite Extra Gel 0.5Oz 376-1616 4.45Benadryl Extra Strength Itch Stopping 2% Cream 1Oz 735-7791 6.45Benadryl Regular Strength Itch Relief 1% Cream 1Oz 735-7783 6.00Calamine Lotion 6Oz 359-1146 4.10Cortaid Anti-Itch Maximum Strength Cream 1% 1Oz 241-1668 7.20Cortizone 10 Creme 1Oz 455-5561 6.70Cortizone 10 Ointment 1Oz 455-5587 6.95Cortizone-10 Intensive Healing Formula Anti-Itch Creme 1Oz 211-7380 7.00Diphenhydramine 2%Cream 1Oz

150-6468 5.00

Gold Bond Medicated Body Powder 10Oz 799-0955 8.85Gold Bond Medicated Maximum Strength Cream 1Oz 799-0930 5.15Hydrocortisone 1% Anti-Itch Cream 1Oz

099-0994 5.15

Hydrocortisone 1% Ointment 1Oz 099-0978 5.65Psoriasin Ointment 4Oz 177-7002 12.70

Seguridad para el bañoAdjustable Transfer Bench 142501 98.99Bath Seat 121-4162 50.00Bath Seat With Back 170-1622 49.00Bath Seat With Back, Carex 361-8402 42.00Bathroom Safety Shower Tub Bench Chair 448-8185 41.57Bathtub Grab Bar Safety Rail 541-3513 45.72Bathtub Mat, 28”X 16” 149-1760 15.95Economy Elevated Toilet Seat 7000404 16.99Raised Toilet Seat With Arms And Lock, 5 Inches 20273501 33.99Safety Treads 356-3277 5.00Suction Cup Grab Bar With 180 Swivel Action, 19Inch 7001924 39.99Suction Tub And Shower Bar 16 Inch 7003516 17.95Toilet Safety Rails 448-8276 35.00Toilet Seat Raised Lock 232-5348 52.99

Resfrío y alergiaAfrin Nasal Spray Original 0.5Oz 525-4941 8.15Afrin Nasal Spray Sinus 0.5Oz 525-6821 8.15Airborne Immune Support Chewable Tablets Berry 32Ct 566-4149 10.90Airborne Immune Support Chewable Tablets Citrus 32Ct 256-4565 10.90Alka-Seltzer Plus Cold Formula Effervescent Tablets Original 36Ct 567-2225 11.12All Night Cold Original Liquid 8Oz 352-2372 5.67Allegra Otc 180Mg Tablets 24 Hour 15Ct 563-7806 20.75



Resfrío y alergiaAllegra Otc 180Mg Tablets 24 Hour 30Ct 235-5113 27.75Allegra Otc 60Mg Tablets 12 Hour 12Ct 235-5139 14.80Benadryl Allergy Softgels Dye Free 24Ct 362-5738 7.15Breathe Right Nasal Strips Clear Large 30Ct 146-8883 16.50Breathe Right Nasal Strips Tan Small/Medium 30Ct 814-0097 17.80Cepacol Maximum Strength Lozenge Honey Lemon 16Ct 361-6034 4.35Cetirizine 10Mg Tablets 30Ct 221-2652 11.85Chloraseptic Sore Throat Spray Cherry 6Oz Sugar Free 532-4876 7.30Chloraseptic Sore Throat Spray Menthol 6Oz Sugar Free 532-4892 7.30Claritin Allergy 24 Hour 10Mg 30Ct 145-5054 33.40Claritin Allergy 24 Hour 10Mg 20Ct 135-5098 27.20Contac Cold/Flu Day/Night Caplet 28Ct 355-8814 9.25Coricidin Hbp Chest Congestion & Cough Liqui-Gels 20Ct 134-2476 8.45Coricidin Hbp Cough & Cold Tablets 16Ct 525-7134 8.45Coricidin Hbp Maximum Strength Flu Tablets 20Ct 115-5324 8.45Cough Drops Black Cherry Sugar Free 25Ct 133-8839 2.05Cough Drops Cherry 30Ct 133-8805 2.05Cough Drops Honey Lemon 30Ct 133-8813 2.05Daytime Multi-Symptom Cold/Flu Relief 16Ct 564-4059 4.53Diphenhydramine 25Mg Capsules 100Ct 904-0981 4.65Diphenhydramine 25Mg Tablet 24Ct 133-2253 4.10Effervescent Cold Relief Tablets 20Ct 565-5683 7.50Fexofenadine Allergy Tablets 12 Hour 12Ct 255-1117 11.72Fexofenadine Allergy Tablets 24 Hour 30Ct 565-5915 20.41Halls Cough Drop Honey Lemon 30Ct 735-7346 3.10Halls Defense Strawberry 30Ct 103-8751 3.20Halls Defense Vitamin C Drops Sugar Free Assorted Citrus 25Ct 230-4830 3.20Halls Mentho-Lyptus Drops Cherry 30Ct 735-7338 3.10Loratadine 10Mg Tablet 30Ct 149-7379 4.10Loratadine 10Mg Tablets 100Ct 234-1964 12.35Medicated Chest Rub 3.53Oz 162-4311 4.10Mucinex Dm Extended Release Tablets 20Ct 158-9670 16.75Mucinex Dm Maximum Strength Tablets 14Ct 206-5191 17.95Mucinex Dm Maximum Strength Tablets 28Ct 208-3053 33.55Mucinex Extended Release Tablets 20Ct 143-8928 15.30Mucus Relief Tablets 60Ct 244-3901 5.15Nasacort Allergy 24 Hour Spray 0.5Oz 367-7085 27.75Nasal Spray 1Oz 163-1522 6.70Ocean Nasal Spray 1.5Oz 355-5547 5.15Robitussin Dm Peak Cold Cough/Congestion 4Oz 248-6637 7.95



Resfrío y alergiaRobitussin Dm Sugar Free Peak Cold Cough/Congestion 4Oz 248-6686 7.95Saline Nasal Spray 1.5Oz 904-1468 3.60Sore Throat Spray Cherry 6Oz 565-7901 4.49Sucrets Regular Lozenges Wild Cherry 18Ct 464-6022 4.10Sudogest Pe Tab 10Mg 36Ct 172-4897 6.20Tussin Dm Sugar Free Liquid Clear 4Oz 133-2964 4.10Tussin Form Cf 8Oz 192-8985 5.15Tussin Form Dm 8Oz 146-5095 6.10Vicks Dayquil Liquid Capsules 24Ct 249-1736 13.05Vicks Nyquil Liquid 8Oz 249-1645 11.10Vicks Nyquil Liquid Capsules 24Ct 249-1769 13.05Vicks Vaporub 1.76Oz 532-5816 6.60Vicks Vaporub 6Oz 532-5832 17.25Vicks Vaporub 3.53Oz 532-5824 11.55Vicks Vaporub Lemon Scent 1.76Oz 217-7335 6.60Zyrtec Otc Adult 10Mg 24 Hour Tab 5Ct 210-6722 9.80

DiabetesDiabetiderm Foot Rejuvenating Cream 4Oz 148-4575 14.10Glucose Tablets 4Gm 10Ct 221-8162 3.95Gold Bond Ultimate Diabetic Dry Skin Relief Foot Cream 3.4 Oz 356-0273 8.46

DiagnósticosBlood Pressure Monitor Digital, Talking 860214 55.55Deluxe Heating Pad Moist/Dry 589102 24.95Digital Blood Pressure Monitor, Automatic Wrist Monitor 5219999 25.99Heating Pad Econo Dry 11.5 X 14 110-0445 20.90Heating Pad Moist/Dry With Select Temp 549-0313 34.65Omron Blood Pressure Cuff Large - Cuff Only 898-0997 22.95Omron Blood Pressure Monitor Manual 145-2739 38.40Smartheart Blood Pressure Monitor 564-1469 42.10Smartheart Blood Pressure Monitor, 2 Cuffs 01-554 37.99

Cuidado del oídoDebrox Drops Earwax Removal Aid 0.5Oz 464-5313 8.10Ear Wax Drop 0.5Oz 217-4373 4.95Ear Wax Drop Removal Kit 0.5Oz 217-4365 5.15Macks Wax Away Earwax Removal System 554-2592 6.60Murine Ear Wax Removal System 0.5Oz 479-0283 8.45Murine Earwax Removal Drops 0.5Oz 479-0317 7.75



Cuidado oftalmológicoArtificial Tears 0.5Oz W/ Polyvinyl Alcohol 0.5%, Povidone 0.6% 565-6889 8.25Artificial Tears 0.5Oz Polyvinyl 1.4% 133-7120 8.25Bausch & Lomb Renu Advanced Multi-Purpose No Rub 4Oz 567-4478 7.55Bausch & Lomb Soothe Hydration Lubricant Eye Drops 15Ml 250-6624 13.45Blink Contacts Lubricant Eye Drops 10Ml 175-7509 8.60Clear Eyes Itchy Eye Relief Drops 0.5Oz 222-0937 5.35Clear Eyes Maximum Redness Relief Drops 0.5Oz 210-5542 5.50Contact Lens Solution 12Oz *Contains Hydrogen Peroxide* 375-2243 9.79Eye Drops 0.5Oz 133-7096 3.10Eye Drops Ac 0.5Oz 565-6871 3.39Eye Drops Moisture 0.5Oz 565-6863 2.95Freshkote Eye Drop 15Ml 192-5189 49.08Multi-Purpose No Rub Solution 12Oz 133-7138 5.87Ocusoft Retaine Mgd Eye Drop 30 Each 553-6172 28.45Ocuvite Tablet 60Ct 370-2016 12.80Opti-Free No-Rub Express Solution 4Oz 030-4246 7.30Opti-Free Replenish Multi-Purpose Solution 10Oz 547-4713 15.00Opti-Free Rewetting Drops 10Ml 030-3529 9.70Refresh Liquigel 0.5Oz 122-3809 14.60Systane Lubricant Eye Drops 15Ml 144-3415 16.20Thera Tears Sterilid Lid Scrub 1.62Oz 201-8265 20.03Visine A Drops 0.5Oz 455-5504 9.15Visine Ac Eye Drops 0.5Oz 455-4531 6.20Visine Original Eye Drops 0.5Oz 455-1073 6.20

Suplementos a base de fibraFiber Laxative Caplets 100Ct 565-6616 10.80Fiber Laxative Capsules Psyllium 160Ct 565-6723 10.79Fibercon Tablet 90Ct 193-3647 17.35Fiberlax Tablets 90Ct 141-0224 7.30Metamucil Capsules 100Ct 135-2343 21.15Natural Fiber Powder 13Oz 110-8646 9.80Natural Fiber Powder Orange 13Oz 130-2637 9.25

Suministros para primeros auxiliosAce Bandage Velcro 2 Inch 287-8056 5.45Ace Bandage Velcro 3 Inch 287-8064 8.25Ace Cold Compress Reusable 287-6639 7.50Ace Elastic Bandage 3 Inch 287-5417 8.25Ace Self-Adhering Bandage 2 Inch 287-6530 5.15



Suministros para primeros auxiliosAdhesive Bandage Plastic 3/4In 60Ct 133-8201 2.50Adhesive Fabric Strips Assorted 30Ct 133-8110 3.60Adhesive Pads Non-Stick Large 3X4in 10Ct 260-8941 3.60Adhesive Sheer Strips Assorted 60Ct 565-9487 3.50Adhesive Tape 1/2 X 5Yd 133-8144 2.60Adhesive Waterproof Tape 1/2 X 10Yd 259-6922 3.10Alcohol Prep Pads 100Ct 354-0663 3.10Bandaid Comfort-Flex Plastic All One Size 60Ct 427-6143 2.85Bandaid Flex Fabric 3/4 30Ct 427-7497 4.25Bandaid Flexible Fabric Assorted Sizes 30Ct 427-7505 4.30Basic Thermometer Digital 8350 5.15Bd Alcohol Swabs 100Ct 108-2494 3.60Bd Home Sharps Container 124-1462 4.10Cotton Balls 300Ct 133-7716 4.10Cotton Swabs 300Ct 133-7617 4.65Elastic Bandage 2In 116-7659 3.79Elastic Bandage 3In 376-5435 5.79Epsom Salt 16Oz 18752700 4.65Hand Sanitizer 8Oz 197-9681 4.02Hot And Cold Mircro Therapy Gel Pack 5X10 230-9557 4.65Hot Cold Compress Gel Reusable 1Ct 560-7403 4.29Hydrogen Peroxide 3% 8Oz 457-4539 3.50Hydrogen Peroxide 3% 16Oz 220-1283 3.60Ice Bag 9Inch 110-0080 10.40Ice Compress - 1 Time Use 359-2896 3.95Ice Compress 1Ct 565-7481 4.29Johnson & Johnson First Aid Kit Mini 172-3139 2.59Johnson & Johnson First Aid Kit 140 Pieces 563-8606 20.10Johnson & Johnson Tape Waterproof 1/2 X 10Yd 427-0401 5.15New-Skin Liquid Bandage 1Oz 608-0410 7.20Purell Hand Sanitizer 8Oz 518-0021 5.05Rubbing Alcohol 70% 16Oz 219-9305 4.50Sterile Pads 3X3in 25Ct 193-6525 4.10Thermometer Digital Flexible Tip 133-8060 8.25Thermometer Forehead Strips 564-0156 5.10Vaseline Petroleum Jelly 13 Oz 651-0267 6.50



Cuidado de los piesCorn Cushions 9Ct 565-7614 1.99Dr Scholl Callous Remover One Step 4Ct 550-2299 5.85Dr Scholl Clear Away One Step Wart Remover 550-4618 10.45Dr Scholl Corn Remover Pads 9Ct 1863653 3.85Dr Scholls Corn Cushion Regular 9Ct 550-0129 3.60

Medicamentos gastrointestinalesAlka-Seltzer Original 24Ct 564-5536 6.05Alka-Seltzer Tablets Original 12Ct 472-0025 3.75Antacid Assorted Tablet 150Ct 433-6400 4.20Antacid Chewable Extra Strength 96Ct 547-9993 5.20Antacid Liquid Ds 12Oz 904-3829 4.65Antacid Regular Strength Liquid 12Oz 133-3244 5.85Antacid Ultra Strength Tablets 72Ct 133-3434 7.20Anti-Diarrheal Caplet 2Mg 24Ct 904-3639 5.65Anti-Diarrheal Caplet 2Mg 12Ct 107-4129 3.60Anti-Gas 80Mg Tablets 100Ct 107-3998 4.50Azo Standard Tablet 95Mg 30Ct 443-0054 11.35Beano Tablets 30Ct 308-3466 6.70Bisacodyl 5Mg Tablet 25Ct 120-8701 4.15Bisacodyl 5Mg Tablet 100Ct 553-2650 7.20Biscolax 10Mg Suppositories 12Ct 904-1971 1.60Clearlax Powder 4.1 Oz 228-9783 6.20Clearlax Powder 8.3Oz 228-9791 13.90Dulcolax 10Mg Rectal Suppositories 4Ct 201-9123 7.23Dulcolax Tablets 5Mg 100Ct 201-9198 27.20Dulcolax Tablets 5Mg 25Ct 201-9172 9.20Effervescent Pain Relief Tablets 36Ct 565-6400 6.45Enema Adult 4.5Oz 369-2209 3.50Ex-Lax Pieces Regular Strength 24Ct 213-4773 6.50Ex-Lax Tablets Regular Strength 30Ct 224-0851 7.75Famotidine 10Mg Tablets 60Ct 155-4260 11.35Famotidine 10Mg Tablets 30Ct 155-4278 6.20Fleet Glycerin Suppository 24Ct 371-0530 4.10Gas Relief Softgel Extra Strength 30Ct 564-0750 6.20Gas-X Extra Strength Cherry Creme 18Ct 224-1354 6.20Gas-X Extra Strength Softgels 10Ct 224-1586 3.57Imodium A-D Liquid Cool Mint 4Oz 172-2016 8.15Kaopectate Liquid Regular Flavor 8Oz 241-0280 6.65Magnesium Citrate Cherry 10Oz 565-6574 3.10



Medicamentos gastrointestinalesMagnesium Citrate Lemon 10Oz 565-6582 3.10Magnesium Oxide 400Mg Tablet 120Ct 357-2724 9.00Milk Of Magnesia 12Oz 150-6682 4.10Milk Of Magnesia Suspension 16Oz 155-6323 5.65Miralax Powder 17.9Oz 209-3177 29.00Miralax Powder 8.3Oz 202-4701 16.75Miralax Pwd 7 Doses 4.1Oz 202-4693 9.65Nexium 24Hr Heartburn Relief 42Ct 372-4903 39.85Nexium 24Hr Heartburn Relief 20Mg 14Ct 372-4929 16.55Nexium 24Hr Heartburn Relief 20Mg 28Ct 372-4580 29.15Omeprazole 20Mg Tablets 42Ct 565-6350 30.83Pepcid Ac Tablets Original Strength 30Ct 161-6093 14.60Pepcid Complete Chewable Tablet Berry 50Ct 134-5149 27.40Pepto-Bismol Caplets Original 40Ct 532-8208 10.57Pepto-Bismol Liquid Original 8Oz Sugar Free 532-1237 6.55Pepto-Bismol Liquid Original 16 Oz Sugar Free 532-1211 9.75Phillips Colon Health 45Ct 243-3860 27.60Phillips Colon Health 60Ct 260-6903 35.20Phillips Colon Health 30Ct 218-6989 19.70Pink Bismuth Liquid 8Oz 150-6260 3.60Pink Bismuth Tablet - Chewable 30Ct 114-3692 5.03Prevacid Otc 24 Hour Caplets 42Ct 225-4167 33.50Prevacid Otc 24 Hour Capsules 14Ct 225-4142 17.50Prilosec Otc 20Mg Tab 14Ct 145-6714 18.10Prilosec Otc Tablets 28Ct 145-7050 29.85Prilosec Otc Tablets 42Ct 145-7068 39.60Ranitidine 75Mg Tablet 30Ct 371-1934 5.15Rolaids Extra Strength Chewable Tablets Fruit 96Ct 390-8423 6.85Rolaids Extra Strength Chewable Tablets Mint 96Ct 379-9525 6.85Rolaids Regular Strength Chewable Tablets Mint 150Ct 379-9517 6.85Senna Tablet 100Ct 115-1208 6.70Senokot-S Tablet 30Ct 184-2707 22.80Stool Softener Softgels 100Ct 553-6867 5.00Tagamet Hb Otc 200Mg Tablets 6Ct 567-6812 3.60Tums Extra Strength Smoothies Tab Assorted Fruit 60Ct 191-8531 7.30Tums Extra Strength Tablets Assorted 96Ct 464-3664 6.97Zantac 150Mg Maximum Strength 24Ct 170-8890 14.45Zantac 75Mg Tablets 10Ct Sugar Free 735-7254 7.15Zantac 75Mg Tablets 30Ct 735-7700 14.45Zegerid Otc 20Mg 14Ct 230-2750 16.25



Artículos para las hemorroides Antiseptic Cleansing Pads 100Ct 244-4529 6.20Hemorrhoidal Cream 1.8Oz 133-4036 5.85Hemorrhoidal Ointment 2Oz 565-6814 5.79Hemorrhoidal Suppositories 12Ct 904-1484 5.15Preparation H Cream Maximum Strength 0.9Oz 170-2489 9.80Preparation H Ointment 2Oz 193-3910 19.10Preparation H Suppositories 24Ct 193-5113 20.90Tucks Medicated Pads 40Ct 564-5197 6.60

Kits para cuidado en el hogarEar Eye And Nose Combo 999244 13.30First Aid Essentials 999826 15.65Hemorrhoid Care Combo 999027 12.45Oral Care Combo 999115 8.10Pain Relief Combo 999053 12.90

Artículos para la incontinenciaA & D Ointment 4Oz 103-3364 6.30Adult Pullup Underwear Large 18Ct Heavy Absorbency 83883100 14.00Adult Pullup Underwear Medium 20Ct Heavy Absorbency 83873100 14.00Adult Pullup Underwear Xlarge 14Ct Heavy Absorbency 83733100 14.00Attends Brief *Diapers* Medium 24Ct 209-8192 23.63Balmex Clear Protection Ointment 3.5Oz 148-2942 6.45Balmex Diaper Rash Cream With Zinc Oxide 2Oz 308-3052 5.15Balmex Diaper Rash Cream With Zinc Oxide 4Oz 308-3326 6.25Depends Poise Pads Regular Light 30Ct 571-8432 10.30Desitin Ointment 2Oz 455-0380 5.75Desitin Ointment 4Oz 455-0398 8.70Diaper Rash Paste 4Oz 559-9600 5.79Fitted Brief Large 18Ct 193-3761 15.45Fitted Briefs Extra Large 15Ct Diapers 146-2316 15.45Fitted Briefs Medium 16Ct Diapers 193-3720 15.45Nice N Clean Baby Wipes Scented 72Ct 362-4418 3.05Nice N Clean Baby Wipes Unscented 72Ct 362-4426 3.05Perfit Protective Underwear 14Ct X-Large 175-7400 15.45Perfit Protective Underwear 18Ct Large 175-7392 15.45Perfit Protective Underwear 20Ct Medium 175-7376 15.45Perineum Wash 8Oz 521-4850 7.20Prevail Bladder Control Pads Pvx-120 Overnight 30Ct 562-8102 18.80Prevail Bladder Control Pads, Moderate 20Ct 146-2571 15.00Prevail Underpad 30X36 10Ct 146-2621 10.30



Artículos para la incontinenciaProcare Briefs Large 18Ct **Tabs** 371-2825 12.50Procare Briefs Medium 16Ct **Tabs** 371-2817 12.50Procare Briefs Xlarge 15Ct **Tabs** 371-2833 12.50Surecare Protective Underwear 14Ct X-Large 187-4866 22.30Surecare Protective Underwear 18Ct Large 187-4841 23.60Surecare Protective Underwear 20Ct Medium 187-4858 20.40Underpad Reusable 34X36 1Ct 178-7910 16.80

Artículos para la intolerancia a la lactosaLactaid Caplets 120Ct 554-2790 20.10Lactaid Fast Act Caplets 32Ct 172-2073 12.10

PediculicidasNix Control Spray Pump 5Oz 103-3182 9.25Nix Lice Treatment Creme Rinse 2Oz Single 735-6421 14.95Nix Lice Treatment Creme Rinse 2 X 2Oz 735-6447 23.45

Productos medicinales para los labiosAbreva Cold Sore Cream 2Gm 116-6586 26.20Blistex Lip Balm Reg Spf 0.15Oz 296-0656 2.15Blistex Lip Ointment Medicated 0.21Oz 296-0557 2.60Carmex Jar 0.25 Oz 790-0046 2.05Carmex Easy-On Applicator 0.35Oz 211-5715 2.05Herpecin L Lip Protectant Spf 30 0.1Oz 799-0997 6.58Lip Balm Regular Twin Pack Spf4 457-4471 2.05

Artículos diversosOptichamber Diamond Valved Holding Chamber 356-5462 18.85

Mareos por movimientoBonine Tablets 8Ct 455-4762 4.65Dramamine 50Mg 12Ct 241-0843 5.85Motion Sickness Tab 12Ct 196-4071 2.60

Cuidado bucalAct Total Care Anticavity Fluoride Rinse Fresh Mint 18Oz 224-7161 6.85Aim Anti-Tartar Gel Toothpaste 5.5Oz 102-5105 1.60Anbesol Gel Regular Strength Cool Mint 0.33Oz 109-0166 7.40Anbesol Liquid Regular Strength Cool Mint 0.41Oz 109-0141 7.40Biotene Dry Mouth Fluoride Toothpaste Fresh Mint 4.3Oz 711-0026 8.25Biotene Moisturizing Mouth Spray W/ Xylitol 1.5Oz 214-3865 7.63Biotene Mouthwash Antibacterial W/ Calcium 16Oz 711-0034 8.45Colgate Cavity Protection Toothpaste 1Oz 557-9446 1.55Colgate Extra Clean Adult Toothbrush Soft 553-4961 3.10Dental Floss 100Yd 359-2920 2.95



Cuidado bucalDental Floss Mint Waxed 100Yd 133-8987 2.95Dental Flossers Mint 60Ct 5845410 2.50Denture Brush 1Ct 565-7929 2.52Denture Cleaner Tablets 90Ct 235-7697 7.80Denture Cleaner Tablets Mint 40Ct 520239 3.95Efferdent Denture Cleanser Tablets 102Ct 735-8021 7.80Efferdent Denture Cleanser Tablets 44Ct 735-7957 4.00Efferdent Plus Mint Tablet 90Ct 735-8286 7.80Fixodent Control Denture Adhesive Cream 2Oz 162-8718 7.65Fixodent Control Denture Adhesive Cream Plus Scope Flavor 2Oz 186-3695 7.65Fixodent Denture Adhesive Cream Original 2.5Oz 532-5170 7.65Fixodent Fresh 2 1/2 Oz 532-7762 7.65G-U-M Eez-Thru X-Treme Fresh 75Ct 554-2642 2.65Oral Denture Brush 091-0950 4.00Oral Pain Relief Gel 0.5Oz 220-1457 5.79Polident 3 Minute Tablets 120Ct 257-3228 11.00Polident Overnight Cleanser 120Ct 552-5837 11.25Sea Bond Denture Bath 524-0064 2.05Sea-Bond Denture Adhesive Lowers Original 15Ea 358-0800 4.50Sea-Bond Denture Adhesive Uppers Original 15Ea 358-0792 4.50Super Poligrip Denture Adhesive Cream Zinc Free Formula 2.4Oz 308-0397 8.25Toothbrush Full Head Soft 560-5142 1.55Toothpaste Crest Large 4.6Oz 532-0080 3.60Toothpaste Colgate Regular 8Oz 557-9438 5.15Toothpaste Complete Care Original 5.5Oz 557-6863 2.99

AnalgésicosAcetaminophen 325Mg Tablet 100Ct 218-8928 4.65Acetaminophen 500Mg Caplets 100Ct 150-5916 5.15Acetaminophen Extra Strength 500Mg Tablet 100Ct 115-2438 5.15Acetaminophen Extra Strength Rapid Release Gels 500Mg 100Ct 213-2603 7.75Advil 200Mg Caplet 100Ct 193-2979 16.10Advil 200Mg Caplets 50Ct 193-2961 9.85Advil 200Mg Caplets 200Ct 192-3127 24.55Advil 200Mg Gel Caplets 24Ct 193-3043 5.75Advil 200Mg Liqui-Gel 80Ct 193-5030 16.85Advil 200Mg Liqui-Gel 160Ct 222-6272 25.75Advil 200Mg Liqui-Gel 20Ct 193-5014 6.20Advil 200Mg Liqui-Gel 40Ct 193-5022 10.75Advil 200Mg Migraine Liquigels 20Ct 107-5308 5.95



AnalgésicosAdvil 200Mg Tablets 24Ct 193-3100 5.75Advil Child Suspension Fruit 4Oz 193-4363 7.95Advil Pm Caplet 40Ct 190-7526 11.45Aleve 220Mg Arthritis Gelcaps 40Ct Easy Open 162-4501 10.75Aleve 220Mg Arthritis Liquigels 80Ct Easy Open 229-0971 22.05Aleve 220Mg Caplet 100Ct 472-4456 18.00Aleve 220Mg Caplets 50Ct 472-4449 10.75Aleve 220Mg Caplets 24Ct 472-4530 6.40Aleve 220Mg Tablets 24Ct 472-4472 6.40Aleve 220Mg Tablets 100Ct 472-4498 18.00Anacin Tablets 100Ct 193-1914 12.60Aspirin 325Mg Tablet 100Ct 540-8596 3.60Aspirin 325Mg Tablets Enteric Coated 100Ct 189-2132 3.60Aspirin Adult Enteric Coated 81Mg 120Ct 205-4898 3.60Aspirin Child Chew 81Mg 36Ct 904-0148 2.05Bayer 325 Tablets 100Ct 472-3433 11.00Bayer 325 Tablets 200Ct 472-3441 16.20Bayer Adult 81Mg Enteric Coated Low Dose Aspirin 120Ct 472-3375 11.75Bayer Chld Chew Aspirin Low Dose 36Ct 472-3367 3.80Bc Arthritis Powders 24 Packets 112-7307 6.10Bc Headache Powder 24 Packets 308-2351 5.80Ecotrin 325Mg Regular Strength Tablets 125Ct 145-9890 10.05Headache Relief Added Strength Tablet 100Ct 904-0486 5.65Ibuprofen 200Mg Caplet 100Ct 904-1674 6.20Ibuprofen 200Mg Caplet 50Ct 150-6583 3.10Ibuprofen 200Mg Softgels 80Ct 252-9543 10.30Ibuprofen 200Mg Tablet 100Ct 115-2594 6.20Ibuprofen Child Susp Berry 4Oz 208-0612 5.55Ibuprofen Pm Caplets 40Ct 223-0886 8.58Midol Maximum Strength Menstrual Form Caplet 24Ct 472-4670 7.70Midol Maximum Strength Menstrual Form Gelcap 24Ct 472-4696 7.70Migraine Formula Caplet 24Ct 133-1149 4.10Motrin Ib 200Mg Caplet 100Ct 161-6739 14.70Naproxen Sodium 220Mg Caplet 100Ct 565-5048 9.20Non-Aspirin Child Chewable 80Mg Fruit 30Ct 150-5981 4.10Orajel Maximum Strength Gel 0.25Oz 435-0492 7.40Orajel Maximum Strength Gel 0.42Oz 363-3187 8.35Orajel Mouth Sore Gel 0.18Oz 558-1525 7.20Orajel Mouth Sore Gel 0.42Oz 565-4470 8.85



AnalgésicosPain Reliever Pm Extra Strength Caplet 50Ct 141-1941 4.10Pamprin Multi-Symptom Caplets 20Ct 570-7435 5.65Sleep Aid Tablets 24Ct 133-4200 5.40St Joseph Adult Aspirin 81Mg Chew Tab 36Ct 248-0614 3.60Tylenol Extra Strength 500Mg Caplet 100Ct 161-3629 16.75Tylenol Extra Strength 500Mg Caplet 24Ct 161-3603 5.70Tylenol Regular Strength 325Mg Tablets 100Ct 161-0872 12.05

Organizadores de pastillasMedichest With 7 Day Planner 564-0115 9.80Pill Organizer 7 Day Xxl 108-9739 5.65

Oxímetro de pulsoEconomy Pulse Oximeter 1150K 564-1477 32.00Pulse Oximeter Deluxe 1150D 351-5921 42.00

Artículos para dejar de fumarNicoderm Cq Clear 1 14Ct 106-4716 73.80Nicotine Gum 4Mg 50Ct 174-9928 26.00Nicotine Gum Mint 2Mg 50Ct 174-9878 26.00Nicotine Patch Step 1 21Mg 14Ct 214-3261 40.25Nicotine Patch Step 2 14Mg 14Ct 214-3253 41.05Nicotine Patch Step 3 7Mg 14Ct 214-3246 33.65

Protección solar y tratamientos para la pielAfterburn Gel Tube 2Oz 254-5614 7.00Aloe Vera 100* Gel *Fruit Of The Earth* 6Oz 423-0256 5.65Aveeno Soothing Oatmeal Bath Treatment 8Pk 772-0188 8.73Fruit Of Earth Aloe Vera Gel 20Oz Pump 220-3321 8.10Neutrogena Sunblock Spf30 3Oz 144-0528 13.78Neutrogena Ultra Stick Spf70 1.5Oz 381-2930 14.98Sunscreen Lotion / Generic Spf 30 8Oz 222-6058 8.75

BalanzasSmartheart Digital Weight Scale 568-2190 26.95

Productos de apoyoAnkle Support Elastic Black Large 376-6219 8.59Ankle Support Elastic Black Medium 376-6201 8.59Ankle Support Elastic Black Small 376-5997 8.59Ankle Support Elastic Black Xlarge 376-6227 8.59Futuro Ankle Support Wrap Around Medium 259-0305 11.70Futuro Ankle Support Wrap Around Large 259-0313 11.70Futuro Knee Support Stabilizing Large 152-9635 17.10Futuro Knee Support Stabilizing Medium 152-9627 17.10



Cremas y ungüentos tópicosFuturo Wrist Stabilizer Deluxe Left Large/X-Large 254-1282 29.15Futuro Wrist Stabilizer Deluxe Left Small/Medium 135-5783 29.15Futuro Wrist Stabilizer Deluxe Right Large/X-Large 242-7607 29.15Futuro Wrist Stabilizer Deluxe Right Small/Medium 135-5791 29.15Jobst Mens Dress Knee High 8-15Mmhg Black Large 2Ct 061-0915 18.60Jobst Mens Dress Knee High 8-15Mmhg Black Medium 2Ct 061-0907 18.60Jobst Mens Dress Knee High 8-15Mmhg Brown Large 2Ct 061-0972 17.55Jobst Mens Dress Knee High 8-15Mmhg Brown Medium 2Ct 124-4235 17.55Jobst Mens Knee High 8-15Mmhg White Large 2Ct 124-4334 18.40Jobst Mens Knee High 8-15Mmhg White Medium 2Ct 061-1939 18.40Jobst Womens Sheer Knee High 8-15Mmhg Large Silky Beige 061-0741 14.30Jobst Womens Sheer Knee High 8-15Mmhg Medium Silky Beige 061-0733 14.60Knee Brace Large 287-5862 10.45Knee Brace Medium 287-5854 10.45Knee Brace Small 287-5847 10.45Wrist Support - Sport, Adjustable 429-2603 6.47Advanced Healing Lotion 10Oz 192-1543 3.28Arthritis Cream 3Oz 359-2854 5.44Arthritis Hot Deep Penetrating Pain Relief Cream 3Oz 584-1168 4.64Arthritis Pain Relief Caplet 650Mg 50Ct 188-3362 7.75Aspercreme Heat Pain Relieving Gel 2.5Oz 212-5664 7.25Aspercreme Pain Relieving Rub 3Oz 584-0129 7.60Aspercreme Patch With Lidocaine 5Ct 560-5811 11.38Bengay Pain Relieving Cream Ultra Strength 2Oz 455-5389 7.55Bengay Pain Relieving Cream Ultra Strength 4Oz 455-5397 11.05Bengay Ultra Strength Pain Relieving Patch Reg Size 5Ct 162-5128 10.15Capsaician No Fuss Applicator 1Oz 228-2846 8.01Capzasin Topical Analgesic Liquid No-Mess Applicator 1Oz 203-3793 11.00Cold Hot Medicated Patch 5Ct 565-3449 5.99Flexall Gel Maximum Strength 3Oz 799-0633 7.85Icy Hot Balm 3.5Oz 799-0534 7.55Icy Hot Cream 1.25Oz 799-0542 5.15Icy Hot Cream With Lidocaine 2.7Oz 557-6616 10.63Icy Hot Medicated Patches Extra Strength Large Back 5Ct 145-1285 9.25Icy Hot Medicated Patches Arm/Neck/Leg 5Ct 121-4733 7.20Icy Hot Sleeve Large Knee Ankle Elbow 3Ct 147-8890 8.45Icy Hot With Lidocaine Patch 5Ct 563-2047 12.32Mederma Gel 50Gm 852-0066 40.75Scar Treatement Gel 1.76Oz 565-7390 13.95



Cuidado vaginalThermacare Heatwraps 8Hr Lower Back & Hip 2Ct 223-6974 9.80Thermacare Heatwraps 8Hr Neck Shoulder Wrist 3Ct 223-6966 9.80Thermacare Heatwraps Menstrual 3Ct 227-0569 9.80Tiger Balm Extra Strength Ointment 0.63Oz 112-8248 7.20Zostrix High Potency Arthritis Pain Relief Cream 2Oz 326-0577 22.95Zostrix Original Strength Arthritis Pain Relief Cream 2Oz 326-0569 18.85Miconazole 3 Day With Applicator 3Ct 141-1537 16.65Miconazole 7 Vaginal Cream 45Gm 803-0744 10.80Miconazole 7 Vaginal Suppositories 7Ct 099-1059 6.20Monistat 7 Cream With Disposable Applicator 1.59Oz 513-7278 14.80Monistat-3 Cream Prefilled Applicator 3Ct 113-9690 19.90

Vitaminas y suplementosAlpha Lipoic Acid 600Mg Cap 30Ct 544449 11.00Alpha Lipoic Acid 600Mg Cap 60Ct 432-9496 22.00B Complex Tablets 100Ct 247-0698 6.00Calcium Carbonate 600Mg + D Tablet 60Ct 904-1385 6.20Calcium Citrate Plus D 120Ct 565-8158 5.20Caltrate 600Mg + D Tablet 60Ct - New Formula 193-3316 11.15Centrum Silver 50+ Mens 100Ct 223-0415 16.75Centrum Silver 50+ Womens 100Ct 223-0407 16.75Centrum Silver Chewable 60Ct 172-2214 17.75Centrum Silver W/ Lutein Tablets 220Ct 357-8200 28.75Cerovite Senior Tablet 60Ct 536-2835 5.65Citrus Calcium Plus D 630Mg Tablets 60Ct 536-4658 5.15Ester C 500Mg Tablets 60Ct 205-8337 9.50Estro Support Maximum Strength 60Ct 530321 10.51Estroven Maximum Strength Caplet 28Ct 196-3859 22.00Estroven Regular Strength Caplets 30Ct 121-0111 16.35Ferrous Sulfate Tablets 325Mg 100Ct 236-4917 6.20Fish Oil 1000Mg Softgels 100Ct 904-1542 7.75Flaxseed Oil 1000Mg Softgel 1000Mg 60Ct 109-2675 10.15Krill Oil 300Mg, Omega-3 Softgels 60Ct 253-1606 22.10Megared Omega-3 Softgel 65Ct 255-3097 37.40Melatonin Chewable Gummies 5Mg 60Ct 370-7569 11.85Melatonin Maximum Strength 10Mg Tablets 60Ct 483-2424 11.65Melatonin Maximum Strength Fast Dissolve Tablets 10Mg 60Ct 547-5868 11.35Melatonin Maximum Strength Tablets 5Mg 120Ct 223-6727 8.80Melatonin Quick Dissolve Berry Tablets 5Mg 60Ct 359-6061 11.35Melatonin Tablets 1Mg 100Ct 209-7558 7.20



Vitaminas y suplementosMelatonin Tablets 3Mg 60Ct 150-6625 6.20Osteo Bi-Flex Triple Strength Caplets 80Ct 200-7144 33.45Osteo Bi-Flex Triple Strength Caplets 40Ct 117-7765 19.85Oyst-Cal + D 500Mg 60Ct 218-8969 3.60Prosight Tablet 60Ct 127-0248 8.75Sentry Senior Mens 50+ Vitamin Tablets 100Ct 410-0277 10.95Sentry Senior Womens 50+ Vitamin Tablets 100Ct 250-6467 10.95Viactiv Calcium Chew Carmel + D 60Ct 105-5912 10.70Viactiv Calcium Chew Milk Chocolate + D 60Ct 154-5144 10.70Vitafusion B Complex Chew Energy 70Ct 554-2634 7.25Vitamin C 500Mg 250Ct 105-7322 13.25Vitamin C 500Mg Tablets 100Ct 110-9131 6.70Vitamin D Tab 400Iu 100Ct 211-0211 5.15Vitamin D3 1000Iu 100Ct 211-0229 7.73Vitamin D3 2000Iu Softgels 100Ct 220-2893 6.70Vitamin E 400Iu Softgel 100Ct 904-3886 11.85Windmill Vitamin A 10000Iu Softgel 100Ct 105-6951 6.10Windmill Vitamin B Complex With Vitamin C + Iron 100Ct 105-7165 9.15Windmill Calcium Chewable 500Mg + D Tab 60Ct 105-7256 7.10Windmill Folic Acid 400 Mcg Tabs 180Ct 105-7660 6.70Windmill Potassium Gluconate 99Mg Tab 100Ct 105-7868 6.25Windmill Vitamin B 6 100Mg Tab 100Ct 105-7058 8.15


FORMULARIOS DE PEDIDOS para productos de venta libre

Identificación de miembro (se encuentra en la tarjeta de identificación de miembro del plan)

Fecha de nacimiento:

Fecha del pedido:

Nombre del miembro:

Dirección de envío:

Ciudad:

Estado:

Código postal:

Número de teléfono:

Complete la siguiente información.

• Envíe el formulario de pedido a: Community Health Plan of Washington OTC Orders P.O. Box 1366 Elk Grove Village, Il 60009-1366

• Espere entre 7 y 10 días hábiles para que llegue su pedido.• Si un producto tiene un retraso del fabricante, un representante de Servicio al cliente se comunicará con usted

para analizar un producto alternativo.• Debido a la naturaleza propia de estos productos, no se aceptan devoluciones.• Como alternativa a realizar el pedido por correo, puede hacerlo en línea en shopping.drugsourceinc.com/chpw

o llamando al Servicio al cliente al 1-877-603-0402 o TTY: 711. El Servicio al cliente está disponible de lunes a vienes, de 8:30 a. m. a 10:00 p. m., hora del centro.

• Complete los casilleros a continuación e incluya el código del artículo (SKU, por sus siglas en inglés), la descripción del producto, la cantidad y el precio que figura en este catálogo de productos.

• Dé vuelta el formulario y complete su información de miembro, incluidos el número de identificación de miembro y su fecha de nacimiento.

• Recuerde que también puede hacer su pedido en línea en http://shopping.drugsourceinc.com/chpw o llamando al 1-877-603-0402 o TTY: 711, línea gratuita, de lunes a viernes, de 8:30 a. m. a 10:00 p. m., hora del centro.


Código de artículo (SKU)

Nombre del producto Precio Cantidad Total

Ejemplo: 219-1004 Aleve 220MG Caplet 100CT 2 12.50

Total

MEDICARE ADVANTAGE COMMUNITY HEALTH PLANof WashingtonTM

The power of community

Multi-Language Insert

H5826_MA_253_2018_v_01_Taglines_Lang_Insert

Multi-Language InsertMulti-language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you.

Call 1-800-942-0247 (TTY: 7-1-1).

(TTY: 7-1-1).1-800-942-0247

Appendix B to Part 92—Sample Tagline Informing Individuals With Limited English Proficiency

of Language Assistance Services

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-xxx-

xxx-xxxx (TTY: 1-xxx-xxx-xxxx).



ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame

al 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).



ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame

al 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

(TTY: 7-1-1).1-800-942-0247



注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-xxx-xxx-xxxx（TTY：1-

xxx-xxx-xxxx）。




xxx-xxx-xxxx）。

(TTY: 7-1-1)1-800-942-0247

(TTY: 7-1-1).1-800-942-0247



주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-xxx-

xxx-xxxx (TTY: 1-xxx-xxx-xxxx)번으로 전화해 주십시오.



주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-xxx-

xxx-xxxx (TTY: 1-xxx-xxx-xxxx)번으로 전화해 주십시오.



ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx).



ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.

Звоните 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx).

1-800-942-0247 : 7-1-1).



PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika

nang walang bayad. Tumawag sa 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).



PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika

nang walang bayad. Tumawag sa 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

1-800-942-0247 : 7-1-1).



УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної

служби мовної підтримки. Телефонуйте за номером 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx).



УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної

служби мовної підтримки. Телефонуйте за номером 1-xxx-xxx-xxxx (телетайп: 1-xxx-xxx-xxxx). 1-800-942-0247 : 7-1-1).

(TTY: 7-1-1)1-800-942-0247

Appendix B to Part 92—Sample Tagline Informing Individuals With Limited English

Proficiency of Language Assistance Services

្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ� រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព�

1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx)។



្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ� រ, េស�ជំនួយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។ ចូរ ទូរស័ព�

1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx)។

: 7-1-1)1-800-942-0247



注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-xxx-xxx-

xxxx（TTY:1-xxx-xxx-xxxx）まで、お電話にてご連絡ください。









1-800-942-0247



ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው

ቁጥር ይደውሉ 1-xxx-xxx-xxxx (መስማት ለተሳናቸው: 1-xxx-xxx-xxxx).









7-1-1).



ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم xxx-xxx-xxxx-1 (رقم

.(xxx-xxx-xxxx-1 :ھاتف الصم والبكم





800-942-0247 7-1-1





Appendix B to Part 92—Sample Tagline Informing Individuals With Limited English Proficiency of

Language Assistance Services

ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ� ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ। 1-xxx-xxx-xxxx

(TTY: 1-xxx-xxx-xxxx) 'ਤੇ ਕਾਲ ਕਰੋ।









1-800-942-0247

7-1-1)

1-800-942-0247 (TTY: 7-1-1).



ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur

Verfügung. Rufnummer: 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).



ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur

Verfügung. Rufnummer: 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

(TTY: 7-1-1).



ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ,

ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).



ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ,

ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-xxx-xxx-xxxx (TTY: 1-xxx-xxx-xxxx).

1-800-942-0247H5826_MA_25?_2017_01_LanguageInsert

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia

lingüística. Llame al 1-800-440-1561 (TTY: 7-1-1).

繁體中文 (Chinese)주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수

있습니다. 1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho

bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).

한국어 (Korean)주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.

Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные

услуги перевода. Звоните 1-800-440-1561 (телетайп: 7-1-1).

Tagalog (Tagalog – Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga

serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-440-1561 (TTY: 7-1-1).

Українська (Ukrainian) УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до

безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-440-1561 (телетайп: 7-1-1).

ែខ�រ (Cambodian) ្របយ័ត�៖ េបើសិន�អ�កនិ�យ ��ែខ�រ, េស�ជនួំយែផ�ក�� េ�យមិនគិតឈ� �ល គឺ�ច�នសំ�ប់បំេរ �អ�ក។

ចូរ ទូរស័ព� 1-800-440-1561 (TTY: 7-1-1)។

日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

1-800-440-1561（TTY: 7-1-1）まで、お電話にてご連絡ください。

አማርኛ (Amharic)ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ

ሚከተለው ቁጥር ይደውሉ 1-800-440-1561 (መስማት ለተሳናቸው: 7-1-1).

Oroomiffa (Oromo/Cushite) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii,

kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-440-1561 (TTY: 7-1-1).

(Arabic) ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقمةيبرعل

).1-1-7(رقم ھاتف الصم والبكم: 1-1651-044-008

ਪੰਜਾਬੀ (Panjabi) ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ� ਪੰਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ� ਭਾਸ਼ਾ ਿਵੱਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਧ ਹੈ।

1-800-942-0247






bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








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bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


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bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








ចូរ ទូរស័ព� 1-800-440-1561 (TTY: 7-1-1)។















bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








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1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








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bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








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bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








ចូរ ទូរស័ព� 1-800-440-1561 (TTY: 7-1-1)។















bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








ចូរ ទូរស័ព� 1-800-440-1561 (TTY: 7-1-1)។










1-800-942-0247






bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.








ចូរ ទូរស័ព� 1-800-440-1561 (TTY: 7-1-1)។















bạn. Gọi số 1-800-440-1561 (TTY: 7-1-1).


1-800-440-1561 (TTY: 7-1-1)번으로 전화해 주십시오.

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