As a member of University of Maryland Health Advantage Dual Plan (HMO SNP), you have an Over-the-Counter (OTC) benefit every quarter. This benefit allows you to get 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. Simply call the toll-free number OR fill out and mail the order form provided. Your order will be shipped directly to your door. 2016 Over-the-Counter (OTC) Benefit Catalog Special Health Plan Benefit Get Over-the-Counter Products Every Quarter at No Cost to You! Information on how to place your OTC order can be found on the last page. *B - May be covered by Medicare Part B. *D - May be covered by Medicare Part D. H8854_16_1097-07_002_OE CMS Approved: 09/11/2015
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As a member of University of Maryland Health Advantage Dual Plan (HMO SNP), you have an Over-the-Counter (OTC) benefit every quarter. This benefit allows you to get 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. Simply call the toll-free number OR fill out and mail the order form provided. Your order will be shipped directly to your door.
2016 Over-the-Counter (OTC) Benefit Catalog
Special Health Plan Benefit
Get Over-the-Counter Products Every
Quarter at No Cost to You!
Information on how to place your OTC order can be
found on the last page.
*B - May be covered by Medicare Part B.*D - May be covered by Medicare Part D.
H8854_16_1097-07_002_OECMS Approved: 09/11/2015
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You can get the following items without having to talk with your doctor, but we always recommend that you talk with your doctor before starting a new product regimen.
Acne Treatment
Acne Gel 10% Benzoyl Peroxide 1.5 oz 1076 $8.00
Allergy, Cold, Flu, Decongestant and Sinus
All Day Allergy Tablets 14 tabs, 10 mg 1090 $8.00
All-Nite Cold/Flu 6 oz, 6.25 mg 1361 $7.00
Children's Dimaphen 4 oz 2.5 mg/5 ml 1426 $8.00
Children's Diphenhydramine HCL 4 oz, 12.5 mg/5 ml 1428 $7.00
Chlorpheniramine Maleate100 tabs, 4 mg 1008 $7.00
Cromolyn Sodium (AllergyNasal Spray), 26 ml 1356 $15.00
Cough & Cold for High Blood Pressure 16 tabs 1166 $8.00
Elastic Bandage *B2” X 5 yd 1207 $6.003” X 5 yd 1209 $6.004” X 5 yd 1211 $7.00 6” X 5 yd 1213 $7.00
Elbow Support 1224 $12.00
First Aid Kit 48-piece 1215 $11.00
Folding Cane with Ergonomic Handle 1726 $22.00
Gel Foam Seat Cushion 1466 $27.00
Hot/Cold Pack1 small / 1 large 1062 $8.00
First Aid and Medical Supplies (continued)
Hydrogen Peroxide 8 oz, 3% 1228 $6.00
Knee Stabilizer 1465 $23.00
Knee Support SMALL 1481 $10.00 MEDIUM 1482 $10.00LARGE 1483 $10.00SMALL with stays 1484 $16.00 MEDIUM with stays 1485 $16.00LARGE with stays 1486 $16.00
Dr. Scholl’s Wart Removal System 18 pack 1288 $14.00
Wart Remover 0.5 oz, 17% 1075 $10.00
Wartners Wart Removal System Kit 1289 $20.00
Helpful Information• If you have questions or would like to place an order over the phone, OTC
Advocates are available Monday – Friday from 8:00am to 8:00pm EST at1-844-479-6334 (TTY: 711).
If you place your order using an order form, your order total will be applied tothe quarter in which we receive your form. For example, if you mail your orderform on June 29th, but we receive it on July 1st, your order total will be applied toyour 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 yourorder form will be received in time, you can call in your order.
You must use your full quarterly benefit amount in one order. This benefit amountdoes not roll over from quarter to quarter.
Your order total may not exceed the quarterly benefit amount of $55. Cash, checksor money orders are not accepted under this OTC benefit.
Orders may only be placed by the member, an authorized representative verballyapproved by the member at time of the order, and/or the member’s power ofattorney representative on file.
To use your benefit, you must select products from this catalog that will helpyou with a health or medical need. Your order total may not exceed your benefitamount. OTC products are intended for member's use only. University of MarylandHealth Advantage Dual Plan prohibits the use of this benefit to order OTC items for family members and friends. OTC items are available through mail-order only.
Once your order is received, please allow 7 - 10 business days for delivery.
Products may not be purchased at a local retail pharmacy or through any other source other than the University of Maryland Health Advantage Dual Plan OTC Catalog.
If you disenroll from the University of Maryland Health Advantage Dual Plan, yourOTC benefit will automatically terminate.
Returns are not accepted.
Some items listed in this catalog may also be covered under your Medicare Part B(medical) benefit or Part D (pharmacy) benefit. These items have a *B or a *D aftertheir name. For example, alcohol pads are covered under Part D if they are usedfor administering insulin. For all other purposes, this item is covered under yourOTC benefit.
Items in the 2016 OTC Benefit Catalog may change throughout the year.A copy of this catalog is also available on the University of Maryland HealthAdvantage Dual Plan website at www.UMMedicareAdvantage.org. For up-to-dateinformation, please call our OTC Advocates from Monday - Friday from 8:00am to8:00pm EST at 1-844-479-6334 (TTY: 711).
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2016 OVER–THE–COUNTER (OTC) BENEFIT ORDER FORM
STEP 1 - COMPLETE YOUR INFORMATION BELOW:
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Member ID (found on Health ID card) Date of Birth
First Name Last Name MI
Street Number Street Name Apt/Suite #
City State Zip Code
Please check box if this is a new addressDaytime Phone Email
STEP 2 - PRODUCT SELECTION:Your quarterly order total may not exceed $55. Cash, checks or money orders are not accepted under this Over-the-Counter (OTC) benefit.
Item # Product Name Quantity Price
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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 quarter in which we receive your form. For example, if you mail your order form on June 29th, but we receive it on July 1st, your order total will be applied to your July (or third quarter) benefit, not your June (or second quarter) benefit.