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Get a $35 allowance EVERY MONTH to spend on health supplies and drug store essentials.

YES. We will cover over-the­counter (OTC) items up to $35 every month for health supplies you order. It’s another way Peach State Health Plan takes care of our Georgia neighbors on Medicare.

When it comes to benefits and value, no one looks out for Medicare beneficiaries in Georgia like Peach State Health Plan.

As a Peach State Health Plan member, you’ll receive $35 per month to spend on commonly used OTC drugstore items— at no extra cost to you.

IMPORTANT: Orders that exceed the monthly allowance will not be processed or covered by Peach State Health Plan. Unused amount cannot be carried over to the next month. The items purchased should only be used as directed, and you should talk to your primary care provider (PCP) if you have any questions on the safe use of these items.

Y0020_OTCBrchre17_FINAL_DSNP_GA_ Accepted_10252016

Here’s more good news.

We deliver. Through this exclusive member program, your selected items will be conveniently shipped directly to your home.

Ordering is EASY. 1. Just choose your items on the opposite

side of this sheet. Each item is numberedfor your convenience in ordering.

2. Then, call toll‑free and let our operatorknow which items you would like, up tothe limit of $35 per calendar month.

1-877-851-3994 (TTY: 711) You’ll talk to a live person.

Operators are available to answer your calls from 9 am CST – 5 pm CST, Monday through Friday.

Be sure to have your Peach State Health Plan ID card available to complete your order.

After the ordering process is complete, your items should arrive at your home in 5 – 12 business days.

Peach State Health Plan is contracted with Medicare for HMO and HMO SNP plans, and with the Georgia Medicaid program. Enrollment in Peach State Health Plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or co‑payments/co‑insur‑ ance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

This plan is available to anyone who has both Medical Assistance from the State and Medicare.

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English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY: 711). Spanish:ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia linguística. Llame al 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711). Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711). 번으로 전화해 주십시오. Chinese: 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 1‑844‑890‑2326 (HMO),1‑877‑725‑7748 (HMO SNP) (TTY:711). Gujarati: સચના: જો તમ ગજરાતી બોલતા હો, તો િન:શલક ભાષા સહાય સવાઓ તમારા માટ ઉપલબધ છ.ફોન કરો 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711).French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711).

Amharic: ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (መስማት ለተሳናቸው : 711).

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711). Arabic: تنبیھ: إذا كنت تتحدث اللغة العربیة فإن خدمات المساعدة اللغویة متاحة لك مجانا. اتصل برقم2326‑890‑844‑1 (منظمة الحفاظ على

(HMO SNP) 7748‑725‑877‑1خططذوي الاحتیاجات الخاصة التابعة لمنظمة الحفاظ على الصحة ،(HMO) الصحة(رقم ھاتف الصم والبكم : 711).

Portuguese:ATENÇÃO: Se fala português, encontram‑se disponíveis serviços linguísticos, grátis. Ligue para 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711).

Ordering is EASY. 1. Select the items you need from the list below

up to your monthly benefit amount. 2. Call the toll‑free order line at:

1-877-851-3994 (TTY: 711)

Operators are available from 9 am CST – 5 pm CST, Monday through Friday. Allow 5 to 12 business days for shipping. (Any unused amount cannot be carried over to the next month.)

ITEM # DESCRIPTION COMPARE TO: PRICE

PAIN RELIEVERS 1 Ibuprofen 200mg tab Motrin $6 2 Naproxen sod 220mg tab Aleve $9 3 Aspirin 325mg tab Bayer Aspirin $5 4 Aspirin ec 325mg tab Ecotrin $6

5 Aspirin ec 81mg Halfprin $56 Acetaminophen 500mg tab Tylenol Extra Str $6 7 Mentholated ointment Bengay $6

ANTACIDS 8 Simethicone 80mg tab Mylanta Anti‑Gas $6 9 Calc Carb 500mg chewable TUMS $6

10 Heartburn Relief (Famotidine) 10mg tab Pepcid AC 10mg $9

ANTI-DIARRHEALS 11 Loperamide 2mg cap Imodium $5 12 Bismuth mixture Pepto‑Bismol $8

ANTI-FUNGALS

13 Clotrimazole 1% vaginal cream Gyne‑Lotrimin $9

14 Tolnaftate 1% Tinactin $7

ITEM # DESCRIPTION COMPARE TO: PRICE

ANTI-HEMORRHOIDALS 15 Hemorrhoidal ointment Preparation‑H $8

BUG REPELLANT

88 Deep Woods Off Insect Repellant Insect Repellant $14

138 Cutter Skin Sensation 6oz Cutter $14

CHILDRENS PRODUCTS 17 Diaper rash ointment (4 oz) Balmex $9

COUGH/COLD/ALLERGY 24 Diphenhydramine 25mg caps Benadryl Caps $525 Diphenhydramine elixir Benadryl Elixir $5

26 Sore throat lozenge Chloraseptic Lozenge

$5

27 Medicated chest rub Vicks Vapo‑Rub $7 28 Guaifenesin syrup Robitussin $5 29 Oxymetazoline 0.05% Afrin $5 30 Loratadine 10mg tab Claritin $10

EYE CARE 31 Tetrahydrozoline drops Visine $4 61 Lubricating Eye Drops Refresh Tears $7

FIRST AID CREAMS & OINTMENTS 32 Calamine lotion Calamine Lotion $7 33 Hydrocortisone 1% cream Cort‑Aid $6 34 Triple antibiotic ointment Neosporin $5 60 Medicated lip balm Carmex $4 78 Psoriasis Cream Eucerin Cream $12

FIRST AID SUPPLIES 35 Athletic bandage Ace Bandage $7 36 Adhesive tape First‑Aid Tape $4 37 Adhesive bandage Band‑Aids $4 39 Gauze pads J&J Gauze Pads $4 40 Cotton swabs Q‑Tips $4 41 Oral thermometer Thermometer $6

ITEM # DESCRIPTION COMPARE TO: PRICE

FIRST AID SUPPLIES (CONTINUED) 43 Ice bag 9 inch Ice Bag $9 85 Hydrogen Peroxide Sol Hydrogen Peroxide Sol $8

158 Rubbing Alcohol 70% Isopropyl 16 oz (473ml) Rubbing Alcohol $8

159 Epsom Salt (Magnesium sulfate) 16 oz Epsom Salt $7

160 Rubbing Alcohol Wintergreen 70% Isopropyl 16 oz (473ml) Rubbing Alcohol $8

LAXATIVES 44 Dss (Docusate) 100mg Colace Stool Softener $6 45 Bisacodyl suppository Dulcolax Supp $4 46 Bisacodyl tabs Dulcolax Tabs $4 82 Iron Plus Stool Softener Iron+ Stool Softener $10

MEDICAL ALERT BRACELET 100 Diabetic Medical Alert Bracelet $7 101 Epileptic Medical Alert Bracelet $7 102 Asthmatic Medical Alert Bracelet $7103 Penicillin Medical Alert Bracelet $7104 Codeine Medical Alert Bracelet $7 105 Peanut Allergy Medical Alert Bracelet $7

MISCELLANEOUS 56 Pill Box‑ 7 days Pill Box‑ 7 days $4

136 Glucose Tablet Fast‑Acting Glucose Tablets $6 137 GNP Glucose Raspberry Glucose Tablets $12 161 Sharps Container, 1 Gallon Sharps Container $10

ORAL CARE 66 Toothbrush Toothbrush $4 67 Denture Tabs Efferdent $6 68 Denture Adhesive Poligrip $6 86 Waxed Dental Floss Waxed Dental Floss $4

109 Adult Toothpaste (6 oz.) Toothpaste $6

112 Toothache Gel Regular Non‑Infant Form (0.25 oz.) Anbesol $10

ITEM # DESCRIPTION COMPARE TO: PRICE

PEDICULICIDES 48 Rid lice treatment RID $9

PERSONAL CARE 75 Sunblock SPF 15 Coppertone $9 71 Bar Soap ‑ Aloe Bar Soap ‑ Aloe $8

113 Ear Wax Drops (0.5 oz.) Debrox $7

SMOKING CESSATION GUM 57 Nicotine Polacrilex Gum 2mg Nicorette $19 58 Nicotine Polacrilex Gum 4mg Nicorette $20

VITAMINS & MINERALS 49 Calcium Carb 600mg tab Caltrate 600 $6 50 Multivitamin w/minerals Theragram‑M $10

59 Senior Multivitamin w/ minerals CentrumSilver $11

52 Vitamin A 10,000u caps Vitamin A $5 53 Vitamin C 500mg tabs Vitamin C $5 54 Vitamin E 400iu gels Vitamin E $9 62 Vitamin D (400 IU) Vitamin D $7

63 Glucosamine/Chondroitin (500/400mg caps)

Glucosamine/ Chondroitin

$12

64 Iron Supplement Iron Supplement $4 65 Omega‑3 Fish Oil 1000mg Omega‑3 Fish Oil $7

81 Folic Acid Tab 400mcg Folic Acid Tabs 400mcg

$6

83 Multivitamin Liquid w/Iron MultiVitamin Liquid w/Iron

$8

87 Lactose Chewable Tab Lactaid $9

SLEEP AIDS 133 Melatonin 3mg Melatonin $6 134 Melatonin 10mg Melatonin $16

Persian: توجه: اگر به زبان فارسی گفتگو می کنید، تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد.

با 1‑877‑725‑7748 (HMO SNP) (TTY:711) ,(HMO) 2326‑890‑844‑1 تماس بگیرید.German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfugung. Rufnummer: 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748 (HMO SNP) (TTY:711). 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。1‑844‑890‑2326 (HMO),1‑877‑725‑7748 (HMO SNP)（TTY: 711）まで、お電話にてご連絡ください。Peach State Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis ofrace, color, national origin, age, disability, or sex. Peach State Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Peach State Health Plan: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified

sign language interpreters and written information in other formats (large print, accessible electronic formats,other formats).

• Provides free language services to people whose primary language is not English, such as qualifiedinterpreters and information written in other languages.

If you need these services, contact Peach State Health Plan at 1‑844‑890‑2326 (HMO), 1‑877‑725‑7748(HMOSNP) (TTY:711). If you believe that Peach State Health Plan has failed to provide these services or discriminated in another way onthe basis of race, color, national origin, age, disability or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Peach State Health Plan’s Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1‑800‑368‑1019,(TDD: 1‑800‑537‑7697).Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.