Your Over-the-Counter Benefit You do not need a prescription to receive products in this program.

You are allowed one (1) order per quarter.

Each order you place must have a minimum total of $25, and you may spend up to $30 per quarter. Unused balances DO NOT carry over to the next quarter.

Orders may be placed up to two (2) months in advance.

Items usually arrive within ten (10) business days from the date your order is received and verified. Orders placed in advance should arrive within the first ten (10) business days of the month.

You’re eligible as an

Inter Valley Health Plan

Service To Seniors (HMO) plan member, to get

over-the-counter items

delivered to your

home at no cost.

Inter Valley Health Plan is a not-for-profit HMO with a Medicare contract. Enrollment in Inter Valley Health Plan depends on contract renewal. Inter Valley Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Inter Valley Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Inter Valley Health Plan 遵守适用的联邦民权法律规定，不因种族、肤色、民族血统、年龄、残障或性别而歧视任何人H0545_FUY2020_C_114

About OTC Products

Products on the Order Form are eligible for coverage. These are products you would likely find on the shelf at your local pharmacy or general store. Braces, bandages, ointments, pain relievers, and cotton balls are all examples of eligible products. Products you order will be mailed to the address you list on the Over-the-Counter Order Form.

Dual-purpose items If a product can be used either to treat a medical condition or for a general health purpose, it is considered a dual-purpose item. For example, vitamins are considered dual-purpose items. Talk to your doctor before ordering or using a dual-purpose product. Do not order a dual-purpose product if your doctor doesn’t recommend it.

If your doctor does advise you to use a dual-purpose item, you may order the item(s) through your OTC benefit. On the order form, dual-purpose products are marked with an asterisk (*).

Some items may be covered under Medicare Part B or Part D. For example, rolled gauze may be covered under Part B when used as prescribed for covering or dressing a surgical wound. On the order form, these items are marked with two asterisks (**).

Items that are not eligible Items that are not eligible for your OTC benefit include but are not limited to:

Deodorant and antiperspirants

Foods and meal replacement items

Birth control medications and contraceptives

Herbal supplements and alternative medications

Lotions, facial creams, and other cosmetic items

Household items including hand soaps, razors, etc.

Baby diapers, formulas, and other childcare products

How to place your order…

Review the items on the following product list and select what you want to order

Please have the following information available when you call Costco Pharmacy.

Your Inter Valley Health Plan ID Card

Your mailing address and phone number

Your credit card. This will be used only if your order exceeds the allowance provided

What quarter would you like this order to be applied to?

To place your Over the Counter order call Costco Pharmacy at 1-866-443-0060 (TTY/TDD 711)

We’re here to take your call Monday through Friday, 6 am to 6 pm (PT) and Saturday 9 am to 2 pm (PT)

$25 Minimum order required

$30 Quarterly allowance

Product Package Price Qty Size

MISCELLANEOUS ITEMS

Weekly Pill Box Planner 1ct $2.00

Dramamine Motion Sickness Tablet 8ct $4.00

ALLERGY

Saline Mist 0.65% Nose Spray 44ml $2.00

Loratadine 10mg Tablet 30ct $5.00

Cetirizine 10mg Tablet 30ct $5.00

LDR Allergy Relief (Fexofenadine) 180mg Tablet 15ct $9.00

Banophen 25mg (Diphenhydramine) Capsule 24ct $2.00

SM Fluticasone Prop 50 mcg Spray 120 sprays 16gm $19.00

SM 4-Hour Allergy (Chlorpenirame) 4mg Tablet 100ct $4.00

Coricidin HBP Cough & Cold Tablet 16ct $6.00

Cromolyn Sodium Nasal Spray 26ml $10.00

ANTACIDS

Milk of Magnesia Suspension 355ml $4.00

Acid Gone Antacid 355ml $6.00

Bismatrol 262mg/15ml 236ml $4.00

SM Famotidine 10mg Tablet 30ct $7.00

Simethicone Chew 125mg 60ct $5.00

Calcium Antacid 500mg 150ct $3.00

Famotidine 10mg Tablet 30ct $7.00

Omeprazole 20mg Tablet 14ct $10.00

Bismatrol 262mg Chewable 30ct $3.00

CANDIDAL

Clotrimazole 1% Cream 45gm $5.00

Miconazole 3 1ct $10.00

Monistat 1 Day 1ct $16.00

ANTIDIARRHEAL AND LAXATIVE

SM Bisacodyl Gentle Laxative Tablet 25ct $3.00

Loperamide 2mg Tablet 12ct $3.00

SM Stool Softener 100mg Softgel 100ct $5.00

Stool Softener 250mg Softgel 100ct $8.00

Enema, Disposable 133ml $2.00

Ex-Lax 15mg Tablet 8ct $3.00

Fleet Glycerin Suppositories 12ct $2.00

GERI-KOT 100ct $3.00

Senna Plus 8.6-50mg Tablet 60ct $3.00

BRACES AND SUPPORT

Ace Elbow Support 1ct $12.00

Ace Wrist Support 1ct $10.00

Ankle Stabilizer 1ct $12.00

Fut Sport Knee Support 1ct $13.00

Sport Aid 2 inch Elastic Bandage** 1ct $5.00

COUGH/COLD

All-Night Cold Flu Relief Liquid 237ml $5.00

Halls Cough Drops 25ct $3.00

Halls Cough Drops Sugar Free 25ct $2.00

Halls Cough Drops Triple Soothing Action Honey Lemon 30ct $3.00

Mucus Relief Guaifenesin 400mg Tablet 60ct $4.00

Mucinex DM Tablet 20ct $12.00

Oxymetazoline 0.05% Spray (Nasal) 30ml $3.00

Robafen 118ml $2.00

Robafen CF 118ml $4.00

Robafen DM Cough Clear 118ml $4.00

Product Package Price Qty Size

COUGH/COLD continued

Siltussin DM Cough Syrup 118ml $7.00

Sore Throat Spray 177ml $4.00

Sudogest PE 10mg Tablet 36ct $3.00

Tylenol Cold Flu Severe 240ml $7.00

Vicks Vaporub 100gm $7.00

DENTAL

Colgate Plus Toothbrush (Medium Soft) 1ct $2.00

Dental Floss (55 yards) 1ct $2.00

Fixodent 68gm $5.00

Floss Pick 90ct $2.00

Orajel 7gm $5.00

Pepsodent Complete Care 156gm $2.00

Polident Overnight Whitening 40ct $4.00

Sensodyne 113gm $7.00

DIAGNOSTICS

Pro Check FeverGlow Instant Ear Thermometer 1ct $29.00

Pro Check Digital Thermometer 1ct $4.00

DIGESTIVE HEALTH

Beano Food Enzyme Tablet 30ct $6.00

Lactase 60ct $8.00

EAR CARE

Ear Syringe 1ct $3.00

Murine Ear Drops 6.5% 15ml $5.00

EYE CARE

Alaway Eye Itch Relief 0.025% 10ml $11.00

Product Package Price Qty Size

EYE CARE continued

Artificial Tears 1.4% 15ml $7.00

B&L Eye Wash 118ml $4.00

Bausch & Lomb Soothe 28ct $10.00

Clear Care Rinse & Go Solution 360ml $4.00

Clear Eyes Redness Relief 0.012% 15ml $4.00

Ketotifen Fum 0.025% Eye Drops 5ml $10.00

Lubricating Plus Drops 0.5% 30ct $11.00

Refresh Tears 0.5% Drops 15ml $10.00

Systane Eye Drops 15ml $11.00

Stye Ointment 3.5gm $9.00

Thera Tears Liquid Gel Single Use Vials 30ct $14.00

FIBER SUPPLEMENTS

Citrucel Fiber Powder 454gm $10.00

Citrucel Fiber Powder S/F 479gm $14.00

Fiber Laxative Capsule 625mg 90ct $8.00

Philips Fiber Gummies 90ct $17.00

FIRST AID

Abreva Cream 2gm $17.00

Alcohol Isopropyl 70%** (Max Quantity of 2 Per Order) 473ml $4.00

Americaine Hemorrhoidal Ointment 28gm $5.00

Aspercreme w/Lidocaine 76.5gm $6.00

B/A Rolled Gauze** (3 inch x 2.5 yards) 1ct $3.00

Bacitracin 500 u/gm ointment 28gm $4.00

BD Single Use Swab (Alcohol) 100ct $2.00

Benzoyl Peroxide 10% Gel 42.5gm $5.00

Blistex Lip Balm 1ct $2.00

Calamine Lotion 8-8% 177ml $3.00

Product Package Price Qty Size

FIRST AID continued

Capsaicin 0.025% Cream 60gm $9.00

Coppertone SPF 50 Lotion 237ml $10.00

J&J First Aid Kit to Go 1ct $4.00

Curad Sheer 80ct $2.00

SM Cotton Balls Jumbo 100ct $2.00

SM Epsom Salt Pouch (Max Quantity of 2 Per Order) 1lbs $2.00

Duofilm Wart Remover Liquid 9.8ml $6.00

Extra Strength Muscle Rub Cream 85gm $6.00

SM Sterile Alcohol Prep Pads* 100ct $2.00

Hemorrhoidal Hygiene Pads 100ct $5.00

Hydrocortisone 1% Cream 28.35gm $3.00

Hydrocortisone 1% Ointment 28.35gm $4.00

Hydrocortisone 1% Cream with Moisturizers 28.35gm $3.00

Hydrogen Peroxide (Max Quantity of 2 Per Order) 473ml $3.00

Icy Hot Advanced Pain Patch 5ct $9.00

Icy Hot Extra Strength Cream 85gm $5.00

Mueller Ice Bag 9 inch 1ct $8.00

Nexcare Tape (1 inch x 5 yards) 1ea $4.00

Nix Créme Rinse 59ml $10.00

Preparation H Hemorrhoidal Suppository 12ct $7.00

Rid Shampoo with Comb 118ml $10.00

Salonpas 60ct $12.00

Salonpas Deep Pain Gel 78gm $7.00

SM Heating Pad Dry and Moist 1ct $17.00

SM Triple Antibiotic Ointment 28gm $5.00

Vaseline Jelly 106gm $3.00

Product Package Price Qty Size

Product Package Price Qty Size

FOOT CARE

SM Clotrimazole 1% Cream 30gm $5.00

Dr. Scholls Bunion Cushions 6ct $4.00

Dr. Scholls Corn Remover Pads 9ct $3.00

Dr. Scholls Original Foot Powder 198gm $6.00

Freezone Corn Remover Liquid 9.3ml $5.00

Miconazole Nitrate 2% Cream 28gm $3.00

Terbinafine HCL 1% Cream 15gm $10.00

Tolnaftate 1% Cream 30gm $7.00

Tolnaftate 1% Powder 45gm $4.00

INCONTINENCE SUPPLIES

A&D Ointment 113gm $4.00

Attends Briefs Regular 20ct $20.00

Attends Classic Briefs Large 24ct $20.00

Attends Classic Briefs Medium 24ct $20.00

Attends Classic Briefs XL 20ct $25.00

Depend Fitted Briefs Small/Med 20ct $20.00

Fluff Underpad 23X36 15ct $4.00

Sensi-Care Protective Barrier Cream 113gm $9.00

Sure Care Bladder Control Pad (4 inch x 9.75 inch) 22ct $15.00

PAIN RELIEVERS

Alka-Seltzer Effervescent Tablet 12ct $3.00

SM All Day Relief Naproxen 220mg Tablet 50ct $6.00

APAP - Diphenhydramine 500-25mg 50ct $4.00

SM Aspirin 325mg Tablet 100ct $3.00

Aspirin 81mg Chew Tablet 36ct $2.00

Aspirin EC 325mg Tablet 100ct $3.00

Product Package Price Qty Size

PAIN RELIEVERS continued

Aspirin EC 81mg Tablet 120ct $3.00

Cystex Plus Urinary Pain Relief Tablet 40ct $8.00

Ibuprofen 200mg Tablet 50ct $2.00

MAPAP Arthritis 650mg Tablet 100ct $8.00

Acetaminophen 325mg Tablet 50ct $2.00

Acetaminophen Extra Strength 500mg Tablet 100ct $3.00

Pain Reliever Plus (APAP/ASA/CAFF) 100ct $3.00

VITAMINS

Calcium 500mg + D 400U Chewable* 60ct $4.00

Calcium Carb w/D 600-400* 60ct $3.00

Calcium Citrate/Vit D 315mg-300IU* 60ct $5.00

Cerovite Senior Tablet* 60ct $5.00

Coenzyme Q10 50mg Gel Capsule* 30ct $11.00

Daily-Vites Tablet* 100ct $4.00

Daily-Vites w/Iron Tablet* 100ct $3.00

Ferrous Sulfate 325mg Tablet* 100ct $2.00

Fish Oil 1000mg Capsule* 100ct $6.00

Folic Acid 400mcg Tablet* 100ct $3.00

Glucosamine Chondrotin 500-400mg* 60ct $12.00

Healthy Eyes Supervision 2 Capsule* 120ct $18.00

Magnesium 250mg Tablet* 100ct $3.00

Melatonin 3mg Tablet* 60ct $4.00

Niacin 100mg Tablet* 100ct $3.00

Niacin 250mg Time Release Capsule* 90ct $7.00

NM Fish Oil 1000mg Burp-less 150ct $18.00

Oyster Shell Calcium + D 500mg/200u* 60ct $4.00

Product Package Price Qty Size

VITAMINS continued

Oyster Shell Calcium 500mg* 60ct $3.00

Osteo Bi-Flex Triple Strength Coated Tablet* 80ct $30.00

SM Iron Slow Release 45mg Tablet* 60ct $7.00

Vitamin B-50 Complex Tablet* 60ct $6.00

Vitamin B-12 1000mcg Tablet Sublingual* 100ct $8.00

Vitamin B-12 100mcg Tablet* 100ct $3.00

Vitamin B-6 50mg Tablet* 100ct $3.00

SM Vitamin C 500mg Chew Tablet* 100ct $7.00

Vitamin C 500mg Tablet* 100ct $3.00

Vitamin D 1000 IU Tablet* 100ct $4.00

Vitamin D 2000 U Tablet* 100ct $6.00

Vitamin E 400 unit Capsule* by Gericare 100ct $7.00

Zinc Gluconate 50mg Tablet* 100ct $2.00

MK0 406 STS 12/19

2020For more information please call the number below or visit us at www.ivhp.com.

Contact our Pharmacy Care Team October 1 to March 31: 8 am to 8 pm, 7 days a week. We are closed on Thanksgiving Day and Christmas Day.

Contact us April 1 – September 30: 8 am to 8 pm, Monday through Friday. We are closed on federal holidays.

NOTE: When we are closed you have the option to leave a message. Messages received will be returned within one (1) business day.

You can see our plan’s provider/pharmacy directory on our website at www.ivhp.com.

You can see the complete Plan formulary (list of Part D prescription drugs) and restrictions on our website at www.ivhp.com

800-523-3142 or TTY/TDD 7118 am to 8 pm, 7 days a week. 300 S. Park AvenuePO Box 6002, Pomona, CA 91769-6002www.ivhp.comwww.facebook.com/intervalley