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 $50 per quarter. Unused balances DO NOT carry over to the next quarter.

Items usually arrive within ten (10) business days from the date your order is received and verified.

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.

2021

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_FUY2021_009_STS_C

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 marked with 3 asterisks *** have limits and or requirements. All *** are limited to one order per member per year. The digital scale also can only be ordered by members with a confirmed diagnosis of Chronic Heart Failure and or Liver Disease.

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.

You may place your order via phone, email, fax or mail. If using email, fax or mail please fill out the order form below completely in

addition to marking which items you would like 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 The items you want to order and total cost 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 877-445-0984 (TTY 711)

We’re here to take your call Monday through Friday, 8 am to 7 pm (PT) and Saturday 9:30 am to 2 pm (PT)

Fax 888-545-4615

Email webpharmacy@costco.com

Costco Mail Order Pharmacy 215 Deininger Circle, Corona, CA 92880-9911

$25 Minimum order required

$50 Quarterly allowance

Name DOB

Address Order Date

Inter Valley Member Number Grp Number Order Month Received by:

ORDER FORM

Product Active Ingredient/Item Detail Package Price Qty Size

MISCELLANEOUS ITEMSDramamine Motion Sickness Tablet meclizine 25mg 8ct $8.00

Weekly Pill Box Planner 1ct $4.00

ALLERGY

Banophen 25mg Capsule diphenhydramine 25mg 24ct $6.00

Cetirizine 10mg Tablet cetirizine 10mg 30ct $6.00

chlorpheniramine maleate 4mg Coricidin HBP Cough & Cold Tablet dextromethorphan hydrobromide 30mg 16ct $10.00

Cromolyn Sodium Nasal Spray cromolyn sodium 5.2mg per spray 26ml $11.00

LDR Allergy Relief 180mg Tablet fexofenadine 180mg 15ct $10.00

Loratadine 10mg Tablet loratadine 10mg 30ct $6.00

Saline Mist 0.65% Nose Spray sodium chloride 0.65% 44ml $3.00

SM Allergy Relief Nasal Spray fluticasone propionate 50mcg 50mcg $13.00 50mcg/Act 120 sprays

Sun Mark 4-Hour Allergy 4mg Tablet chlorpheniramine 4mg 100ct $6.00

ANTACIDS

aluminum hydroxide 95mg, Acid Gone Antacid magnesium carbonate 358mg 355ml $9.00

Bismatrol 262mg/15ml bismatrol 262mg/15ml 236ml $7.00

Bismatrol 262mg Chewable bismatrol 262mg chewable 30ct $4.00

Calcium Antacid 500mg calcium carbonate chew 500mg 150ct $7.00

Heartburn Relief 10mg Tablet famotidine 10mg 30ct $7.00

Milk of Magnesia Suspension magnesium hydroxide 1200mg per 15mL 355ml $4.00

Omeprazole 20mg Tablet omeprazole 20mg 14ct $10.00

Simethicone Chew 125mg simethicone 125mg 60ct $7.00

CANDIDAL

Clotrimazole 1% Cream clotrimazole 1% 45gm $6.00

miconazole Nitrate (200mg in each suppository); 1ct $10.00 Miconazole 3 miconazole nitrate 2% (external cream)

Monistat 1 Day tioconazole 300mg (6.5%) per applicator 4.6gm $18.00

Product Active Ingredient/Item Detail Package Price Qty Size

ANTIDIARRHEAL & LAXATIVE

Enema, Disposable sodium phosphate 133ml $6.00

Ex-Lax 15mg Tablet sennosides 8.6mg 30ct $4.00

Fleet Glycerin Suppositories glycerin 2 g 12ct $6.00

GERI-KOT sennosides 8.6mg 100ct $6.00

Loperamide 2mg Tablet loperamide 2mg 12ct $5.00

Senna Plus 8.6-50mg Tablet sennosides 8.6mg/docusate sodium 50mg 60ct $3.00

SM Bisacodyl Gentle Laxative Tablet bisacodyl 5mg 25ct $4.00

SM Stool Softener 100mg Softgel docusate sodium 100mg 100ct $5.00

Stool Softener 250mg Softgel docusate sodium 250mg 100ct $8.00

BRACES AND SUPPORT

Ace Elbow Support Sizing: 9 – 11 in (8 – 27.9 cm) 1ct $10.00

Ace Wrist Support Adjustable size 1ct $12.00

Ankle Stabilizer Adjustable size 1ct $10.00

Fut Sport Knee Support Sizing: 13.0 – 17.5 in (33.0 – 14.4 cm) 1ct $13.00

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

COUGH/COLD

dextromethorphan 15mg/acetaminophen All-Night Cold Flu Relief Liquid 325mg/doxylamine 6.25 per 15mL 237ml $5.00

Halls Cough Drops menthol 7.5mg 25ct $4.00

Halls Cough Drops Triple Soothing menthol 7.5mg 30ct $6.00 Action Honey - Lemon

Halls Cough Drops Sugar Free menthol 5mg 25ct $4.00

Mucinex DM Tablet dextromethorphan HBr 30mg guaifenesin 600mg 20ct $14.00

Mucus & Chest Congestion guaifenesin 100mg/5mL 118ml $6.00

Mucus Relief 400mg Tablet guaifenesin 400mg 60ct $7.00

Oxymetazoline 0.05% Spray (Nasal) oxymetazoline 0.05% 30ml $6.00

guaifenesin 100mg/dextromethorphan 10mg/ Robafen CF phenylephrine 5mg per 5mL 118ml $7.00

guaifenesin 100mg/dextromethorphan 118ml $7.00 Robafen DM Cough Clear 10mg per 5mL

guaifenesin 100mg/dextromethorphan Siltussin DM Cough Syrup 10mg per 5mL 118ml $9.00

Sore Throat Spray phenol 1.4% 177ml $6.00

Sudogest PE 10mg Tablet phenylephrine 10mg 36ct $6.00

acetaminophen 325mg/dextromethorphan HBr 10mg/guaifenesin 200mg/phenylephrine HCI Tylenol Cold Flu Severe 5mg per 15 mL 240ml $10.00

camphor 4.8%/eucalyptus oil Vicks Vaporub 1.2%/menthol 2.6% 100gm $11.00

DENTAL

Colgate Plus Toothbrush Soft 1ct $4.00

Colgate Plus Toothbrush Medium 1ct $4.00

Dental Floss (55 yards) 1ct $4.00

Fixodent 68gm $6.00

Floss Pick 90ct $6.00

Orajel benzocaine 10% 7gm $9.00

Pepsodent Complete Care sodium fluoride 0.24% 156gm $6.00

Polident Overnight Whitening 40ct $5.00

potassium nitrate 5%/sodium fluoride 0.25% Sensodyne (w/v fluoride ion) 113gm $8.00

DIAGNOSTICS

Floor Scale Digital Audio Display 550lbs*** 1ct $35.00

Infrared Thermometer*** 1ct $35.00

Omron 3 Series Blood Pressure Monitor*** 1ct $35.00

DIGESTIVE HEALTH alpha-galactosidase enzyme Beano Food Enzyme Tablet 300 per 2 tablets 30ct $8.00

Lactase lactase 3000 units per caplet 60ct $10.00

EAR CARE

Ear Syringe latex free 1ct $5.00

Murine Ear Drops 6.5% carbamide peroxide 6.5% 15ml $6.00

Product Active Ingredient/Item Detail Package Price Qty Size

COUGH/COLD continued

EYE CARE ketotifen 0.025% (equivalent to Ketotifen Alaway Eye Itch Relief 0.025% fumarate 0.035%) 10ml $13.00

Artificial Tears 15ml $8.00

B&L Eye Wash purified water 99.05% 118ml $8.00

Bausch & Lomb Soothe glycerin 0.6%; propylene glycol 0.6% 28ct $12.00

Clear Care Rinse & Go Solution aqueous saline solutions 360ml $5.00

glycerin 0.25%; naphazoline Clear Eyes Redness Relief 0.012% hydrochloride 0.012% 15ml $5.00

ketotifen 0.025% (equivalent to Ketotifen Ketotifen Fum 0.025% Eye Drops fumarate 0.035%) 5ml $11.00

Lubricating Plus Drops 0.5% carboxymethylcellulose sodium 0.5% 30ct $7.00

Preservision AREDS 2 Softgel vitamin C 250mg, vitamin E 200iu zinc 40mg, copper 1mg, lutein 5mg 60ct $18.00

Refresh Tears 0.5% Drops carboxymethylcellulose sodium 0.5% 15ml $10.00

polyethylene glycol 400 0.4%; Systane Eye Drops propylene glycol 0.3% 15ml $14.00

Stye Ointment mineral oil 31.9%; white petrolatum 57.7% 3.5gm $9.00

Thera Tears Liquid Gel Single Use Vials sodium carboxymethylcellulose 1% 30ct $13.00

FIBER SUPPLEMENTS methylcellulose 2g (a non-allergic fiber) Citrucel Fiber Powder per heaping tablespoon 454gm $12.00

methylcellulose 2g (a non-allergic fiber) Citrucel Fiber Powder S/F per heaping tablespoon 479gm $16.00

calcium polycarbophil 625mg equivalent Fiber Laxative Capsule 625mg to 500mg polycarbophil per caplet 90ct $9.00

Philips Fiber Gummies inulin 4g 120ct $13.00

FIRST AID Abreva Cream docosanol 10% 2gm $21.00

Alcohol Isopropyl 70% (Max 2 Per Order) isopropyl alcohol 70% 473ml $4.00

Americaine Hemorrhoidal Ointment benzocaine 20% 28gm $7.00

Aspercreme w/Lidocaine lidocaine HCL 4% 76.5gm $8.00

B/A Rolled Gauze** 1ct $7.00

Bacitracin 500 u/gm ointment bacitracin 500 units per gram 28gm $5.00

Product Active Ingredient/Item Detail Package Price Qty Size

Product Active Ingredient/Item Detail Package Price Qty Size

FIRST AID continued

BD Single Use Swab (Alcohol) isopropyl alcohol 70% 100ct $4.00

Benzoyl Peroxide 10% Gel benzoyl peroxide 10% 60gm $4.00

Blistex Lip Balm dimethicone 2%/octinoxate 6.6%/octisalate 4.4% 1ct $6.00

Calamine Lotion 8-8% calamine/zinc oxide 177ml $4.00

Capsaicin 0.025% Cream capsaicin 0.25% 60gm $8.00

Compound W Max Strength salicylic acid 17% 9ml $9.00

avobenzone 3%/homosalate 13%/octisalate 5% Coppertone SPF 50 Lotion /octocrylente 7%/oxbenzone 4% 237ml $10.00

J&J First Aid Kit to Go 1ct $6.00

Curad Sheer 80ct $6.00

SM Cotton Balls Jumbo 100ct $4.00

SM Epsom Salt Pouch (Max 2 per order) magnesium sulfate USP 100% 454gm $4.00

Extra Strenth Muscle Rub Cream methyl salicylate 15%/menthol 10% 85gm $8.00

Hemorrhoidal Suppository cocoa butter 88.44%/phenylephrine HCI 0.25% 12ct $4.00

Hemorrhoidal Hygiene Pads witch hazel 50% 100ct $5.00

Hydrocortisone 1% Cream hydrocortisone 1% 28.4gm $4.00

Hydrocortisone 1% Ointment hydrocortisone 1% 28.4gm $4.00

Hydrogen Peroxide (Max 2 per order) hydrogen peroxide 3% 473ml $3.00

Icy Hot Advanced Pain Patch menthol 7.5% 5ct $10.00

Icy Hot Extra Strength Cream menthol 10%; menthyl salicylate 30% 85gm $7.00

Mueller Ice Bag 9 inch 1ct $11.00

Nexcare Tape 1ct $8.00

Nix Créme Rinse permethrin 280mg (1%) per fluid ounce 59ml $11.00

Preparation H Hemorrhoidal Suppository cocoa butter 88.44%/ phenylephrine HCI .25% 12ct $11.00

piperonyl butoxide (4%); pyrethrum extract Rid Shampoo with Comb (equivalent to 0.33% pyrethrins 120ml $13.00

Salonpas camphor 3.1%; menthol 6%; methyl Salicylate 10% 60ct $11.00

Salonpas Deep Pain Gel camphor 3.1%; menthol 6%; methyl Salicylate 15% 78gm $8.00

SM Heating Pad Dry/Moist 1ct $13.00

SM Hydrocortisone 1% Cream W / Moisturizer hydrocortisone 1% 28.4gm $4.00

FIRST AID continued

SM Triple Antibiotic Ointment bactiracin 400 Units; neomycin 3.5mg; polymyxin B 5000 Units per gram 28.4gm $5.00

SM Sterile Alcohol Prep Pad** isopropyl alcohol 70% 100ct $3.00

Surgical Masks – Black 50ct $16.00

Surgical Masks – Blue 50ct $16.00

Vaseline Jelly white petrolatum, USP 100% 106gm $7.00

FOOT CARE

Dr. Scholls Bunion Cushions 6ct $5.00

Dr. Scholls Corn/Callus Remover Liquid salicylic acid 17% 9.8ml $8.00

Dr. Scholls Corn Remover Pads salicylic acid 40% 9ct $5.00

Dr. Scholls Original Foot Powder talc; salicylic acid; methyl salicylate 198gm $8.00

Miconazole Nitrate 2% Cream miconazole nitrate 2% 28gm $7.00

SM Clotrimazole 1% Cream clotimazole 1% 30gm $6.00

Terbinafine HCL 1% Cream terbinafine 1% 15gm $11.00

Tolnaftate 1% Cream tolnaftate 1% 30gm $9.00

Tolnaftate 1% Powder tolnaftate 1% 45gm $7.00

INCONTINENCE SUPPLIES

A&D Ointment vitamins A and D/white petrolaum/lanolin 113gm $8.00

Attends Briefs Regular 44 to 56 In. waist/hip 20ct $15.00

Attends Adult Underwear Medium 34 to 44 In. waist/hip 20ct $12.00

Attends Adult Underwear Large 44 to 58 In. waist/hip 18ct $12.00

Attends Adult Underwear XL 58 to 68 In. waist/hip 14ct $12.00

Attends Classic Briefs Large 44 to 58 In. waist/hip 24ct $15.00

Attends Classic Briefs Medium 32 to 44 In. waist/hip 24ct $15.00

Attends Classic Briefs XL 58 to 63 In. waist/hip 20ct $15.00

Depend Fitted Briefs Small/Med 19 to 34 In. waist/hip 20ct $20.00

Fluff Underpad 23X36" 23 x 36 In. 15ct $7.00

Sensi-Care Protective Barrier Cream petrolatum 49%; zinc oxide 15% 113gm $10.00

Sure Care Bladder Control Pad 4 x 103/4 In. 22ct $10.00Tena Ultra Washcloth 48ct $6.00

Product Active Ingredient/Item Detail Package Price Qty Size

Product Active Ingredient/Item Detail Package Price Qty Size

PAIN RELIEVERS

Acetaminophen 325mg Tablet acetaminophen 325mg 50ct $5.00

Acetaminophen Extra Strength 500mg Tablet acetaminophen 500mg 100ct $3.00

Alka-Seltzer Effervescent Tablet citric acid 1000mg/aspirin 325mg (NSAID) /sodium bicarbonate 1916mg 12ct $7.00

APAP - Diphenhydramine 500-25mg acetaminophen 500mg/diphenhydramine 25mg 50ct $4.00

Aspirin 81mg Chew Tablet chewable aspirin 81mg 36ct $4.00

Aspirin EC 325mg Tablet enteric coated aspirin 325mg 100ct $4.00

Aspirin EC 81mg Tablet enteric coated aspirin 81mg 120ct $4.00

Cystex Plus Urinary Pain Relief Tablet methenamine 162mg/sodium salicylate 162.5mg (NSAID) 40ct $9.00

Ibuprofen 200mg Tablet ibuprofen 200mg 50ct $4.00

MAPAP Arthritis 650mg Tablet acetaminophen 650mg 100ct $11.00

Pain Reliever Plus (APAP/ASA/CAFF) aspirin 250mg/acetaminophen 250mg /caffeine 65mg 100ct $7.00

SM All Day Relief Naproxen 220mg Tablet naproxen sodium 220mg (NSAID) 50ct $6.00

SM Aspirin 325mg Tablet aspirin 325mg (NSAID) 100ct $4.00

VITAMINS

Calcium 500mg + D 400U Chewable* calcium carrbonate 500mg/vitamin D3 400IU 60ct $5.00

Calcium Carb w/D 600-400* calcium carrbonate 600mg/vitamin D3 400IU 60ct $6.00

Calcium Citrate/Vit D 315mg-200IU* calcium citrate 315mg/vitamin D3 2000IU 60ct $6.00

Cerovite Senior Tablet* multivitamin with minerals/lutein 60ct $6.00

Citracal Max Plus Caplets vitamin D 500iu/calcium citarate 630mg 120ct $12.00

Coenzyme Q10 50mg Gel Capsule* coenzyme Q10 50mg 30ct $11.00

Daily-Vites Tablet* multivitamin 100ct $4.00

Daily-Vites w/Iron Tablet* multivitamin with iron 100ct $7.00

Ferrous Sulfate 325mg Tablet* ferrous sulfate 325mg 100ct $6.00

Fish Oil 1000mg Capsule* omega-3 fatty acids 340/fish oil 1000mg 100ct $6.00

Folic Acid 400mcg Tablet* folic acid 400mg 100ct $4.00

Glucosamine Chondrotin 500-400mg* glucosamine 500mg/chondrotin 400mg 60ct $9.00

Product Active Ingredient Package Price Qty Size

Vitamins continued vitamin C 250mg/vitamin E 200 IU/zinc 40mg Healthy Eyes Supervision 2 Capsule* /copper 1mg/lutein 5mg/zeaxanthin 1mg 120ct $18.00

Magnesium 250mg Tablet* magnesium oxide 250mg 100ct $5.00

Melatonin 3mg Tablet by Gericare* melatonin 3mg 60ct $5.00

Niacin 100mg Tablet* niacin 100mg 100ct $6.00

Niacin 250mg Time Release Capsule* niacin 250mg 90ct $10.00

fish oil 1000mg (total omega-3 fatty acids 300mg [omega-3 EPA & DHA] NM Fish Oil 1000mg 250mg, omega-3 other 50mg) per capsule 150ct $15.00

glucosamine HCI 1,500mg/joint shield 5-loxin advanced boswellia serrata extract (resin) Osteo Bi-Flex Triple 100mg/methylsulfonylmethatne (MSM) Strength Coated Tablet* 1,500 mg per 2 tablets 80ct $23.00

Oyster Shell Calcium + D 500mg/200u* calcium carbonate 500mg/vitamin D3 200IU 60ct $6.00

Oyster Shell Calcium 500mg* calcium carbonate 500mg 60ct $4.00

SM Iron Slow Release 45mg Tablet* iron 45mg (ferrous sulfate) 60ct $7.00

chewable vitamin C SM Vitamin C 500mg Chew Tablet* (as sodium ascorbate & ascorbic acid) 500mg 100ct $5.00

thiamin (vitamin B-1) 50mg/riboflavin (viatmin B-2 50mg/niacin 50mg/folic acid 400mcg/vitamin B-6 (as pyridoxine hydrochloride) 50mg/folic acid 400mcg/vitamin B-12 (as cyancobalamin) 50mcg /biotin 50mg/pantothenic acid (as calcium Vitamin B-50 Complex Tablet* pantothenate) 10mg/calcium (as calcium carbonate) 115mg 60ct $9.00

Vitamin B-12 1000mcg Tablet Sublingual* calcium (as diacalcium phosphate) 100mg/vitamin B-12 (as cyanocobalamin) 1,000mcg 100ct $9.00

Vitamin B-12 100mcg Tablet* cyanocobalamin (vitamin B-12) 100mcg 100ct $4.00

Vitamin B-6 50mg Tablet by Major* pyridoxine HCI (vitamin B6) 50mg 100ct $6.00

Vitamin C 500mg Tablet* ascorbic acid 500mg 100ct $4.00

Vitamin D 1000 IU Tablet* vitamin D3 (as cholecalciferol) 1000 IU 100ct $6.00

Vitamin D 2000 U Tablet* vitamin D3 (as cholecalciferol) 2000 IU 100ct $7.00

Vitamin E 400 unit Capsule by Gericare* vitamin E (dl,tocopheryl acet) 400 units 100ct $7.00

Zinc Gluconate 50mg Tablet* zinc gluconate 50mg 100ct $4.00

MED 406 STS 9/20

2021For more information please call the number below or visit us at 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 ivhp.com.

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

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