Ordering deadlines If your order is received after a quarter deadline listed below, it will apply toward the next quarter. Copyright © 2021 Drug Source, Inc. only. This benefit allows you to purchase medications, health- and wellness-related items, first-aid only. Your current plan may have an over-the-counter benefit that would allow you to . STEP 1 - COMPLETE YOUR INFORMATION BELOW . IR_234.2 H5496 OTC Order Form 005 007 009 75_C ENG 07/27/20 Over-the-Counter Order Form Imperial Senior Value (HMO C-SNP) 005: $75 allowance every quarter Imperial Traditional (HMO) 007: $75 allowance every quarter Imperial Traditional Plus (HMO) 009: $75 allowance every quarter Please complete the form below with the items you wish to order. A representative can help you place the order. purchase OTC health and wellness products from Humana Pharmacy. Shop at participating pharmacy and retail locations using your over-the-counter retail card. • There may be order quantity limits on certain OTC items. Participating locations. Some participating locations include Rite Aid, Family Dollar, Dollar General, Walgreens, and Walmart. Over-the-Counter (OTC) Catalog Order Form, OTC, How do I use this order form, How often can I place an order, How long will it take for me to get my products, What if a product I want is back ordered, Can I return the products I get, Are there other ways for me to order my OTC products, Blue Cross Blue Shield of Tennessee, Blue Care Plus, Fill out the Over-the-Counter (OTC) Mail Order Form and mail . ORDER FORM . 1 Order your diabetic supplies by visiting our Member Portal Website or by calling us at 1-866-900-2688 - TTY:711. ... Download the Physician's Order Form here. By Mail: Fill out and return the OTC Order Form in the OTC Product Catalog. Health Plan Members Please Login Below. well. Participating pharmacies and retail locations may vary from month to month. 2021 Over-the-Counter (OTC) Health and Wellness Product Order Form. The Over-the-Counter (OTC) Catalog contains over 100+ items that can help you save between $420 to $1500 over the course of a year. STEP 2 - PRODUCT SELECTION Print an Over-the-Counter (OTC) Catalog Order Form. First Name Last Name MI . By Mobile Application: Place an order and manage your account through the OTC-Anywhere mobile app. For example, if we receive your order on June 29, it will apply toward Quarter 3. Daytime Phone Email (Optional) Please check box if this is a new address @ . 10749 Marks Way Miramar, FL 33025 • Fax: Fill out the Over-the-Counter (OTC) Mail-Order Form and fax . H8016_21WEB001_2021_A (Accepted 10/4/2020) Disclaimers. Over-the-Counter (OTC) Medications and Products 2020 Benefit Catalog and Order Form. How to order over-the-counter (OTC) items ... To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form. One order is allowed per quarter. By debit card/retail: At any Walmart store; Your order will be shipped to the address you give when ordering. To verify your 2021 Health and Wellness allowance, please contact customer service or check your Summary of Benefits. You have an over-the-counter benefit of a certain amount that can save you money and help you stay . Diabetic Supplies - It's Easy as 1-2-3. Date of Birth (MMDDYYYY) Example: 06091947. Street Number Street Name Apt/Suite # City State Zip Code . the order form pages, using the postage-paid envelope provided, to: PrescribeIT Rx. Member ID. OVER–THE–COUNTER (OTC) BENEFIT . Member ID (found on plan member ID card) Date of Birth .
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