2018 彙整 櫃檯成藥(OTC) 訂購表格 0001_2018_OTCOrderForm_CH BND_6364
作為 Brand New Day 的會員, 您有資格獲得櫃檯成藥 (OTC) 免費送到您的家中 參與本計劃, 您不需要處方箋來收取產品 您可以每月發出一 (1) 份訂單 您所下的每個訂單必須至少有 $25 元 未使用的餘額, 將不會由上一季度轉移到下一季 訂單可以提前兩 (2) 個月預訂 物品通常會在收到您的訂單並驗證之日起, 十 (10) 個工作日內到達 提前下訂單者, 應在當月前十 (10) 個工作日內到達 查詢您的季度櫃檯成藥 (OTC) 補助, 請參閱您的福利說明 (EOC) 或致電 Brand New Day 會員服務中心 1-866-255-4795 (TTY 用戶請致電 1-866-321-5955), 星期一至星期五, 上午 8:00 至晚上 8:00 下訂單的兩種方法 1: 請上網 : www.integratedotc.com 上網至 IntegratedOTC.com 是查看可訂購產品 ( 包括新產品 ) 下訂單和追踪貨品的最佳方式 2: 電話訂購 傳真或郵寄 a) 請查看本表格另一邊的列表, 並選擇您想要的物品 b) 如果您以電話訂購, 請打 1-866-632-7961 (TTY: 1-866-706-4757), 星期一至星期五, 上午 6:00 至下午 6:00 (PT) c) 如果您以傳真或郵寄方法訂購, 請填寫此表格的另一面 將填好的表格傳真至 1-888-260-2323 選擇郵寄者, 請沿著虛線折起來並用膠帶密封, 且在背面貼上郵票 有任何櫃檯成藥福利或櫃檯成藥訂單的問題? 請撥打 1-866-632-7961(TTY / TDD: 1-866-706-4757)
姓名 電話號碼 會員編號 郵寄地址 城市 州名 郵遞區號 遞交月份 : 圈選一個 ; 可以提前兩個月 一月 二月 三月 四月 五月 六月 七月 八月 九月 十月 十一月 十二月 簽名 COLUMN 1 PRODUCT QTY COLUMN 2 Additional Items G001 Pill Box $3 G002 Travel Sickness 25mg 8ct $3 Allergy J005 Cetirizine 10mg 30ct J009 Chlorpheniramine 4mg 100ct J010 J011 Cough & Cold High BP Tablet 16ct Cromolyn Sodium Nasal Spray 26ml $15 J007 Diphenhydramine 25mg 24ct $3 J006 Fexofenadine 180mg 15ct $10 J008 Fluticasone Nasal Spray 60 sprays PRODUCT J004 Loratadine 10mg 30ct $5 J003 Saline Nasal Spray 0.65% 44ml $3 Antacids C009 Antacid Liquid 12oz $4 C013 Assorted Antacid 500mg 150ct $3 C014 Famotidine 10mg 30ct $5 C008 Milk of Magnesia 12oz $3 C015 Omeprazole Magnesium 20.6mg 14ct $12 C010 Pink Bismuth 8oz $5 C011 Ranitidine 75mg 30ct $5 C012 Simethicone 125mg 60ct $5 C016 Stomach Relief Chewable Tablet 30ct Anticandidal $4 QTY MINIMUM $25
COLUMN 1 PRODUCT QTY COLUMN 2 R001 Clotrimazole 1% Vaginal Cream 45gm $10 R002 Miconazole 3 Day Treatment $17 R003 Tioconazole 1 Day Treatment Antidiarrheal and Laxative H055 Bisacodyl 5mg 25ct $3 H058 H057 Docusate Sodium 100mg 100ct Docusate Sodium 250mg 100ct $4 H060 Ex-Lax 24ct $12 H061 Glycerin Suppository 12ct $4 H056 Loperamide 2mg 12ct $3 H062 H059 Natural Vegetable Laxative 8.6mg 100 ct Ready to Use Saline Enema 118ml $3 H063 Senna Plus 60ct $8 Braces & Supports S006 Adjustable Ankle Support $15 PRODUCT S001 Elastic Bandage 3in x 5yd $5 S005 Universal Back Support $35 S003 Universal Tennis Elbow Strap $10 S004 S002 Universal Wrap Around Knee Support Universal Wrap Around Wrist Support Cough/Cold $25 F015 Cough Drops 30ct $3 F025 Cough Drops Sugarfree 25ct $3 F026 Daytime Cold/Flu Relief 8oz $6 F019 Guaifenesin 4oz $4 F023 Medicated Chest Rub 3.5oz $3 F028 Mucus Relief DM Tablet 24ct $8 F027 Mucus Relief Tablet 30ct F022 F021 Nasal Decongestant PE 10mg 36ct Nasal Spray (Oxymetazoline) 0.05% 30ml $5 $3 F024 Night Time Liquid 12oz $6 F020 Sore Throat Spray 6oz $4 F018 Tussin CF Syrup 4oz $4 F017 Tussin DM Sugar Free Syrup 4oz $4 F016 Tussin DM Syrup 4oz $4 Dental M101 Dental Floss 55yd $3 M098 Denture Adhesive Cream 2.4oz $6 M102 Denture Cleanser Tablets 40ct $5 M104 Floss Pick 90ct $5 M105 Oral Pain Relief Gel 20% QTY
COLUMN 1 PRODUCT QTY COLUMN 2 M103 Sensitive Teeth Toothpaste 4.3oz $6 M100 Toothbrush $3 M099 Toothpaste 5.5oz $3 G005 Diagnostics Automatic Blood Pressure Monitor $40 G004 Digital Ear Thermometer $30 G003 Digital Thermometer $5 G007 Pulse Oximeter $40 G006 Wrist Blood Pressure Monitor $50 Digestive Health G008 Beano 30ct $8 G009 Dairy Relief Tablet 60ct $12 Ear Care Q001 Ear Syringe $6 Q002 Ear Wax Drops 15ml $3 Eye Care D027 Alaway Eye Itch Relief 10ml $15 D032 Artificial Tears 15ml $4 D036 Contact Rinse/Store Solution 12oz $10 D033 Eye Wash 118ml D034 Ketotifen 0.025% Drops 5ml $10 D035 Lubricant Eye Drops PF 30ct $12 D037 Lubricating Eye Ointment 3.5gm D026 Redness Relief Eye Drops 15ml $3 D029 Refresh Tears 15ml $15 D030 Refresh Tears PF 30ct $15 D028 Systane Eye Drops 15ml $15 Fiber Supplements O001 Fiber Gummies 120ct $15 O002 Fiber Powder 13oz $10 O003 Fiber Powder S/F 10oz $10 O004 Fiber Tablets 625mg 90ct $10 First Aid L099 Abreva Cream 2gm $25 L045 Adhesive Tape 1 in - 5 yd $3 L041 Alcohol Prep Pads 100 ct $3 L101 Anti-Itch Cream 1oz $3 L117 Aspercreme w/lidocaine 2.7oz $8 L037 Assort Sheer Bandages 100ct $3 L040 Bacitracin Ointment 1oz $4 L116 PRODUCT Benzoyl Peroxide 10% Gel 1.5oz $10 L044 Calamine Lotion 6oz $4 L112 Capsaicin 0.025% Cream 2oz $10 L113 Cold & Hot Patch 5ct $10 L038 Cotton Balls 100ct $3 L047 Cotton Swabs 300ct $3 L043 Epsom Salt 16oz $4 L103 First Aid Kit $10 L104 Heating Pad L105 Hemorrhoid Ointment 2oz QTY
COLUMN 1 PRODUCT QTY COLUMN 2 PRODUCT QTY L106 Hemorrhoid Relief Pads 100ct L107 Hemorrhoid Suppositories 12 ct $5 L032 Hydrocortisone Cream 1oz $3 L031 Hydrocortisone Ointment 1oz $3 L042 Hydrogen Peroxide 16oz $4 L098 Ice Bag 9 inch L049 Icy Hot 3oz L036 Isopropyl Alcohol 70% 16oz $4 L114 Lice Treatment Shampoo 4oz $12 L050 Muscle Rub 3oz $5 L115 Permethrin 1% Creme Rinse 2oz $12 L108 Petroleum Jelly 3.75oz $3 L046 Rolled Gauze 3 in x 2.5 yd $3 L097 Salonpas Gel 2.75oz $10 L035 Salonpas Patch 60ct $10 L039 SPF 15 Lip Balm 0.15oz $3 L111 SPF 50 Sunscreen 8oz $12 L033 Triple Antibiotic Ointment 1oz $4 Foot Care B060 Callus Cushion 6ct $3 B054 Clotrimazole 1% Cream 1oz $5 B055 Corn and Callus Remover Liquid 9ml $6 B053 Foot Powder 7oz $5 B061 Medicated Corn Remover 9ct $4 B056 Miconazole 2% Cream 1oz B057 Terbinafine 1% Cream 0.5oz $12 B058 Tolnaftate 1% Cream 1oz B059 Tolnaftate 1% Powder 45gm Incontinence Supplies N008 A & D Ointment 2oz $4 N009 Barrier Cream 4oz $8 N001 N002 N003 N004 Bladder Control Briefs Large 20ct Bladder Control Briefs Medium 20ct Bladder Control Briefs Regular 20ct Bladder Control Briefs Small 20ct N005 Bladder Control Briefs XL 20ct $25
COLUMN 1 PRODUCT QTY N006 Bladder Control Pads 28ct N007 Disposable Underpad 5ct $5 Pain Reliever A063 Acetaminophen 325mg 100ct $3 A064 Acetaminophen 500mg 100ct $4 A067 A066 Acetaminophen 650mg ER Arthritis Relief 50ct Acetaminophen PM 500/25mg 100ct A058 Adult Chew Aspirin 81mg 36ct $3 A059 Aspirin 325mg 100ct $3 A060 Aspirin EC 325mg 100ct $3 A061 Aspirin EC 81mg 120ct $3 A068 Effervescent Pain Relief 36ct $5 A069 Headache Relief 100ct A062 Ibuprofen 200mg 50ct $3 A065 Naproxen 220mg 50ct $6 A070 Urinary Pain Relief 30ct Smoking Cessation P001 Nicotine Gum 2mg 110ct $40 P002 Nicotine Gum 4mg 110ct $40 P003 Nicotine Lozenge 2mg 72ct $50 P004 Nicotine Lozenge 4mg 72ct $50 P005 Nicotine Patch Step 1 14ct $40 P006 Nicotine Patch Step 2 14ct $40 P007 Nicotine Patch Step 3 14ct $40 E093 E083 E084 Vitamins Calcium 500mg + D Chew Tablets 60ct Calcium Carbonate/Vit D 600mg/400IU 60ct Calcium Citrate/Vit D 315mg/200IU 60ct $3 $5 E087 CoQ10 Softgels 50mg 30ct $10 E094 Eye Health Multivitamin 60ct E079 Ferrous Sulfate 325mg 100ct $3 E088 Fish Oil 1000mg 60ct $6 E089 Fish Oil 1000mg No-Burp 90ct $10 E078 Folic Acid 400mcg 100ct $3 E082 Glucosamine- Chondroitin 500/400mg 60ct $12 E077 Magnesium 250mg 100ct $5 E092 Melatonin 3mg Tablets 60ct $5 E068 Multivitamin 100ct $3 E069 Multivitamin With Iron 100ct $3 E080 Niacin 100mg 100ct $3 E081 Niacin 250mg 100ct E071 E070 Oyster Shell Calcium + D 500mg/ 200IU 60 ct $3 Oyster Shell Calcium 500mg $3 60ct * E067 Senior Multivitamin 60ct $4 E090 Slow Release Iron 60ct $8 E091 Super B- 50 100ct $10 E073 Vitamin B-12 100mcg 100ct $3 E072 Vitamin B-6 50mg 100ct $3 E076 Vitamin C 500mg 100ct $5 E095 Vitamin C 500mg Chew Tablets 100ct $5 E085 Vitamin D 1000IU 100ct $3 E086 Vitamin D 2000IU 100ct $5 E075 Vitamin E 400IU 100ct $5 E096 Zinc 50mg 100ct $4
Integrated HMO Pharmacy Integrated OTC Program P.O. Box 369 Boys Town, NE 68010 PLACE STAMP HERE