2 0 1 8 년도 일반의약품 주문서 0001_2018_OTCOrderForm_KR BND_6240
Brand New Day 의회원은가정으로일반의약품 (over-the-counter, OTC) 을무상으로전달받을수있습니다. 일반의약품을받기위해서는처방전이필요하지않습니다. 매달한번의주문을할수있습니다. 각주문의총액은최소 $25 가되어야합니다 남은잔액은이월되지않습니다. 주문은총 2 개월전에미리할수있습니다. 의약품은보통주문이접수되어확인된날로부터십일내에도착합니다. 미리주문한의약품은달시작첫십일내에주로도착하게되어있습니다 여러분의분기별일반의약품허용량을알기위해서는 EOC 를확인해주시거나 Brand New Day 의멤버서비스전화번호인 1-866-255-4795 에전화주시길바랍니다. (TTY 인분들은 1-866-321-5955 에전화해주시길바랍니다 ) 월요일 - 금요일, 8 a.m - 8 p.m. 주문을위한두가지방법 1: www.integratedotc.com 을방문합니다. IntegratedOTC.com 을방문하여주문하는경우, 주문이가능한모든항목 ( 신제품포함 ) 을볼수있으며주문배송추적정보를확인할수있으므로가장좋은방법입니다. 2: 전화, 팩스또는우편으로주문합니다. a) 본안내서의다른면에있는의약품목록을확인하여원하는제품을선택합니다. b) 전화주문을하시려면 1-866-632-7961 (TTY 1-866-706-4757) 로전화하여주문하시기바랍니다. 통화는월요일부터금요일, 아침 6 시부터저녁 6 시까지가능합니다. c) 팩스나우편발송으로주문하시는경우, 본양식의다른면을작성하십시오. 다작성하신후, 작성한양식을 1-888-260-2323 으로팩스를보내시거나, 우편발송을하시길바랍니다. OTC 혜택이나 OTC 주문에질문이있으신가요? 1-866-632-7961 (TTY/TDD: 1-866-706-4757) 에전화해주세요.
이름 전화번호 멤버아이디넘버 주소 도시 주 집코드 주문하기원하는달 : 하나에동그라미치세요. 두달까지미리주문할수있습니다 : 1 월 2 월 3 월 4 월 5 월 6 월 7 월 8 월 9 월 10 월 11 월 12 월 서명 COLUMN 1 PRODUCT QTY COLUMN 2 PRODUCT QTY Additional Items G001 Pill Box $3 G002 Travel Sickness 25mg 8ct $3 Allergy J005 Cetirizine 10mg 30ct $7 J009 Chlorpheniramine 4mg 100ct $7 J010 Cough & Cold High $7 BP Tablet 16ct J011 Cromolyn Sodium Nasal $15 Spray 26ml J007 Diphenhydramine 25mg 24ct $3 J006 Fexofenadine 180mg 15ct $10 J008 Fluticasone Nasal Spray $20 60 sprays 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 $12 Magnesium 20.6mg 14ct C010 Pink Bismuth 8oz $5 C011 Ranitidine 75mg 30ct $5 C012 Simethicone 125mg 60ct $5 C016 Stomach Relief $4 Chewable Tablet 30ct Anticandidal R001 Clotrimazole 1% $10 Vaginal Cream 45gm R002 Miconazole 3 Day Treatment $17 R003 Tioconazole 1 Day Treatment $20 각주문의총액은최소 $25 가되어야합니다
COLUMN 1 PRODUCT QTY COLUMN 2 PRODUCT QTY Antidiarrheal and Laxative H055 Bisacodyl 5mg 25ct $3 H058 Docusate Sodium 100mg $4 100ct H057 Docusate Sodium 250mg $7 100ct H060 Ex-Lax 24ct $12 H061 Glycerin Suppository 12ct $4 H056 Loperamide 2mg 12ct $3 H062 Natural Vegetable $7 Laxative 8.6mg 100 ct H059 Ready to Use Saline Enema $3 118ml H063 Senna Plus 60ct $8 Braces & Supports S006 Adjustable Ankle Support $15 S001 Elastic Bandage 3in x 5yd $5 S005 Universal Back Support $35 S003 Universal Tennis Elbow Strap $10 S004 Universal Wrap Around Knee $25 Support S002 Universal Wrap Around Wrist Support $7 Cough/Cold 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 $7 F022 Nasal Decongestant PE $5 10mg 36ct F021 Nasal Spray (Oxymetazoline) $3 0.05% 30ml F024 Night Time Liquid 12oz $6 F020 Sore Throat Spray 6oz $4 F018 Tussin CF Syrup 4oz $4 F017 Tussin DM Sugar Free Syrup $4 4oz F016 Tussin DM Syrup 4oz $4 Dental M101 Dental Floss 55yd $3 M098 Denture Adhesive Cream $6 2.4oz M102 Denture Cleanser Tablets 40ct $5 M104 Floss Pick 90ct $5 M105 Oral Pain Relief Gel 20% $7 M103 Sensitive Teeth Toothpaste $6 4.3oz M100 Toothbrush $3 M099 Toothpaste 5.5oz $3 Diagnostics G005 Automatic Blood Pressure $40 Monitor G004 Digital Ear Thermometer $30 G003 Digital Thermometer $5 G007 Pulse Oximeter $40 G006 Wrist Blood Pressure Monitor $50
COLUMN 1 PRODUCT QTY COLUMN 2 PRODUCT QTY 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 $10 12oz D033 Eye Wash 118ml $7 D034 Ketotifen 0.025% Drops 5ml $10 D035 Lubricant Eye Drops PF 30ct $12 D037 Lubricating Eye Ointment 3.5gm $7 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 Benzoyl Peroxide 10% Gel $10 1.5oz 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 $20 L105 Hemorrhoid Ointment 2oz $7 L106 Hemorrhoid Relief Pads 100ct $7 L107 Hemorrhoid Suppositories $5 12 ct L032 Hydrocortisone Cream 1oz $3 L031 Hydrocortisone Ointment 1oz $3 L042 Hydrogen Peroxide 16oz $4 L098 Ice Bag 9 inch $7 L049 Icy Hot 3oz $7 L036 Isopropyl Alcohol 70% 16oz $4 L114 Lice Treatment Shampoo 4oz $12 L050 Muscle Rub 3oz $5 L115 Permethrin 1% Creme Rinse $12 2oz 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
COLUMN 1 PRODUCT QTY COLUMN 2 PRODUCT QTY Foot Care B060 Callus Cushion 6ct $3 B054 Clotrimazole 1% Cream 1oz $5 B055 Corn and Callus Remover $6 Liquid 9ml B053 Foot Powder 7oz $5 B061 Medicated Corn Remover 9ct $4 B056 Miconazole 2% Cream 1oz $7 B057 Terbinafine 1% Cream 0.5oz $12 B058 Tolnaftate 1% Cream 1oz $7 B059 Tolnaftate 1% Powder 45gm $7 Incontinence Supplies N008 A & D Ointment 2oz $4 N009 Barrier Cream 4oz $8 N001 Bladder Control Briefs Large $20 20ct N002 Bladder Control Briefs $20 Medium 20ct N003 Bladder Control Briefs Regular $20 20ct N004 Bladder Control Briefs Small $20 20ct N005 Bladder Control Briefs XL 20ct $25 N006 Bladder Control Pads 28ct $20 N007 Disposable Underpad 5ct $5 Pain Reliever A063 Acetaminophen 325mg 100ct $3 A064 Acetaminophen 500mg 100ct $4 A067 Acetaminophen 650mg ER $7 Arthritis Relief 50ct A066 Acetaminophen PM 500/25mg $7 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 $7 A062 Ibuprofen 200mg 50ct $3 A065 Naproxen 220mg 50ct $6 A070 Urinary Pain Relief 30ct $7 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
COLUMN 1 PRODUCT QTY Vitamins E093 Calcium 500mg + D Chew $7 Tablets 60ct E083 Calcium Carbonate/Vit D $3 600mg/400IU 60ct E084 Calcium Citrate/Vit D $5 315mg/200IU 60ct E087 CoQ10 Softgels 50mg 30ct $10 E094 Eye Health Multivitamin 60ct $7 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- $12 Chondroitin 500/400mg 60ct 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 $7 E071 Oyster Shell Calcium + D $3 500mg/ 200IU 60 ct E070 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 $5 Tablets 100ct 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