Form La-15-11-06 - Aetna Better Health Form
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1
2 N ame (Nombre)
A ddress (Dirección)
AETNA BETTER HEALTH®
d/b/a Aetna Better Health of Louisiana
M ember ID ( Numero de Membresia)
Phone (Telefono)
First Aid
B rand
P rice
Vitamins / Minerals
B rand
P rice
I tem
Q ty
I tem
Q ty
(Primeros Auxilios)
Marca
Precio
(Vitaminas / Minerales)
Marca
Precio
F 1
ELASTIC BANDAGE
1 ct
3 .99
V 1
B -Complex Vitamin 100%
1 00 ct
B-COMPLEX
4 .49
F10
DIAPER RASH OINTMENT
2 oz
3.99
V10
GLUCOSAMIN/CHONDROITIN
50 ct
Nature's Bounty
10.99
F2
MUSCLE RUB
3 oz
BEN-GAY
5.99
V11
CALCIUM 500 MG +D
75 ct
CITRACAL
5.49
F21
IODINE
1 oz
2.49
V14
A 10,000 IU NATURAL
100 ct
Nature's Bounty
4.99
F22
MERTHIOLATE
2 oz
3.99
V15
CHEWABLE MULTIVITAMINS
100 ct FLINTSTONES
6.99
F24
FIRST-AID KIT
Each
6.99
V16
VITAMIN E 400 MG IU
100 ct NATURE MADE
12.99
F34
HOT/COLD MULTI-COMPRESS
1 ct
8.49
V17
FOLIC ACID 800 MCG
100 ct FOLIC ACID
3.49
F62
FIRST AID TAPE
each
1.99
V19
OMEGA-3 FISH OIL 1000 MG
100 ct PURITAN
7.99
F9
CLEAR BANDAGES
45 ct
3.99
V2
VITAMIN C 500 MG
100 ct NATURE MADE
6.99
M53 GAUZE
1 ct
1.99
V22
COLLAGEN 500 MG
100 ct
8.49
BOTANIC CHOICE
M iscellaneous / Sunscreen Lotion (Misceláneo / Locion Protectora Del Sol)
V 26
V ITAMIN D 400 MG IU
1 00 ct NATURE MADE
2.99
M1
SUNBLOCK ULTRA SHEER SPF 45
3 oz
NEUTROGENA
6.99
V3
CALCIUM CARBONATE 600 MG+ D
60 ct
Caltrate
4.49
M23 HAND SANITIZER
2 oz
PUREL
0.99
V6
DAILY MULTI VITAMIN
100 ct ONE A DAY
5.99
M45 ALCOHOL PREP PADS
100 CT
3.99
V7
COMPLETE SENIOR VITAMINS
100 ct Centrum Silver
9.99
X71
Each
24.99
V32
VITAMIN D 1,000 MG IU
100 CT NATURE MADE
3.49
BLOOD PRESSURE MONITOR AUTO INFLATE
X72 BLOOD PRESSURE MONITOR MANUAL
Each
17.99
V33
VITAMIN B-12 1000 MCG
100 CT NATURE MADE
8.99
X80 MAXI PADS REGULAR
48 ct
STAYFREE
5.49
V35
MAGNESIUM 500 MG
100 CT
Nature's Bounty
4.49
X82 TAMPON PLASTIC
20 ct
TAMPAX PEARL
4.49
V36
ZINC GLUCONATE 50 MG CHELATED 100 CT FDC
4.49
D ental Teeth Related (Dental)
F35
LIQUID CORN & CALLUS REMOVER
.5 oz
3.99
M3
LIP BALM
.15 oz
1.99
X 2
D ENTURE TABS
84 ct
5 .49
M11 BABY POWDER WITH CORNSTARCH
4 oz
J&J
1.99
X6
DENTURE ADHESIVE REGULAR
2.4 oz
3.99
M12 BABY WIPES
20 ct
J&J
1.99
M2
TOOTHBRUSH
1 ct
0.99
M48 OIL OF BEAUTY
6 oz
OLAY
6.99
M35
DENTAL FLOSS WAXED
100 yd
2.49
X74 BLADDER CONTROL PADS MODERATE
20 ct
POISE
5.99
X75 WOMEN S/M UNDERWEAR XTRA
20 ct
12.99
X76 MEN L/XL UNDERWEAR MAX
16 ct
12.99
X77 MEN S/M UNDERWEAR MAX
18 ct
12.99
M39 UNISEX FOAM INSOLES
Each
2.49
M51 WEEKLY PILL BOX PLANNER LARGE
Each
2.49
M43 TWEEZERS
Each
1.99
M edicines, ointments and sprays with active medical ingredients that cure, diminish or remove symptoms
Medicamentos, ungüentos y aerosol con ingredientes medicinales activos que curan o eliminan los síntomas
Y ou will receive the generic equivalent of all items.
Usted recibira el generico de todos los productos.
If you need this in larger print or another format, call Member Services at 1-855-242-0802, TTY 7-1-1.
Llame hoy mismo al 1-855-242-0802, TTY, 7-1-1 si usted desea recibir esta carta en español.
LA-15-11-06 Date Issued 12-01-15
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