Sample medications
Sometimes health care providers give sample asthma
medications to their patients. If your health care
provider gave you sample medications, please have
him/her complete and sign this section. Then, include
it with our completed brochure to earn your gift card.
This section should be completed if you received
sample asthma medications.
Name:
Aetna Better Health ID#:
After collecting your signatures and completing the
information on your Asthma care card, send your
completed card to the address below.
You’ll receive your gift card in the mail.
Aetna Better Health of Missouri
QI department
10 S. Broadway, Suite 1200
St. Louis, MO 63102
Member’s Date of Birth:
Health care provider’s name:
Health care provider’s signature:
Indicate any sample medication(s) given along with dose,
route and date provided to member:
Short-Acting
Bronchodilators
• Albuterol
- Proair
- Proventil
- Ventolin
- Accuneb
• Alupert
• Combivent
• Duoneb
• Maxair
• Xopenox
Long-Acting
Bronchodilators
• Serevent
• Foradil
• Perforomist
• Theophylline
- Uniphy
- Theo-dur
- Slo-bid
- Theo24
Oral
Corticosteroid
• Prednisone
Antihistamine
• Claritin (loratidine)
• Zyrtec (ceterizine)
Inhaled
Corticosteroids
• Advair
• Pulmicort
• Flovent
• Asmanex
• Azmacort
• Symbicort
• Pulmicort
• Aerobid
Medication:
___________________
Mast Cell
Stabilizers
• Intal
• Tilade
Medication:
___________________
Antiasthmatic
Combinations
___________________
Dose and route:
___________________
Date provided
to member:
___________________
For more information about this incentive program,
just call Member Services at 1-800-566-6444.
___________________
Dose and route:
___________________
• Dyphylline- guaifenesin
• Guaifenesin-
theophylline
• Potassium
iodide-
theophylline
Date provided
to member:
___________________
Leukotriene
Modifiers
• Accolate
• Singulair
• Zyflo
___________________
Para recibir una copia traducida de este documento,
llame al servicio para miembros al 1-800-566-6444.
Dose and route:
___________________
www.aetnabetterhealth.com/mo
Medication:
___________________
Date provided
to member:
___________________
To receive a translated copy of this document, call
Member Services at 1-800-566-6444.
MO-15-05-59
AETM15008 7/17/2015
OF MISSOURI
Asthma care for your child
Your Asthma care card
Name:__________________________________________
Aetna Better Health ID #:___________________________
Member’s Date of Birth:____________________________
Address:________________________________________
City:____________________________________________
Routine asthma care is very important for both adults
and children. Regular asthma visits help you live with
few or no asthma symptoms. At your asthma visits,
your health care provider makes sure you have the right
asthma medications to keep your asthma in control.
Your health care provider also makes sure that you
have an asthma action plan. Having the right
medications and knowing what to do if you have
asthma symptoms help make sure asthma symptoms
do not limit your activities.
How do I qualify?
To qualify for the gift card,
Aetna Better Health of Missouri members must:
1. Have regular checkups
2. Fill the prescribed asthma medicines at a local
pharmacy or clinic
• Your provider may give you a sample asthma
medication. If so, your provider should complete
the Sample Medications section of this brochure.
3. Have your brochure signed by
• Your PCP or asthma care provider
• The person who fills your prescriptions
4. Mail the completed and signed brochure to
Aetna Better Health of Missouri. We’ll send you a
gift card.
Who keeps the brochure?
You should keep this Asthma care brochure in a safe
place. You won’t receive the gift card until both
signatures are completed. If the brochure is lost, please
call us so we can send another one.
State, Zip:______________________________________
Telephone #:_____________________________________
Only one (1) $30 gift card will be sent per member, per
month.
When do I turn the card in?
Send the brochure to Aetna Better Health of Missouri
after:
Regular checkup or asthma visit
Signature
Date
• Your provider visit
• The asthma medications are filled
Make sure valid representatives sign the brochure for
each step. Mail the completed brochure to:
Aetna Better Health of Missouri
10 S. Broadway, Suite 1200
St. Louis, MO 63102
Filled prescription at clinic or pharmacy
Signature
Lost or stolen gift cards cannot be replaced.
Date