Humana Order Form PDF Details

Have you ever had to order insurance materials from Humana? If so, you know that the process can be a bit confusing. Thankfully, our guide will take the guesswork out of it for you. We'll provide an overview of the Humana order form, as well as information on how to submit your request.

Here is some data that may be useful in case you're aiming to find out the time it'll require you to complete humana order form and the number of PDF pages it has.

QuestionAnswer
Form NameHumana Order Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other nameshumana otc catalog, humana otc catalog 2021, humana wellness order form, humana otc

Form Preview Example

Did you know that depending on your current Humana plan, you may be able to purchase

Health and Wellness products from the RightSource mail-order pharmacy?

Call RightSource at 1-855-211-8370 (TTY: 711) to verify your eligibility or request an order form. Customer Care Representatives are available Monday Friday, 8 a.m. to 11 p.m. and Saturday, 8 a.m. to 6:30 p.m., Eastern time.

How to Order:

Keep this catalog. You will need this to look up the Health and Wellness products you want to order each month.

Place your order no later than the 20th of each month to ensure that RightSource is able to process your order within the applicable benefit month. If your total order exceeds your benefit amount limit, please be sure to include a check, money order, or credit card information to pay the remaining amount due. Failure to submit payment in full will lead to a delay in shipment.

You can place your order:

Online: Go to RightSourceRx.com

Mail: Fill out the Health and Wellness Order Form and mail only the order form pages to:

RightSource PO Box 1197

Cincinnati, OH 45201-1197

Fax: Fill out the Health and Wellness Order Form and fax only the order form

pages to: 1-800-379-7617

*This order form is for the 2014 benefit year. Please do not submit your first order until January, 2014

Y0040_GNHHA5RHH_C Accepted

Version 17

 

Humana Health and Wellness Order Form

STEP 1: COMPLETE YOUR INFORMATION BELOW

Member ID (Found on Humana ID card)

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

M

 

D

 

D

 

Y

 

Y

 

Y

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender

Male Female

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Number & Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evening Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEP 2: COMPLETE PRODUCT SELECTION

During which month would you like to receive this order?*

Product Code

Product Name

Check box if this is a new address

M M

Quantity Price

1OTC

____________________________________

_____

2OTC

____________________________________

_____

3OTC

____________________________________

_____

4OTC

____________________________________

_____

5OTC

____________________________________

_____

6OTC

____________________________________

_____

7OTC

____________________________________

_____

8OTC

____________________________________

_____

9OTC

____________________________________

_____

10OTC

___________________________________

_____

*Please note: Orders can only be placed for the current or a future month. RightSource is not able to backdate an order for a previous month.

Y0040_GNHHA5RHH_C Accepted

Humana Health and Wellness Order Form

Member ID (Found on Humana ID card)

Your Total Order Amount

$________

Humana Monthly Allowance

$________

Total Remaining Amount Due

$________

If your total order is less than our pla ’s

o thl

allo a e, you DO NOT need to include

payment and you will receive the items you ordered.

If your order exceeds our pla ’s o thl

allowance, please include your check, money

order, or enter your credit card information below to pay the remaining amount due. Failure to submit payment in full will lead to a delay in shipment.

Step 3: Payment Information (if applicable)

Please make checks payable to RightSource. Please do not send cash. There is a $25 charge for all returned checks.

To pay by Credit Card, please complete the following:

Credit / Debit Card #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

M

 

 

 

Y

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder First Name

 

 

 

 

 

 

 

 

Cardholder Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder Signature

Note: A monthly allowance amount is only available if your plan offers the over-the-

counter (OTC) services as a benefit. Call RightSource at 1-855-211-8370 (TTY: 711) to confirm your eligibility, Monday Friday, 8 a.m. to 11 p.m., and Saturday, 8 a.m. to 6:30 p.m. Eastern time.

Orders will be shipped to your home by UPS or the US Postal Service at no extra charge to

you. Please allow 10 to 14 business days from the time we receive your order to delivery. You’ll re ei e a ge eri o para le to the a e-brand product. Please consult your doctor

before using any over-the-counter (OTC) product. This product list is subject to change.

Y0040_GNHHA5RHH_C Accepted

Humana Health and Wellness Product Catalog

Antacids, Anti-Diarrheals, and Laxatives

Product

Product Name

 

Compare To

Package

Price

Code

 

 

 

Count

 

 

075

 

Antacid / Anti-Gas Chew Tablets

 

Maalox® Plus

100

 

$7

 

032

 

Antacid / Anti-Gas Liquid

 

Mylanta®

360 ml

$9

 

 

 

 

 

 

 

 

 

 

089

 

Antacid Double Strength Chew Tab

 

Mylanta® Double Strength

70

 

$9

 

029

 

Anti-Diarrheal Tablets Loperamide 2 mg

 

Imodium® AD

12

 

$4

 

031

 

Anti-Hemorrhoidal Ointment

 

Preparation H®

60 gm

 

$7

 

203

 

Calcium Carbonate Antacid Regular

 

Tums E-X®

150

 

$4

 

 

Strength

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

227

 

Calcium Carbonate Antacid Chews 750 mg

 

Extra Strength Tums E-X®

96

 

$5

 

116

 

Dairy Digestive Supplement Lactase

 

Lactaid® Tabs

60

 

$10

 

 

Enzyme

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

003

 

Enema

 

Fleet® Enema

2

 

$5

 

098

 

Extra Strength Gas Relief Tablets 125 mg

 

Gas-X® Extra Strength

30

 

$5

 

 

 

 

 

 

 

 

 

 

208

 

Fiber Laxative Tablets

 

Fibercon®

90

 

$9

 

234

 

Glycerin Suppositories for Adults

 

Fleet®

25

 

$5

 

 

 

 

 

 

 

 

 

 

216

 

Hemorrhoidal Suppositories

 

Preparation H® Suppositories

12

 

$6

 

093

 

Laxative Bisacodyl 5 mg

 

Dulcolax®

25

 

$5

 

033

 

Milk of Magnesia Laxative / Antacid

 

Phillips® Milk of Magnesia

360 ml

 

$5

 

120

 

Motion Sickness Tablets

 

Dramamine® Tablets

12

 

$5

 

 

Dimenhydrinate 50 mg

 

 

 

 

 

 

 

 

 

 

 

112

 

Omeprazole Magnesium 20 mg

 

Prilosec OTC® 20 mg

14

 

$11

 

115

 

Pink Bismuth Chewable Tablets

 

Pepto-Bismol® Chew Tabs

30

 

$6

 

 

 

 

 

 

 

 

 

 

258

 

Psyllium Fiber Laxative Capsules

 

Metamucil® Capsules

160

 

$11

 

104

 

Ranitidine Antacid Tablets 75 mg

 

Zantac®

30

 

$7

 

 

 

 

 

 

 

 

 

 

233

 

Senna Laxative Tablets 8.6 mg

 

Senokot

100

 

$10

 

101

 

Stool Softener Capsules

 

Colace®

100

 

$7

 

 

 

 

 

 

 

 

 

 

Cough, Cold, and Allergy

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

113

Antihistamine Cetirizine HCL 10 mg

Zyrtec® 10 mg

30

$12

024

Antihistamine Diphenhydramine Liquid

Benadryl® Allergy Childrens

120 ml

$5

50 mg

 

 

 

 

 

 

 

 

 

110

Antihistamine Loratadine 10 mg

Claritin®

30

$10

023

Antihistamine Diphenhydramine 25 mg

Benadryl®

24

$6

 

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

Page 1

Humana Health and Wellness Product Catalog

Cough, Cold, and Allergy (continued)

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

028

Cough Formula Expectorant

Robitussin®

120ml

$5

210

Cough Suppressant DM Sugar Free

Robitussin® DM Sugar Free

118 ml

$7

 

 

 

 

 

026

Cough Suppressant / Expectorant

Robitussin® DM

120 ml

$6

 

 

 

 

 

096

Cough Suppressant / Expectorant / Nasal

Robitussin® CF

120 ml

$5

Decongestant

 

 

 

 

 

 

 

 

 

260

Cough and Cold High Blood Pressure

Coricidin HBP®

16

$5

 

 

 

 

 

237

Daytime PE Cough and Cold

Dayquil®

16

$6

 

 

 

 

 

111

Expectorant Guaifenesin 400 mg

Mucus Relief 400 mg

30

$11

249

Fexofenadine 24 Hour 180 mg

Allegra Allergy

30

$17

 

 

 

 

 

043

Medicated Chest Rub

Vicks VapoRub®

99 gm

$6

 

 

 

 

 

228

Nasal Decongestant PE Max Strength

Sudafed® PE Tablets

36

$6

10 mg

 

 

 

 

 

 

 

 

 

095

Nasal Decongestant Spray

Afrin®

30 ml

$5

 

 

 

 

 

099

Saline Nasal Spray

Ocean® Saline Nasal Spray

45 ml

$5

 

 

 

 

 

097

Sinus Acetaminophen 325 mg /

Tylenol® Sinus

24

$6

Phenylephrine HCI 5 mg

 

 

 

 

117

Sore Throat Lozenges Menthol /

Chloraseptic® Lozenges

18

$5

Benzocaine

 

 

 

 

220

Sore Throat Spray

Chloraseptic® Spray

180 ml

$6

 

 

 

 

 

First Aid Medical Supplies

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

035

Alcohol Prep Pads

Alcohol Swabs

100

$6

 

 

 

 

 

226

Elastic Bandage

Ace® Bandage

1

$6

 

 

 

 

 

232

First Aid Tape

J&J® First Aid Tape

1

$3

 

 

 

 

 

044

Plastic Bandages

Band-Aids®

100

$5

 

 

 

 

 

040

Triple Antibiotic Ointment

Neosporin®

30 gm

$6

 

 

 

 

 

231

Triple Antibiotic Ointment Plus

Neosporin Plus®

30 gm

$7

 

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

Page 2

Humana Health and Wellness Product Catalog

Pain Relievers

Product

Product Name

Compare To

Package

Price

Code

 

 

 

Count

 

002

Acetaminophen 500 mg

Extra Strength Tylenol

100

$6

 

 

 

 

 

 

020

Acetaminophen 80 mg Chewable

Tylenol® Childre

’s Che a le

30

$5

 

 

 

 

 

021

Acetaminophen Elixir

Childre ’s T le ol® Elixir

120 ml

$5

282

Aspirin 81 mg Chewable

Bayer® Chewable Aspirin

90

$5.50

 

 

 

 

 

 

047

Aspirin 325 mg

Bayer®

 

100

$5

 

 

 

 

 

 

016

Aspirin Low Dose 81 mg EC

Bayer® Adult Low Strength EC

120

$6

 

 

 

 

 

 

229

Aspirin 325 mg Enteric

Ecotrin®

 

100

$6

 

 

 

 

 

 

213

Cold and Hot Patches Pain Relief

Icy Hot® Patch

 

5

$7

 

 

 

 

 

 

215

Effervescent Pain Relief

Alka-Seltzer®

 

36

$6

 

 

 

 

 

 

125

Headache Formula Aspirin,

Excedrin®

 

100

$7

Acetaminophen, Caffeine

 

 

 

 

 

 

 

 

 

 

 

 

019

Ibuprofen 200 mg

Advil®

 

50

$5

 

 

 

 

 

 

094

Ibuprofen Suspension

Childre ’s Motri

®

120 ml

$6

 

 

 

 

 

 

046

Muscle Rub

Ben-Gay®

 

120 gm

$7

 

 

 

 

 

 

283

Naproxen Sodium 220 mg Pain Reliever

Aleve® Caplets

 

100

$9

 

 

 

 

 

 

230

Therapeutic Mineral Ice Gel

Mineral Ice®

 

227 gm

$8

 

 

 

 

 

 

119

Topical Analgesic Capsicum Cream

Zostrix® Cream

 

60 gm

$8

0.025%

 

 

 

 

 

 

Personal Care

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

256

Absorbent U der Pads ” 6”

Protection Plus Under Pad

20

$20

251

Adult Incontinence Underwear Small

Protection Plus Protective

22

$20

Underwear Small

 

 

 

 

252

Adult Incontinence Underwear Medium

Protection Plus Protective

20

$20

Underwear Medium

 

 

 

 

253

Adult Incontinence Underwear Large

Protection Plus Protective

18

$20

Underwear Large

 

 

 

 

254

Adult Incontinence Underwear X-Large

Protection Plus Protective

14

$20

Underwear X-Large

 

 

 

 

255

Adult Incontinence Underwear XX-Large

Protection Plus Protective

12

$20

Underwear XX-Large

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

 

Page 3

Humana Health and Wellness Product Catalog

Personal Care (continued)

Product

Product Name

Compare To

 

Package

Price

Code

 

 

 

 

Count

 

243

Bladder Control Pads (Regular)

Poise® Moderate Pads

 

20

$9

 

 

 

 

 

 

 

242

Blood Pressure Home Kit (Manual pump

Blood Pressure Home Kit

 

1

$17

with Stethoscope)**

 

(Manual pump w/ Stethoscope)

 

 

 

 

 

 

 

 

 

 

 

036

Cotton Swabs

 

Q-Tips®

 

300

$4

 

 

 

 

 

 

 

224

Dental Floss

 

Dental Floss

 

1

$3

 

 

 

 

 

 

 

225

Denture Adhesive

 

Fixodent®

 

42 gm

$5

 

 

 

 

 

 

 

039

Diaper Rash Cream

 

Desitin®

 

120 gm

$6

 

 

 

 

 

 

247

Digital Bathroom Scale (400 lb limit) **

Digital Bathroom Scale

 

1

$35

 

 

 

 

 

 

 

245

Digital Blood Pressure Monitor with

Digital Blood Pressure Monitor

1

$50

Medium and Large Cuffs**

 

with Medium and Large Cuffs

 

 

 

 

 

 

118

Earwax Removal Drops

 

Debrox® Earwax Removal

 

15 ml

$8

Carbamide Peroxide

 

Drops

 

 

 

 

 

 

235

Effervescent Denture Tabs

 

Efferdent®

 

40

$5

 

 

 

 

 

 

 

244

Ele tri al Heati g Pad ”

” **

Electrical Heating Pad

 

1

$40

219

Eye Drops Redness Reliever

Visine® Original

 

15 ml

$5

 

 

 

 

 

 

114

Lubricant Eye Drops (Sterile)

Liquifilm Tears®

 

15 ml

$6

 

 

 

 

 

 

 

048

Oral Thermometer (Digital Display)

B-D® Oral Thermometer

 

1

$6

 

 

 

 

 

 

 

284

Toothbrush

 

Toothbrush

 

3

$5.75

 

 

 

 

 

 

 

285

Toothpaste

 

Toothpaste

 

2

$8

 

 

 

 

 

 

257

7 Day Pill Box (Morning, Noon, Evening,

7 Day Pill Box

 

1

$7

Bed)

 

 

 

 

 

 

 

 

**For items noted above: limit 1 per plan year. Prior to purchase the enrollee must have appropriate

 

o ersatio s ith the e rollee’s perso

al pro ider a d the e rollee’s perso al pro ider

ust orall

 

recommend the OTC item.

 

 

 

 

 

 

 

Skin Care

 

 

 

 

 

 

 

 

 

Product

Product Name

Compare To

 

Package

Price

Code

 

 

 

 

Count

 

217

Allergy Cream Itching and Pain Relief

Benadryl® Extra Strength

 

30 gm

$5

Cream

 

 

 

 

 

 

 

037

Calamine Lotion

 

Caladryl®

 

180 ml

$5

 

 

 

 

 

 

038

Clotrimazole Cream 1% - Athlete’s Foot

Lotrimin AF®

 

15 gm

$6

004

Hydrocortisone Cream 1%

 

Cortizone 10®

 

30gm

$5

 

 

 

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

Page 4

 

Humana Health and Wellness Product Catalog

Skin Care (continued)

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

241

Medicated Callus Remover

Dr. S holl’s® Callus Re o er

6

$4

Patches

 

 

 

 

286

Medicated Lip Balm

ChapStick®

3

$5

 

 

 

 

 

106

Sunscreen

Coppertone® Sunscreen

120 ml

$7

 

 

 

 

 

218

Tolnaftate Antifungal Cream 1%

Tinactin® Cream

30 gm

$8

 

 

 

 

 

Sleeping Aids

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

121

Acetaminophen 500 mg and

Tylenol® PM Extra Strength

50

$6

Diphenhydramine 25 mg

 

 

 

 

122

Diphenhydramine 25 mg Night Time

Sominex® Tablets

50

$8

Sleep Aid Tablets

 

 

 

 

 

 

 

 

 

Smoking Cessation

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

123

Stop Smoking Gum 2 mg

Nicorette® 2 mg Gum

50

$20

 

 

 

 

 

124

Stop Smoking Gum 4 mg

Nicorette® 4 mg Gum

50

$20

 

 

 

 

 

Vitamins, Minerals, and Dual Purpose Items*

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

250

Almebex Plus B-12

Almebex Plus B-12

473 ml

$27

 

 

 

 

 

911

Antioxidant Tablets

Antioxidant Tablets

60

$7

 

 

 

 

 

903

B-Complex with B-12

B-Complex with B-12

100

$8

 

 

 

 

 

902

Co-Enzyme Q10 30 mg

Co-Enzyme Q10 30 mg

30

$10

 

 

 

 

 

109

Calcium Citrate plus Vitamin D

Citracal® Caplets plus D

60

$7

 

 

 

 

 

248

Chewable Calcium with Vitamin D

Caltrate® 600 + D plus Minerals

60

$9

 

 

 

 

 

063

Complete Senior Vitamins and Minerals

Centrum® Silver

60

$10

 

 

 

 

 

011

Daily Multivitamin and Mineral

Advanced Formula Centrum®

130

$8

 

 

 

 

 

907

Eye Care Vitamins

Ocuvite Lutein

36

$9

 

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

Page 5

 

Humana Health and Wellness Product Catalog

 

 

 

Vitamins, Minerals, and Dual Purpose Items (continued)*

 

 

 

 

 

 

 

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

013

Ferrous Sulfate 5 gr

Feosol®

100

$5

 

 

 

 

 

246

Ferrous Sulfate Elixir 200 mg / 5 ml

Ferrous Sulfate Elixir

480 ml

$7

 

 

 

 

 

014

Folic Acid 400 mcg

Folic Acid 400 mcg

100

$6

 

 

 

 

 

240

Folic Acid 800 mcg

Folic Acid 800 mcg

100

$5

 

 

 

 

 

223

Glucose Chewable Tablets

DEX4® Glucose Tablets

10

$5

 

 

 

 

 

107

One-a-Da Wo e ’s Multi ita i

One-a-Da Wo e ’s

60

$7

 

 

 

 

 

015

Oyster Calcium plus Vitamin D

Os-Cal 500 plus D

60

$6

 

 

 

 

 

910

Selenium 200 mcg

Selenium 200 mcg

60

$5

 

 

 

 

 

909

Timed Release Niacin 500 mg

Timed Release Niacin 500 mg

100

$8

 

 

 

 

 

238

Vitamin B12 1000 mcg

Vitamin B12 1000 mcg

100

$7

 

 

 

 

 

010

Vitamin C 500 mg

Vitamin C 500 mg

100

$6

 

 

 

 

 

209

Vitamin D 1000 IU

Vitamin D 1000 IU

100

$7

 

 

 

 

 

239

Vitamin D 5000 IU

Vitamin D 5000 IU

100

$9

 

 

 

 

 

012

Vitamin E 400 IU Synthetic

Vitamin E 400 IU Synthetic

100

$7

 

 

 

 

 

*For items noted above: Prior to purchase the enrollee must have appropriate conversations with

the e rollee’s perso al pro ider a d the e rollee’s perso al pro ider ust orall

recommend the

OTC item.

 

 

 

 

 

 

Wo e

’s Health

 

 

 

Product

Product Name

 

Compare To

 

Package

Price

Code

 

 

 

 

Count

 

041

Clotrimazole 1% Vaginal Cream

 

Gyne-Lotrimin®

 

45 gm

$8

 

 

 

 

 

 

 

042

Miconazole Nitrate 2% Vaginal Cream

 

Monistat-7®

 

45 gm

$8

7 Day

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTC items may only be purchased for the plan enrollee. It is prohibited to purchase OTC items for family members and friends. Purchase of covered OTC products made under emergency circumstances may be eligible for reimbursement when the monthly benefit allowance is available.

The following items are not covered under this OTC benefit (non-eligible items): Alternative medicines (including botanicals, herbals, probiotics and neutraceuticals including fish oil, glucosamine and chondroitin, garlic, Echinacea, saw palmetto, ginkgo biloba, etc), Baby items, Contraceptives, Convenience (non-medical items), Cosmetics, Food Supplements, Replacement Items, Attachments, and Peripherals (including hearing aid batteries, contact lens containers, etc when not factory packaged with original item).

Y0040_GNHHA5RHH_C Accepted

Page 6

Humana is a Medicare Advantage organization and a stand-alone prescription drug plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal. Other pharmacies are available in our network. Limitations, copayments and restrictions may apply.

Y0040_GNHHA5RHH_C Accepted

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