Humana Order Form ≡ Fill Out Printable PDF Forms Online

Question	Answer
Form Name	Humana Order Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	humana 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

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Humana Health and Wellness Order Form

STEP 1: COMPLETE YOUR INFORMATION BELOW

Member ID (Found on Humana ID card)

Date of Birth

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.

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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

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.

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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
203	Strength	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
116	Enzyme	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
120	Dimenhydrinate 50 mg	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
024	50 mg	Benadryl® Allergy Childrens	120 ml	$5
	50 mg

110	Antihistamine – Loratadine 10 mg	Claritin®	30	$10
023	Antihistamine – Diphenhydramine 25 mg	Benadryl®	24	$6

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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
096	Decongestant	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
228	10 mg	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
097	Phenylephrine HCI 5 mg	Tylenol® Sinus	24	$6
	Phenylephrine HCI 5 mg
117	Sore Throat Lozenges – Menthol /	Chloraseptic® Lozenges	18	$5
117	Benzocaine	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

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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
125	Acetaminophen, Caffeine	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
119	0.025%	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

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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
242	with Stethoscope)**		(Manual pump w/ Stethoscope)		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
245	Medium and Large Cuffs**		with Medium and Large Cuffs		1	$50
	Medium and Large Cuffs**		with Medium and Large Cuffs
118	Earwax Removal Drops –		Debrox® Earwax Removal		15 ml	$8
118	Carbamide Peroxide		Drops		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
257	Bed)		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
217	Allergy Cream – Itching and Pain Relief		Cream		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

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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
241	Medicated Callus Remover	Patches	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
121	Diphenhydramine 25 mg	Tylenol® PM Extra Strength	50	$6
	Diphenhydramine 25 mg
122	Diphenhydramine 25 mg – Night Time	Sominex® Tablets	50	$8
122	Sleep Aid Tablets	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

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	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
042	7 Day		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).

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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.

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