Question	Answer
Form Name	Humana Order Form
Form Length	10 pages
Fillable?	Yes
Fillable fields	90
Avg. time to fill out	20 min 34 sec
Other names	humana wellness order form, humana otc 2021 catalog, wellness order form, humana otc catalog

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

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

	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

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

Y0040_GNHHA5RHH_C Accepted	Version 17

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

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

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

Humana Order Form – Fill Out and Use This PDF

Humana Order Form PDF Details