Rx Right Source – Fill Out and Use

		Patient Information					Gender
Member ID		Date of Birth
							Male
	-		/	/
							Female
First Name		Last Name					M.I.
Street Number	Street Name						Apt/Suite #
City			State		ZIP Code
						-
Phone Number		Allergies:	No Known		Aspirin	Codeine	Penicillin
-	-
		Peanuts	Sulfa		Other ___________________________
Prescriber First Name		Prescriber Information
		Prescriber Last Name					M.I.
DEA Number		NPI Number
Street Number	Street Name						Suite #
City			State		ZIP Code
						-
Phone Number		Fax Number
-	-		-		-

Prescription Information

Must be completed, signed and faxed from provider’s office. This is not valid for CII medications. We will dispense a 90-day supply unless the quantity is otherwise noted or the medication is a controlled substance. In order to require

that a brand-name product be dispensed, the prescriber must write ‘brand medically necessary.’

	Drug Name and Strength	Directions	Quantity	# of Refills
			(Alpha & Numeric required
			for controlled substances)
1.
2.
3.

Prescriber Signature (required) _____________________________________________	Today’s Date _____ / _____ /_____
Supervising Prescriber Signature (if applicable) _________________________________	Today’s Date _____ / _____ /_____

Supervising Prescriber DEA Number______________________ Supervising Prescriber NPI Number: _________________

Please fax completed form with secure cover sheet to Humana Pharmacy at 1-800-379-7617

-or-

Send this prescription electronically (eRx) by selecting “Humana Pharmacy Mail Delivery” from the list of pharmacies on your e-prescribing tool. All eRxs from your office will be routed through SureScripts directly to Humana Pharmacy.

GHC 19856A 03/17

PLEASE NOTE: It is standard pharmacy practice to substitute generic equivalents for brand-name drugs whenever possible. Humana Pharmacy will dispense an FDA-approved generic equivalent whenever available, when permitted by the prescriber and allowable by law. If you do not want a generic equivalent, write ‘brand medically necessary,’ which may result in a higher copay for the patient. Your fax can take up to 48 hours to be entered into our system after it is received.

2935ALL0417