Humana Pharmacy Refill Form Details

Pharmacies are now able to fill prescriptions from select doctors and hospitals without prior authorization. This new program, Rx Right Source Form, is a way for pharmacies to get their products to patients more quickly. Patients who need medications that are not available through the pharmacy's normal wholesaler can have the prescription filled through this special program. The process is simple-just ask your pharmacist about Rx Right Source Form. The new Rx Right Source Form program allows pharmacies to get their products to patients more quickly. This program is available for patients who need medications that are not available through the pharmacy's normal wholesaler. The process is simple-just ask your pharmacist about Rx Right Source Form.

This knowledge will help you comprehend better the details of the rx right source before you begin filling it out.

QuestionAnswer
Form NameRx Right Source
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrightsource pharmacy fax form, rightsource rx form, right source fax form, humana prescription fax form

Form Preview Example

Physician Fax Form

206

 

 

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