Rx Right Source – Fill Out and Use This PDF

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.’

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