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
Y0040_GNHHA5RHH_C Accepted |
Version 17 |
|
Humana Health and Wellness Order Form
STEP 1: COMPLETE YOUR INFORMATION BELOW
Member ID (Found on Humana ID card) |
Date of Birth |
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Gender
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Female
Street Number & Name |
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Apt/Suite # |
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Daytime Phone |
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Evening Phone |
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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
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
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____________________________________
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*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.
Y0040_GNHHA5RHH_C Accepted
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 # |
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Expiration Date |
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Cardholder First Name |
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Cardholder Last Name |
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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.
Y0040_GNHHA5RHH_C Accepted
Humana Health and Wellness Product Catalog
Antacids, Anti-Diarrheals, and Laxatives
Product |
Product Name |
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Compare To |
Package |
Price |
Code |
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Count |
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075 |
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Antacid / Anti-Gas Chew Tablets |
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Maalox® Plus |
100 |
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$7 |
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032 |
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Antacid / Anti-Gas Liquid |
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Mylanta® |
360 ml |
$9 |
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089 |
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Antacid Double Strength Chew Tab |
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Mylanta® Double Strength |
70 |
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$9 |
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029 |
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Anti-Diarrheal Tablets – Loperamide 2 mg |
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Imodium® AD |
12 |
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$4 |
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031 |
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Anti-Hemorrhoidal Ointment |
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Preparation H® |
60 gm |
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$7 |
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203 |
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Calcium Carbonate Antacid Regular |
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Tums E-X® |
150 |
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$4 |
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Strength |
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227 |
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Calcium Carbonate Antacid Chews 750 mg |
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Extra Strength Tums E-X® |
96 |
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$5 |
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116 |
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Dairy Digestive Supplement – Lactase |
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Lactaid® Tabs |
60 |
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$10 |
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Enzyme |
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003 |
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Enema |
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Fleet® Enema |
2 |
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$5 |
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098 |
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Extra Strength Gas Relief Tablets 125 mg |
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Gas-X® Extra Strength |
30 |
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$5 |
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208 |
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Fiber Laxative Tablets |
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Fibercon® |
90 |
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$9 |
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234 |
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Glycerin Suppositories for Adults |
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Fleet® |
25 |
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$5 |
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216 |
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Hemorrhoidal Suppositories |
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Preparation H® Suppositories |
12 |
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$6 |
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093 |
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Laxative – Bisacodyl 5 mg |
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Dulcolax® |
25 |
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$5 |
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033 |
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Milk of Magnesia – Laxative / Antacid |
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Phillips® Milk of Magnesia |
360 ml |
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$5 |
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120 |
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Motion Sickness Tablets – |
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Dramamine® Tablets |
12 |
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$5 |
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Dimenhydrinate 50 mg |
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112 |
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Omeprazole Magnesium 20 mg |
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Prilosec OTC® 20 mg |
14 |
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$11 |
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115 |
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Pink Bismuth Chewable Tablets |
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Pepto-Bismol® Chew Tabs |
30 |
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$6 |
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258 |
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Psyllium Fiber Laxative Capsules |
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Metamucil® Capsules |
160 |
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$11 |
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104 |
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Ranitidine Antacid Tablets 75 mg |
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Zantac® |
30 |
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$7 |
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233 |
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Senna Laxative Tablets 8.6 mg |
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Senokot |
100 |
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$10 |
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101 |
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Stool Softener Capsules |
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Colace® |
100 |
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$7 |
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Cough, Cold, and Allergy
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Product |
Product Name |
Compare To |
Package |
Price |
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Code |
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Count |
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113 |
Antihistamine – Cetirizine HCL 10 mg |
Zyrtec® 10 mg |
30 |
$12 |
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024 |
Antihistamine – Diphenhydramine Liquid |
Benadryl® Allergy Childrens |
120 ml |
$5 |
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50 mg |
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110 |
Antihistamine – Loratadine 10 mg |
Claritin® |
30 |
$10 |
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023 |
Antihistamine – Diphenhydramine 25 mg |
Benadryl® |
24 |
$6 |
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Y0040_GNHHA5RHH_C Accepted
Humana Health and Wellness Product Catalog
Cough, Cold, and Allergy (continued)
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Product |
Product Name |
Compare To |
Package |
Price |
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Code |
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Count |
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028 |
Cough Formula – Expectorant |
Robitussin® |
120ml |
$5 |
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210 |
Cough Suppressant DM Sugar Free |
Robitussin® DM Sugar Free |
118 ml |
$7 |
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026 |
Cough Suppressant / Expectorant |
Robitussin® DM |
120 ml |
$6 |
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096 |
Cough Suppressant / Expectorant / Nasal |
Robitussin® CF |
120 ml |
$5 |
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Decongestant |
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260 |
Cough and Cold High Blood Pressure |
Coricidin HBP® |
16 |
$5 |
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237 |
Daytime PE Cough and Cold |
Dayquil® |
16 |
$6 |
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111 |
Expectorant – Guaifenesin 400 mg |
Mucus Relief 400 mg |
30 |
$11 |
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249 |
Fexofenadine 24 Hour 180 mg |
Allegra Allergy |
30 |
$17 |
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043 |
Medicated Chest Rub |
Vicks VapoRub® |
99 gm |
$6 |
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228 |
Nasal Decongestant PE Max Strength |
Sudafed® PE Tablets |
36 |
$6 |
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10 mg |
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095 |
Nasal Decongestant Spray |
Afrin® |
30 ml |
$5 |
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099 |
Saline Nasal Spray |
Ocean® Saline Nasal Spray |
45 ml |
$5 |
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097 |
Sinus – Acetaminophen 325 mg / |
Tylenol® Sinus |
24 |
$6 |
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Phenylephrine HCI 5 mg |
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117 |
Sore Throat Lozenges – Menthol / |
Chloraseptic® Lozenges |
18 |
$5 |
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Benzocaine |
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220 |
Sore Throat Spray |
Chloraseptic® Spray |
180 ml |
$6 |
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First Aid Medical Supplies
Product |
Product Name |
Compare To |
Package |
Price |
Code |
|
|
Count |
|
035 |
Alcohol Prep Pads |
Alcohol Swabs |
100 |
$6 |
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226 |
Elastic Bandage |
Ace® Bandage |
1 |
$6 |
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232 |
First Aid Tape |
J&J® First Aid Tape |
1 |
$3 |
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044 |
Plastic Bandages |
Band-Aids® |
100 |
$5 |
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040 |
Triple Antibiotic Ointment |
Neosporin® |
30 gm |
$6 |
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231 |
Triple Antibiotic Ointment – Plus |
Neosporin Plus® |
30 gm |
$7 |
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Y0040_GNHHA5RHH_C Accepted |
Page 2 |
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 |
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020 |
Acetaminophen 80 mg Chewable |
Tylenol® Childre |
’s Che a le |
30 |
$5 |
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021 |
Acetaminophen Elixir |
Childre ’s T le ol® Elixir |
120 ml |
$5 |
282 |
Aspirin 81 mg Chewable |
Bayer® Chewable Aspirin |
90 |
$5.50 |
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047 |
Aspirin 325 mg |
Bayer® |
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100 |
$5 |
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016 |
Aspirin Low Dose 81 mg EC |
Bayer® Adult Low Strength EC |
120 |
$6 |
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229 |
Aspirin 325 mg Enteric |
Ecotrin® |
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100 |
$6 |
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213 |
Cold and Hot Patches Pain Relief |
Icy Hot® Patch |
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5 |
$7 |
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215 |
Effervescent Pain Relief |
Alka-Seltzer® |
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36 |
$6 |
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125 |
Headache Formula – Aspirin, |
Excedrin® |
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100 |
$7 |
Acetaminophen, Caffeine |
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019 |
Ibuprofen 200 mg |
Advil® |
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50 |
$5 |
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094 |
Ibuprofen Suspension |
Childre ’s Motri |
® |
120 ml |
$6 |
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046 |
Muscle Rub |
Ben-Gay® |
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120 gm |
$7 |
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283 |
Naproxen Sodium 220 mg – Pain Reliever |
Aleve® Caplets |
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100 |
$9 |
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230 |
Therapeutic Mineral Ice Gel |
Mineral Ice® |
|
227 gm |
$8 |
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119 |
Topical Analgesic – Capsicum Cream |
Zostrix® Cream |
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60 gm |
$8 |
0.025% |
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Personal Care
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Product |
Product Name |
Compare To |
Package |
Price |
|
Code |
|
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Count |
|
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256 |
Absorbent U der Pads ” 6” |
Protection Plus Under Pad |
20 |
$20 |
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251 |
Adult Incontinence Underwear Small |
Protection Plus Protective |
22 |
$20 |
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Underwear Small |
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252 |
Adult Incontinence Underwear Medium |
Protection Plus Protective |
20 |
$20 |
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Underwear Medium |
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253 |
Adult Incontinence Underwear Large |
Protection Plus Protective |
18 |
$20 |
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Underwear Large |
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254 |
Adult Incontinence Underwear X-Large |
Protection Plus Protective |
14 |
$20 |
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Underwear X-Large |
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255 |
Adult Incontinence Underwear XX-Large |
Protection Plus Protective |
12 |
$20 |
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Underwear XX-Large |
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Y0040_GNHHA5RHH_C Accepted |
|
Page 3 |
Humana Health and Wellness Product Catalog
Personal Care (continued)
Product |
Product Name |
Compare To |
|
Package |
Price |
Code |
|
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|
Count |
|
243 |
Bladder Control Pads (Regular) |
Poise® Moderate Pads |
|
20 |
$9 |
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242 |
Blood Pressure Home Kit (Manual pump |
Blood Pressure Home Kit |
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1 |
$17 |
with Stethoscope)** |
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(Manual pump w/ Stethoscope) |
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036 |
Cotton Swabs |
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Q-Tips® |
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300 |
$4 |
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224 |
Dental Floss |
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Dental Floss |
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1 |
$3 |
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225 |
Denture Adhesive |
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Fixodent® |
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42 gm |
$5 |
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039 |
Diaper Rash Cream |
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Desitin® |
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120 gm |
$6 |
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247 |
Digital Bathroom Scale (400 lb limit) ** |
Digital Bathroom Scale |
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1 |
$35 |
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245 |
Digital Blood Pressure Monitor with |
Digital Blood Pressure Monitor |
1 |
$50 |
Medium and Large Cuffs** |
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with Medium and Large Cuffs |
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118 |
Earwax Removal Drops – |
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Debrox® Earwax Removal |
|
15 ml |
$8 |
Carbamide Peroxide |
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Drops |
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235 |
Effervescent Denture Tabs |
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Efferdent® |
|
40 |
$5 |
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244 |
Ele tri al Heati g Pad ” |
” ** |
Electrical Heating Pad |
|
1 |
$40 |
219 |
Eye Drops – Redness Reliever |
Visine® Original |
|
15 ml |
$5 |
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114 |
Lubricant Eye Drops (Sterile) |
Liquifilm Tears® |
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15 ml |
$6 |
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048 |
Oral Thermometer (Digital Display) |
B-D® Oral Thermometer |
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1 |
$6 |
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284 |
Toothbrush |
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Toothbrush |
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3 |
$5.75 |
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285 |
Toothpaste |
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Toothpaste |
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2 |
$8 |
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257 |
7 Day Pill Box (Morning, Noon, Evening, |
7 Day Pill Box |
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1 |
$7 |
Bed) |
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**For items noted above: limit 1 per plan year. Prior to purchase the enrollee must have appropriate |
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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. |
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Skin Care |
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Product |
Product Name |
Compare To |
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Package |
Price |
Code |
|
|
|
|
Count |
|
217 |
Allergy Cream – Itching and Pain Relief |
Benadryl® Extra Strength |
|
30 gm |
$5 |
Cream |
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037 |
Calamine Lotion |
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Caladryl® |
|
180 ml |
$5 |
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038 |
Clotrimazole Cream 1% - Athlete’s Foot |
Lotrimin AF® |
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15 gm |
$6 |
004 |
Hydrocortisone Cream 1% |
|
Cortizone 10® |
|
30gm |
$5 |
|
|
|
|
|
|
|
Y0040_GNHHA5RHH_C Accepted |
Page 4 |
|
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 |
|
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 |
|
Diphenhydramine 25 mg |
|
|
|
|
|
|
122 |
Diphenhydramine 25 mg – Night Time |
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 |
|
|
|
|
|
Y0040_GNHHA5RHH_C Accepted |
Page 5 |
|
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 |
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).
Y0040_GNHHA5RHH_C Accepted |
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.
Y0040_GNHHA5RHH_C Accepted