Homepage / Fill in a Valid Humana Order Template
Jump Links

The Humana Order form is an essential tool for members looking to purchase various Health and Wellness products through the RightSource mail-order pharmacy. Eligibility to use this service is determined by your current Humana plan, which can be verified by calling RightSource. To place an order, members should keep a catalog of products, ensuring they choose items within their monthly allowance. Orders must be submitted by the 20th of each month to be processed within that benefit month. Acceptable payment methods include checks, money orders, or credit cards, which are necessary only if the order exceeds the allocated benefit limit. Furthermore, members can easily place orders online, via mail, or by faxing the completed form. The order form captures personal information along with product selections, ensuring correct shipment and billing. Orders are shipped at no additional charge, usually within 10 to 14 business days. Notably, it is important to consult with a healthcare provider before using over-the-counter products, and the product list may be subject to change. With these guidelines, members can navigate the ordering process efficiently and access necessary health items seamlessly.

Humana Order Example

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

M

 

D

 

D

 

Y

 

Y

 

Y

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender

Male Female

First Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Number & Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt/Suite #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evening Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

1OTC

____________________________________

_____

2OTC

____________________________________

_____

3OTC

____________________________________

_____

4OTC

____________________________________

_____

5OTC

____________________________________

_____

6OTC

____________________________________

_____

7OTC

____________________________________

_____

8OTC

____________________________________

_____

9OTC

____________________________________

_____

10OTC

___________________________________

_____

*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 #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

M

 

 

 

Y

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardholder First Name

 

 

 

 

 

 

 

 

Cardholder Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

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

 

 

Strength

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

227

 

Calcium Carbonate Antacid Chews 750 mg

 

Extra Strength Tums E-X®

96

 

$5

 

116

 

Dairy Digestive Supplement Lactase

 

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

 

 

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

 

 

 

 

 

 

 

 

 

 

Cough, Cold, and Allergy

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

50 mg

 

 

 

 

 

 

 

 

 

110

Antihistamine Loratadine 10 mg

Claritin®

30

$10

023

Antihistamine Diphenhydramine 25 mg

Benadryl®

24

$6

 

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

Page 1

Humana Health and Wellness Product Catalog

Cough, Cold, and Allergy (continued)

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

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

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

Phenylephrine HCI 5 mg

 

 

 

 

117

Sore Throat Lozenges Menthol /

Chloraseptic® Lozenges

18

$5

Benzocaine

 

 

 

 

220

Sore Throat Spray

Chloraseptic® Spray

180 ml

$6

 

 

 

 

 

First Aid Medical Supplies

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

 

 

 

 

 

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

 

 

 

 

 

 

020

Acetaminophen 80 mg Chewable

Tylenol® Childre

’s Che a le

30

$5

 

 

 

 

 

021

Acetaminophen Elixir

Childre ’s T le ol® Elixir

120 ml

$5

282

Aspirin 81 mg Chewable

Bayer® Chewable Aspirin

90

$5.50

 

 

 

 

 

 

047

Aspirin 325 mg

Bayer®

 

100

$5

 

 

 

 

 

 

016

Aspirin Low Dose 81 mg EC

Bayer® Adult Low Strength EC

120

$6

 

 

 

 

 

 

229

Aspirin 325 mg Enteric

Ecotrin®

 

100

$6

 

 

 

 

 

 

213

Cold and Hot Patches Pain Relief

Icy Hot® Patch

 

5

$7

 

 

 

 

 

 

215

Effervescent Pain Relief

Alka-Seltzer®

 

36

$6

 

 

 

 

 

 

125

Headache Formula Aspirin,

Excedrin®

 

100

$7

Acetaminophen, Caffeine

 

 

 

 

 

 

 

 

 

 

 

 

019

Ibuprofen 200 mg

Advil®

 

50

$5

 

 

 

 

 

 

094

Ibuprofen Suspension

Childre ’s Motri

®

120 ml

$6

 

 

 

 

 

 

046

Muscle Rub

Ben-Gay®

 

120 gm

$7

 

 

 

 

 

 

283

Naproxen Sodium 220 mg Pain Reliever

Aleve® Caplets

 

100

$9

 

 

 

 

 

 

230

Therapeutic Mineral Ice Gel

Mineral Ice®

 

227 gm

$8

 

 

 

 

 

 

119

Topical Analgesic Capsicum Cream

Zostrix® Cream

 

60 gm

$8

0.025%

 

 

 

 

 

 

Personal Care

Product

Product Name

Compare To

Package

Price

Code

 

 

Count

 

256

Absorbent U der Pads ” 6”

Protection Plus Under Pad

20

$20

251

Adult Incontinence Underwear Small

Protection Plus Protective

22

$20

Underwear Small

 

 

 

 

252

Adult Incontinence Underwear Medium

Protection Plus Protective

20

$20

Underwear Medium

 

 

 

 

253

Adult Incontinence Underwear Large

Protection Plus Protective

18

$20

Underwear Large

 

 

 

 

254

Adult Incontinence Underwear X-Large

Protection Plus Protective

14

$20

Underwear X-Large

 

 

 

 

255

Adult Incontinence Underwear XX-Large

Protection Plus Protective

12

$20

Underwear XX-Large

 

 

 

 

Y0040_GNHHA5RHH_C Accepted

 

Page 3

Humana Health and Wellness Product Catalog

Personal Care (continued)

Product

Product Name

Compare To

 

Package

Price

Code

 

 

 

 

Count

 

243

Bladder Control Pads (Regular)

Poise® Moderate Pads

 

20

$9

 

 

 

 

 

 

 

242

Blood Pressure Home Kit (Manual pump

Blood Pressure Home Kit

 

1

$17

with Stethoscope)**

 

(Manual pump w/ Stethoscope)

 

 

 

 

 

 

 

 

 

 

 

036

Cotton Swabs

 

Q-Tips®

 

300

$4

 

 

 

 

 

 

 

224

Dental Floss

 

Dental Floss

 

1

$3

 

 

 

 

 

 

 

225

Denture Adhesive

 

Fixodent®

 

42 gm

$5

 

 

 

 

 

 

 

039

Diaper Rash Cream

 

Desitin®

 

120 gm

$6

 

 

 

 

 

 

247

Digital Bathroom Scale (400 lb limit) **

Digital Bathroom Scale

 

1

$35

 

 

 

 

 

 

 

245

Digital Blood Pressure Monitor with

Digital Blood Pressure Monitor

1

$50

Medium and Large Cuffs**

 

with Medium and Large Cuffs

 

 

 

 

 

 

118

Earwax Removal Drops

 

Debrox® Earwax Removal

 

15 ml

$8

Carbamide Peroxide

 

Drops

 

 

 

 

 

 

235

Effervescent Denture Tabs

 

Efferdent®

 

40

$5

 

 

 

 

 

 

 

244

Ele tri al Heati g Pad ”

” **

Electrical Heating Pad

 

1

$40

219

Eye Drops Redness Reliever

Visine® Original

 

15 ml

$5

 

 

 

 

 

 

114

Lubricant Eye Drops (Sterile)

Liquifilm Tears®

 

15 ml

$6

 

 

 

 

 

 

 

048

Oral Thermometer (Digital Display)

B-D® Oral Thermometer

 

1

$6

 

 

 

 

 

 

 

284

Toothbrush

 

Toothbrush

 

3

$5.75

 

 

 

 

 

 

 

285

Toothpaste

 

Toothpaste

 

2

$8

 

 

 

 

 

 

257

7 Day Pill Box (Morning, Noon, Evening,

7 Day Pill Box

 

1

$7

Bed)

 

 

 

 

 

 

 

 

**For items noted above: limit 1 per plan year. Prior to purchase the enrollee must have appropriate

 

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.

 

 

 

 

 

 

 

Skin Care

 

 

 

 

 

 

 

 

 

Product

Product Name

Compare To

 

Package

Price

Code

 

 

 

 

Count

 

217

Allergy Cream Itching and Pain Relief

Benadryl® Extra Strength

 

30 gm

$5

Cream

 

 

 

 

 

 

 

037

Calamine Lotion

 

Caladryl®

 

180 ml

$5

 

 

 

 

 

 

038

Clotrimazole Cream 1% - Athlete’s Foot

Lotrimin AF®

 

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

File Breakdown

Fact Name Detail
Eligibility Verification Before placing an order, it is essential to verify your eligibility for purchasing health and wellness products through RightSource. You can call 1-855-211-8370 (TTY: 711) for assistance.
Ordering Timeline Ensure to place your order no later than the 20th of each month to allow RightSource enough time to process it within that benefit month.
Payment Information If your order exceeds your monthly benefit limit, you must provide additional payment. Be mindful that failure to submit the full payment may delay shipment.
Form Submission Methods You can order products online via RightSourceRx.com, by mail to RightSource's PO Box, or by faxing the order form directly.
Shipping Details RightSource ships orders at no extra charge using UPS or the US Postal Service. Expect delivery within 10 to 14 business days after placing your order.
Applicable State Law For states where the OTC product benefit is applicable, reach out to RightSource for state-specific governing laws around the order process and eligibility.

Guide to Using Humana Order

Upon receiving the Humana Order form, the next steps involve providing your personal information, selecting your desired health and wellness products, and processing any necessary payments. Completing this form accurately is crucial to ensure timely delivery of your items. Follow the steps below to fill out the form correctly.

  1. STEP 1: COMPLETE YOUR INFORMATION
    • Locate your Member ID from your Humana ID card.
    • Fill in your Date of Birth using the format MM/DD/YYYY.
    • Select your Gender (Male or Female).
    • Write your First and Last Name.
    • Provide your Street Number and Name, and if applicable, your Apt/Suite number.
    • Enter your City, State, and ZIP Code.
    • Supply your Daytime Phone and Evening Phone numbers.
  2. STEP 2: COMPLETE PRODUCT SELECTION
    • Indicate the month you wish to receive the order.
    • List the Product Code and Product Name for each item you want to order.
    • Check the box if you are using a new address.
    • Specify the Quantity for each product.
    • Document the Price for each item.
  3. STEP 3: REVIEW TOTALS
    • Calculate your Total Order Amount.
    • Refer to your Humana Monthly Allowance.
    • Determine the Total Remaining Amount Due, if applicable.
    • If your order exceeds your monthly allowance, ensure you include a payment method.
  4. STEP 4: PAYMENT INFORMATION (if applicable)
    • For checks, make it payable to RightSource.
    • Do not send cash.
    • If using a credit or debit card, complete that section with the relevant information.
    • Be sure to include the Cardholder's First Name, Last Name, and Signature.
  5. STEP 5: SUBMITTING THE FORM
    • Mail the completed order form pages to RightSource at the designated address.
    • Alternatively, fax the form to the provided fax number.
    • Consider placing your order online through RightSourceRx.com if it's more convenient.

Get Answers on Humana Order

1. What products can I order with the Humana Order Form?

You can order Health and Wellness products offered through the RightSource mail-order pharmacy. The products include various over-the-counter (OTC) options, such as antacids, cough and cold medications, and first aid supplies. A catalog is provided to help you select the items you want. Remember to verify if your Humana plan includes OTC services as a benefit.

2. How do I submit my order?

You have three ways to place your order:

  1. Online: Visit RightSourceRx.com to order through their website.
  2. Mail: Fill out the Health and Wellness Order Form and send only the order form pages to:
    RightSource PO Box 1197
    Cincinnati, OH 45201-1197
  3. Fax: Complete the Health and Wellness Order Form and fax it to:
    1-800-379-7617

Make sure to complete your order by the 20th of each month for timely processing within that month's benefits.

3. What if my order exceeds my benefit amount limit?

If your total order amount is higher than your monthly allowance, you will need to include additional payment. This can be done by check, money order, or providing credit card information. It’s essential to submit full payment to avoid shipment delays. If your order total is below the allowance, you don’t need to include payment—you will receive the items you ordered at no charge.

4. How will my order be delivered?

Your order will be shipped to your home through UPS or the US Postal Service at no extra cost to you. Once your order is received, please allow 10 to 14 business days for delivery. You'll receive generic products comparable to the name-brand items you selected. Before using any OTC products, it's a good idea to consult with your doctor for safety.

Common mistakes

Filling out the Humana Order form can sometimes lead to common mistakes that might delay the processing of your order. One frequent error is forgetting to include the **member ID**. This number is essential and can be found on your Humana ID card. Without it, your order could end up being delayed or even rejected.

Another mistake is not checking the **date of birth** carefully. Ensure that the month, day, and year are accurate. A simple typo can cause a significant delay because it might affect your eligibility verification.

Often, people forget to fill in their **contact information** completely. Missing a phone number can make it difficult for customer service to reach you for any questions or issues related to your order.

Additionally, people sometimes skip writing down the **product codes** for the items they wish to order. Without these codes, it can be challenging for RightSource to process your request correctly and efficiently.

Another error involves the **quantity** of items. Double-check that the quantity is filled in for each product you want. Leaving this blank might lead to confusion and could result in receiving fewer items than you need.

Some individuals also overlook the **payment information** section. If your order exceeds the allowable monthly limit, failing to include payment details could delay your shipment. Always double-check that you have filled this out correctly if applicable.

It's crucial to remember that orders can only be placed for the **current or future months**. A common pitfall is trying to backdate an order for a previous month. This mistake can lead to the rejection of your order altogether.

Another common oversight occurs when individuals forget to check the box if they have a **new address**. Not indicating a change of address could result in your order being sent to the wrong location.

Finally, missing the submission **deadline** is a mistake that can cause significant delays. Make sure to place your order before the 20th of each month to ensure timely processing. Keeping track of this date is essential for a smooth ordering experience.

Documents used along the form

When utilizing the Humana Order Form for Health and Wellness products, several other forms and documents may be required to ensure that your order is processed efficiently. Understanding these documents can help streamline your experience.

  • Eligibility Verification Form: This document confirms your eligibility for Health and Wellness products under your Humana plan. It ensures that you can access the benefits available to you.
  • Payment Authorization Form: If you're required to make additional payments above your monthly allowance, this form allows you to provide payment information securely, ensuring that your order is fulfilled promptly.
  • Shipping Information Form: This form gathers your delivery preferences and ensures your order is sent to the correct address. A clear shipping address helps avoid any shipping delays.
  • Change of Address Form: In case you need to update your address, submitting this form is essential. Keeping your information current ensures you receive your products without interruption.
  • Privacy Notice: This document outlines how your personal information is used and protected during the order process. Understanding this can provide peace of mind regarding your data security.
  • Product Catalog: A detailed list of available Health and Wellness products, including descriptions and prices. Keeping this catalog handy will assist in selecting the right items for your needs.

Familiarizing yourself with these documents and their purposes will help reinforce a smooth ordering experience while using the Humana Order Form. The right preparation can alleviate any concerns, allowing you to focus on your health and well-being.

Similar forms

  • Order Form for Over-the-Counter Medications: Similar to the Humana Order form, this document allows members to select and order OTC medications. It includes sections for personal information and product selection, making it easy for users to specify their needs.
  • Medicare Part D Enrollment Form: This document facilitates enrollment in Medicare Part D drug plans. Like the Humana Order form, it requires member identification and offers structured fields for personal and health information.
  • Prescription Claim Form: Similar to the Humana Order form, the Prescription Claim Form is used by members to submit claims for medications. Both documents have sections for medication details, member information, and payment submission.
  • Health Savings Account (HSA) Reimbursement Form: This form allows individuals to claim reimbursements for qualified medical expenses. Its format is similar, requiring detailed member information and expense itemization like the Humana Order form.
  • Flexible Spending Account (FSA) Request for Reimbursement: Just as with the Humana Order form, this document organizes member data and specifies the expenses for reimbursement. Both are designed to process requests efficiently.
  • Medical Supply Order Form: Used for ordering medical supplies, this form parallels the Humana Order form’s structure. Members can list required supplies and provide personal information to ensure proper delivery.
  • Wellness Benefit Request Form: Similar in its purpose, this form requests wellness benefits through health plans. It requires personal details and specific benefit requests, akin to the order selection process on the Humana Order form.

Dos and Don'ts

When filling out the Humana Order form, it's important to keep certain best practices in mind. Here are ten things you should and shouldn’t do:

  • Do verify your eligibility by calling RightSource at 1-855-211-8370 before placing your order.
  • Don't submit your order until January 2014 if this is your first order.
  • Do ensure you fill out all the required personal information accurately.
  • Don't forget to include payment if your total order exceeds your monthly allowance.
  • Do request assistance from Customer Care if you have questions about the form or the process.
  • Don't send cash; checks and money orders are acceptable forms of payment.
  • Do refer to the product catalog to choose the right Health and Wellness products.
  • Don't submit your order form pages with any additional documents or unrelated requests.
  • Do mail your order form to the address provided to avoid delays.
  • Don't place orders for previous months; orders can only be placed for the current or future month.

Misconceptions

Misconception 1: The Humana Order Form is only for specific health plans.

This is incorrect. The form can be used by members of any Humana plan that offers the option to purchase Health and Wellness products. Eligibility should be confirmed by contacting RightSource.

Misconception 2: Orders can be placed at any time without restrictions.

Orders must be placed by the 20th of each month to ensure processing within that benefit month. Additionally, orders cannot be backdated for previous months.

Misconception 3: Payment is always required for orders.

This is not true. If the total order amount is less than the monthly allowance under the plan, no payment is required. However, if the order exceeds the allowance, payment is necessary to process the order.

Misconception 4: Customers can submit cash as payment.

Cash should never be sent with the order. Payments can be made via check, money order, or credit card only. Sending cash poses security risks and is not recommended.

Misconception 5: Deliveries occur immediately after placing an order.

Orders will be delivered within 10 to 14 business days from the time RightSource receives them. It is important to account for this timeframe when placing an order.

Key takeaways

1. Verify your eligibility before placing an order. You can call RightSource at 1-855-211-8370 (TTY: 711) for assistance.

2. Keep the product catalog handy. It is essential for selecting the Health and Wellness products you want each month.

3. Submit your order by the 20th of each month. This deadline ensures that RightSource processes your order within the appropriate benefit month.

4. Include payment if your order exceeds your monthly allowance. You can use a check, money order, or credit card information, as necessary.

5. Orders can be placed online, by mail, or via fax. Choose the method that works best for you.

6. Don't backdate your order. RightSource only accepts orders for the current or upcoming month.

7. Expect delivery within 10 to 14 business days. Your order will arrive by UPS or the US Postal Service with no additional charge.

8. Consult your doctor before using any over-the-counter products. This ensures that the products are suitable for your health needs.