Over-The-Counter Health & Wellness Products - Catalog And Order Form

Over-The-Counter Health & Wellness Products - Catalog And Order Form - 2015 Page 4

2 page of Order Form

OTC Health and Wellness Product Order Form

Member ID (from your Humana ID card)

Your total order amount

$ ________________

Humana monthly allowance

$ ________________

Coversheet

Total remaining amount due

$ ________________

If your total order is less than your plan’s monthly allowance, you DO NOT need to include payment and

you will receive the items you ordered.

If your order exceeds your plan’s monthly 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) if you have questions about your

order, or about how to use this benefit at RightSource, Monday – Friday, 8 a.m. – 11 p.m., and Saturday,

8 a.m. – 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 RightSource receives your order to delivery. You’ll receive a generic

comparable to the name-brand product. Please consult your doctor before using any over-the-counter

(OTC) product. This product list is subject to change.

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Over-The-Counter Health & Wellness Products - Catalog And Order Form - 2015 Page 4