Tier 1: Preferred Generic $10 $30 $2 $0 
Tier 2: Generic $20 $60 $8 $0 
Tier 3: Preferred Brand $47 $141 $47 $131 
Tier 4: Non-Preferred 
Drug $100 $300 $100 $290 
Tier 5: Specialty Tier 29% N/A 29% N/A 14 Summary of Benefits H5216324000SB23 H5216324000 
Retail Cost-Sharing 
Pharmacy options Retail All network retail pharmacies. To find the retail pharmacies near 
you, go to  Humana.com/pharmacyfinder 
N/A 30-day supply 90-day supply* 
Tier 1: Preferred Generic $2 $6 
Tier 2: Generic $8 $24