document for specific details.  
Preferred cost-sharing 
Pharmacy options Retail 
To find the preferred cost-share retail 
pharmacies near you, go to  
Humana.com/pharmacyfinder Mail order 
Humana Pharmacy ®
N/A 30-day supply 90-day supply 30-day supply 90-day supply 
Tier 1: Preferred Generic $0 $0 $0 $0 
Tier 2: Generic $0 $0 $0 $0 
Tier 3: Preferred Brand $45 $135 $45 $125 
Tier 4: Non-Preferred 
Drug $95 $285 $95 $275 
Tier 5: Specialty Tier 33% N/A 33% N/A 2022 - 11 - Summary of Benefits H1036265001