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HumanaPPO Rx4 Prescription Drug Coverage
Level One - $10, Level Two - $25, Level Three - $40, Level Four - 25%

Covered prescription drugs are assigned to one of four different levels with corresponding copayment amounts. The levels are organized as follows: • Level One: lowest copayment for low cost generic and brand-name drugs.
Level Two: higher copayment for higher cost generic and brand-name drugs.
Level Three: higher copayment than Level Two for higher cost, mostly brand-name drugs that may
have generic or brand-name alternatives on Levels One or Two.
Level Four: highest copayment for high-technology drugs (certain brand-name drugs, biotechnology
drugs and self-administered injectable medications). Prescription drug products, or classes of certain prescription drug products, are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists. Drugs are reviewed for safety, effectiveness and cost-effectiveness prior to assignment or a change in assignment to one of the levels. Coverage of a prescription drug or placement of the drug within a level are subject to change throughout the year. Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness.
Check our Website or contact Customer Service for the most up-to-date information about the Drug List.
Some drugs in all levels may be subject to dispensing limitations, based on age, gender, duration or quantity. Additionally, some drugs may need prior authorization in order to be covered. In these cases, your physician should contact Humana Clinical Pharmacy Review at 1-800-555-CLIN (2546).
Members can visit Humana’s Website,, to obtain information about their prescription
drug and corresponding benefits and for possible lower cost alternatives, or they can call Humana’s Customer Service with questions or to request a partial Humana Rx4 Drug List by mail.
For a complete listing of participating pharmacies, please refer to our Web site or your participating When you present your membership card at a participating pharmacy, you are required to make a copayment for each prescription based on the current assigned level of the drug.
Drugs assigned to:
Copayment per prescription or refill
25%* of the total required payment to the dispensing pharmacy per
* The total maximum out-of-pocket copayment costs for drugs in Level Four is limited to $2,500 per • If the dispensing pharmacy’s charge is less than the corresponding copayment, you will only be responsible • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates.
There are no claim forms to file if you use a participating pharmacy and present your membership card with You may also purchase prescribed medications from a nonparticipating pharmacy. You will be required to pay for your prescriptions according to the following rule.
• You pay 100 percent of the dispensing pharmacy’s charges.
– You file a claim form with Humana (address is on the back of ID card).
– Claim is paid at 70 percent of the dispensing pharmacy’s charges, after they are first reduced by the • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates.
* In Georgia, the nonparticipating benefits are paid the same as the participating benefits, per state regulation.
• A 30-day supply or the amount prescribed, whichever is less, for each prescription or refill.
• Certain self-administered injectable drugs and related supplies approved by Humana.
• Certain drugs, medicines or medications that, under federal or state law, may be dispensed only by For your convenience, you may receive a maximum 90-day supply per prescription or refill through the mail (maximum 30-day supply for self-administered injectable drugs). The same requirements apply when purchasing medications through a participating mail-order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or visit our Web site for more information, • Drug List: a list of prescription drugs, medicines, medications and supplies specified by us. This list identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and/or any prior authorization requirements. (This list is subject to change.) • Copayment: the amount to be paid by the member toward the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy.
• Nonparticipating pharmacy: a pharmacy that has not been designated by us to provide services to • Participating pharmacy: a pharmacy that has signed a direct agreement with us as an independent contractor or has been designated by us as an independent contractor to provide services to all Unless specifically stated otherwise, no coverage is provided for the following: • Any drug prescribed for a sickness or bodily injury not covered under the policy.
• Any drug, medicine or medication labeled “Caution-Limited by Federal Law to Investigational Use” or any experimental drug, medicine or medication, even though a charge is made to you.
• Anorectic or any drug used for the purpose of weight control.
• Any drug used for cosmetic purposes, including but not limited to: – Tretinoin, e.g. Retin A, except if you are under the age of 45 or are diagnosed as having adult acne; – Dermatologicals or hair growth stimulants; or – Pigmenting or de-pigmenting agents, e.g. Solaquin.
– Lawfully obtainable without a prescription (over the counter drugs), except insulin; or – Available in prescription strength without a prescription.
• Abortifacients (drugs used to induce abortions).
• Infertility services including medications.
• Any drug prescribed for impotence and/or sexual dysfunction, e.g. Viagra.
• Any drug for which prior authorization is required, as determined by us, and not obtained.
• Any service, supply or therapy to eliminate or reduce a dependency on, or addiction to tobacco and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services • Treatment for onychomycosis (nail fungus).
• Any portion of a prescription or refill that exceeds a 30-day supply (or a 90-day supply for a prescription or refill that is received from a mail order pharmacy).
• Legend drugs which are not recommended and not deemed necessary by a health care practitioner This is only a partial list of limitations and exclusions. Please refer to the Certificate of
Coverage/Insurance for complete details regarding prescription drug coverage.


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