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Humana Basic Rx Plan (PDP) (S5884-105-0)
Tier 1 (214)
Tier 2 (637)
Tier 3 (716)
Tier 4 (1054)
Tier 5 (590)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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2024 Medicare Part D Plan Formulary Information
Humana Basic Rx Plan (PDP) (S5884-105-0)
Benefits & Contact Info           
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Call drug plan for more details.
The Humana Basic Rx Plan (PDP) (S5884-105-0)
Formulary Drugs Starting with the Letter I

in CMS PDP Region 11 which includes: FL
Drugs Starting with Letter I

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
IBANDRONATE SODIUM 150 MG TABLET [Boniva]   3 Preferred Brand 24%15%Q:1
/28Days
IBRANCE 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 100 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 125 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 125 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 75 MG CAPSULE   5 Specialty Tier 25%N/AP Q:21
/28Days
IBRANCE 75 MG TABLET   5 Specialty Tier 25%N/AP Q:21
/28Days
IBU 600 MG TABLET [Toxicology Saliva Collection]   1 Preferred Generic $0.00$0.00None
IBU 800 MG TABLET [Samson-8]   1 Preferred Generic $0.00$0.00None
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [PediaCare Children's Pain Reliever/Fever Reducer IB]   2 Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IBUPROFEN 400 MG TABLET [Motrin]   1 Preferred Generic $0.00$0.00None
IBUPROFEN 600 MG TABLET [Toxicology Saliva Collection]   1 Preferred Generic $0.00$0.00None
IBUPROFEN 800 MG TABLET [Samson-8]   1 Preferred Generic $0.00$0.00None
ICATIBANT 30 MG/3 ML SYRINGE [FIRAZYR]   5 Specialty Tier 25%N/AP Q:18
/30Days
ICLEVIA 0.15 MG-0.03 MG TABLET TBDSPK 3MO [Setlakin]   4 Non-Preferred Drug 47%30%Q:91
/90Days
ICLUSIG 10 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ICLUSIG 15 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
ICLUSIG 30 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
ICLUSIG 45 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IDHIFA 100 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
IDHIFA 50 MG TABLET   5 Specialty Tier 25%N/AP Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ILEVRO 0.3% OPHTH DROPS EYE DROPPER   3 Preferred Brand 24%15%Q:3
/30Days
IMATINIB MESYLATE 100 MG TABLET [Gleevec]   5 Specialty Tier 25%N/AP Q:90
/30Days
IMATINIB MESYLATE 400 MG TABLET [Gleevec]   5 Specialty Tier 25%N/AP Q:60
/30Days
IMBRUVICA 140 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
IMBRUVICA 420 MG TABLET   5 Specialty Tier 25%N/AP Q:28
/28Days
IMBRUVICA 70 MG CAPSULE   5 Specialty Tier 25%N/AP Q:28
/28Days
IMBRUVICA 70 MG/ML ORAL SUSPENSION   5 Specialty Tier 25%N/AP
IMIPRAMINE HCL 10 MG TABLET [Tofranil]   2 Generic $1.00$0.00None
IMIPRAMINE HCL 25 MG TABLET [Tofranil]   2 Generic $1.00$0.00None
IMIPRAMINE HCL 50 MG TABLET [Tofranil]   2 Generic $1.00$0.00None
IMIPRAMINE PAMOATE 100 MG CAPSULE [Tofranil-PM]   4 Non-Preferred Drug 47%30%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IMIPRAMINE PAMOATE 125 MG CAPSULE [Tofranil-PM]   4 Non-Preferred Drug 47%30%None
IMIPRAMINE PAMOATE 150 MG CAPSULE [Tofranil-PM]   4 Non-Preferred Drug 47%30%None
IMIPRAMINE PAMOATE 75 MG CAPSULE [Tofranil-PM]   4 Non-Preferred Drug 47%30%None
IMIQUIMOD 5% CREAM PACKET   3 Preferred Brand 24%15%Q:12
/30Days
IMOVAX RABIES VACCINE VIAL   1 Preferred Generic $0.00$0.00P
INBRIJA 42 MG INHALATION CAPSULE W/DEV   5 Specialty Tier 25%N/AP Q:300
/30Days
INCASSIA 0.35 MG TABLET [Sharobel 28-Day]   4 Non-Preferred Drug 47%30%None
Increlex 40mg/4mL 1 VIAL, MULTI-DOSE per CARTON / 4 mL in 1 VIAL, MULTI-DOSE   5 Specialty Tier 25%N/AP
INDAPAMIDE 1.25 MG TABLET [Lozol]   1 Preferred Generic $0.00$0.00None
INDAPAMIDE 2.5 MG TABLET [Lozol]   1 Preferred Generic $0.00$0.00None
INDOMETHACIN 25 MG CAPSULE [Indocin]   2 Generic $1.00$0.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INDOMETHACIN 50 MG CAPSULE [Indocin]   2 Generic $1.00$0.00None
INDOMETHACIN ER 75 MG CAPSULE ER [Indocin SR]   4 Non-Preferred Drug 47%30%None
INFANRIX DTAP SYRINGE   1 Preferred Generic $0.00$0.00None
INLYTA 1 MG TABLET   5 Specialty Tier 25%N/AP Q:180
/30Days
INLYTA 5 MG TABLET   5 Specialty Tier 25%N/AP Q:60
/30Days
INQOVI 35 MG-100 MG TABLET   5 Specialty Tier 25%N/AP Q:5
/28Days
INREBIC 100 MG CAPSULE   5 Specialty Tier 25%N/AP Q:120
/30Days
INSULIN LISPRO 100 UNIT/ML VIAL [LYUMJEV]   3 Preferred Brand 24%15%None
INTELENCE 200 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
INTELENCE 25 MG TABLET   4 Non-Preferred Drug 47%30%Q:120
/30Days
INTRALIPID 20% IV FAT EMULSION   4 Non-Preferred Drug 47%30%P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INTRALIPID 30% IV FAT EMULSION   4 Non-Preferred Drug 47%30%P
INVEGA HAFYERA 1,092 MG/3.5 ML SYRINGE   4 Non-Preferred Drug 47%30%Q:3.5
/180Days
INVEGA HAFYERA 1,560 MG/5 ML SYRINGE   4 Non-Preferred Drug 47%30%Q:5
/180Days
Invega Sustenna 117 mg/0.75mL Prefilled Syringe   4 Non-Preferred Drug 47%30%Q:1.5
/28Days
Invega Sustenna 156 mg/mL Prefilled Syringe   4 Non-Preferred Drug 47%30%Q:1
/28Days
Invega Sustenna 234 mg/1.5mL Prefilled Syringe   4 Non-Preferred Drug 47%30%Q:1.5
/28Days
Invega Sustenna 39 mg/0.25mL Prefilled Syringe   4 Non-Preferred Drug 47%30%Q:1.5
/28Days
Invega Sustenna 78 mg/0.5mL Prefilled Syringe   4 Non-Preferred Drug 47%30%Q:1.5
/28Days
INVEGA TRINZA 273 MG/0.875 ML   4 Non-Preferred Drug 47%30%Q:0.88
/90Days
INVEGA TRINZA 410 MG/1.315 ML   4 Non-Preferred Drug 47%30%Q:1.32
/90Days
INVEGA TRINZA 546 MG/1.75 ML   4 Non-Preferred Drug 47%30%Q:1.75
/90Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
INVEGA TRINZA 819 MG/2.625 ML   4 Non-Preferred Drug 47%30%Q:2.63
/90Days
INVOKAMET 150-1,000 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET 150-500 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET 50-1,000 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET 50-500 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET XR 150-1,000 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET XR 150-500 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET XR 50-1,000 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKAMET XR 50-500 MG TABLET   3 Preferred Brand 24%15%Q:60
/30Days
INVOKANA 100 MG TABLET   3 Preferred Brand 24%15%Q:30
/30Days
INVOKANA 300 MG TABLET   3 Preferred Brand 24%15%Q:30
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
IPOL VIAL 40;8;32; UNT   1 Preferred Generic $0.00$0.00None
IPRAT-ALBUT 0.5-3(2.5) MG/3 ML AMPUL-NEB [DuoNeb]   2 Generic $1.00$0.00P
IPRATROPIUM 0.03% SPRAY [Atrovent]   2 Generic $1.00$0.00Q:30
/30Days
IPRATROPIUM 0.06% SPRAY [Atrovent]   2 Generic $1.00$0.00Q:45
/30Days
IPRATROPIUM BR 0.02% SOLUTION [Atrovent]   2 Generic $1.00$0.00P
IRBESARTAN 150 MG TABLET [Avapro]   2 Generic $1.00$0.00Q:30
/30Days
IRBESARTAN 300 MG TABLET [Avapro]   2 Generic $1.00$0.00Q:30
/30Days
IRBESARTAN 75 MG TABLET [Avapro]   2 Generic $1.00$0.00Q:30
/30Days
IRBESARTAN-HCTZ 150-12.5 MG TABLET [Avalide]   2 Generic $1.00$0.00Q:60
/30Days
IRBESARTAN-HCTZ 300-12.5 MG TABLET [Avalide]   2 Generic $1.00$0.00Q:30
/30Days
ISENTRESS 100 MG POWDER PACKET   3 Preferred Brand 24%15%Q:300
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISENTRESS 100 MG TABLET CHEWABLE   5 Specialty Tier 25%N/AQ:180
/30Days
ISENTRESS 25 MG TABLET CHEWABLE   4 Non-Preferred Drug 47%30%Q:180
/30Days
ISENTRESS 400MG TABLET   5 Specialty Tier 25%N/AQ:120
/30Days
ISENTRESS HD 600 MG TABLET   5 Specialty Tier 25%N/AQ:60
/30Days
ISIBLOOM 28 DAY TABLET [Solia]   4 Non-Preferred Drug 47%30%None
ISONIAZID 100 MG TABLET   2 Generic $1.00$0.00None
ISONIAZID 300 MG TABLET   2 Generic $1.00$0.00None
ISONIAZID 50MG/5ML SYRUP   4 Non-Preferred Drug 47%30%None
ISOSORBIDE DINITRATE 10 MG TABLET [Wesorbide]   3 Preferred Brand 24%15%None
ISOSORBIDE DINITRATE 20 MG TABLET [Wesorbide]   3 Preferred Brand 24%15%None
ISOSORBIDE DN 30 MG TABLET   3 Preferred Brand 24%15%None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISOSORBIDE DN 5 MG TABLET   3 Preferred Brand 24%15%None
ISOSORBIDE MN ER 30 MG TABLET   1 Preferred Generic $0.00$0.00None
ISOSORBIDE MONONIT 10 MG TABLET [Monoket]   2 Generic $1.00$0.00None
ISOSORBIDE MONONIT 20 MG TABLET [Monoket]   2 Generic $1.00$0.00None
ISOSORBIDE MONONIT ER 120 MG TABLET 24H [Imdur]   2 Generic $1.00$0.00None
ISOSORBIDE MONONIT ER 60 MG TABLET 24H [Isotrate ER]   1 Preferred Generic $0.00$0.00None
ISOSORBIDE-HYDRALAZINE 20-37.5 TABLET [BiDil]   4 Non-Preferred Drug 47%30%Q:180
/30Days
ISOTRETINOIN 10 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 47%30%Q:60
/30Days
ISOTRETINOIN 20 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 47%30%Q:60
/30Days
ISOTRETINOIN 30 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 47%30%Q:60
/30Days
ISOTRETINOIN 40 MG CAPSULE [ZENATANE]   4 Non-Preferred Drug 47%30%Q:120
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ISRADIPINE 2.5 MG CAPSULE [DynaCirc]   4 Non-Preferred Drug 47%30%None
ISRADIPINE 5 MG CAPSULE [DynaCirc]   4 Non-Preferred Drug 47%30%None
ISTURISA 1 MG TABLET   5 Specialty Tier 25%N/AP Q:240
/30Days
ISTURISA 5 MG TABLET   5 Specialty Tier 25%N/AP Q:360
/30Days
ITRACONAZOLE 10 MG/ML SOLUTION [Sporanox]   4 Non-Preferred Drug 47%30%None
ITRACONAZOLE 100 MG CAPSULE [Sporanox]   4 Non-Preferred Drug 47%30%Q:120
/30Days
IVERMECTIN 3 MG TABLET [Stromectol, Sklice]   3 Preferred Brand 24%15%None
IWILFIN 192 MG TABLET   5 Specialty Tier 25%N/AP Q:240
/30Days
IXCHIQ Chikungunya 18 Years + Injectable 0.5mL Live SDV Ea   1 Preferred Generic $0.00$0.00None
IXIARO 6 UNIT(6 MCG)/0.5ML SYRINGE   1 Preferred Generic $0.00$0.00None

Chart Legend:

Below are a few notes to help you understand the above 2024 Medicare Part D Humana Basic Rx Plan (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug or Medicare Advantage plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region). The plan name is followed by the plan type (PDP, HMO, HMO-POS, PPO, PFFS, etc.)

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $545 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.
    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.

  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have five (5) tiers 1=Preferred Generics, 2=Generics, 3=Preferred Brands, 4=Non-preferred Brands, 5=Specialty Drugs.
    • Tier Number* - Some Part D drug plans exclude one or more drug tiers from the plan’s deductible. If the drug tier field above is followed by * (example: 2*), then this drug tier is excluded from the plan’s deductible.
    • Tier Description - This is the Medicare Part D plan’s description of this particular drug tier.

  • Cost Sharing - Copay / Coinsurance - This is what you will pay for formulary drugs in the Initial Coverage Phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $5,030) at a "Preferred" network pharmacy. In most cases, the "Preferred" network pharmacy cost-sharing is lower than the standard (non-preferred) network pharmacy cost-sharing.

      *All forms of insulin covered by any Medicare Part D plan will have a copay of $35 or less through all phases of coverage. Please contact the drug plan for more details.

    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).

  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data June 2024)

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Medicare plan provider.