b'UnitedHealthcare Group Medicare Advantage PPO with Express Scripts Medicare (PDP) for CTPFHumana Group Medicare HMOMedicare Advantage planwith Part D Pharmacy Medicare Advantage planPLAN FEATURES PLAN FEATURESUse any physician who accepts Medicare. EnhancedTraditional HMO with network, referrals and prior Medicare Part D prescription coverage. Pays 100% afterauthorization required. Includes Humana Group plan deductible is met, with the exception of EmergencyMedicare prescription coverage. Room visits. CONTACT INFORMATIONCONTACT INFORMATION Group number 303611 for Chicago plansUnitedHealthcare Group Number: 12830 For other service areas, group number is listed on Toll free 1-866-572-9396, TTY 711 insurance card8 a.m.8 p.m., local time | 7 days a week 1-866-396-8810 Customer Service1-877-365-7949 NurseLinewww.humana.comwww.UHCRetiree.com/ctpf | www.uhcvirtualretiree.com/ctpfExpress Scripts Group number: CTPFRX HOW TO ENROLL1-800-864-1416 Customer Service Contact CTPF Member Services at 312-641-4464 and www.Express-Scripts.com/medd/ctpf request an enrollment packet. Return the completed HOW TO ENROLL packet and CTPF Form 350 (available in the center of this book or online at www.ctpf.org), to CTPF.Complete CTPF Form 350 (available in the center of thisSERVICE AREAbook or online at www.ctpf.org). Return with required documentation to CTPF. Chicago (Cook, DuPage, Kane, Kendall, & Will counties) and some areas in AZ, AL, CA, CO, FL, IN, KS, LA, NM, NV, SERVICE AREA MO, MS, PR, TN, UT, TX, call for more info. Nationwide; All 50 states, the District of Columbia and theFOREIGN TRAVEL5 US Territories. Foreign travel emergency benefits available. Limited to FOREIGN TRAVEL emergency Medicare-covered services.Foreign travel emergency benefits available. PHYSICIAN SELECTIONPHYSICIAN SELECTION Select a PCP from the listing at www.humana.comChoose any provider who accepts Medicare. LIFETIME MAXIMUM LIFETIME MAXIMUMNo lifetime maximum except inpatient mental health (see No lifetime maximum behavioral health services).OUT-OF-POCKET MAXIMUMOUT-OF-POCKET MAXIMUM $1,500 (Includes $175 deductible) $2,500 per individual, per calendar year. Excludes Part D Annual Medical Out-of-Pocket Maximum combined forpharmacy, extra services, & the plan premium.IN and OUT of network. ANNUAL PLAN YEAR DEDUCTIBLE ANNUAL PLAN YEAR DEDUCTIBLENone$175 SPECIAL DEDUCTIBLES SPECIAL DEDUCTIBLES None NoneHOSPITAL SERVICES HOSPITAL SERVICESInpatientInpatient$150 Copay, per day, for first five days of each 100% after deductible admission, authorized services onlySkilled Nursing Facility (non-custodial)Skilled Nursing Facility (non-custodial)No copay days 100% after deductible 1-20, no 3-day hospital stay required; $25 Copay per day, 0% coinsurance per day, days 1-20; days 21-100, per benefit period.100% days 21-100 after deductibleCTPF 2021 HEALTH INSURANCE HANDBOOKCTPF 2021 HEALTH INSURANCE HANDBOOK39'