b'UnitedHealthcare Group Medicare AdvantageHumana Group Medicare HMOPPO with Express Scripts Medicare (PDP) for CTPFwith Part D Pharmacy Medicare Advantage planMedicare Advantage planBEHAVIORAL HEALTH SERVICES BEHAVIORAL HEALTH SERVICESOutpatient: 100% after deductible Outpatient: $10 Copay PCP, $25 Copay specialist,Inpatient: 100% after deductible$40 Copay outpatient facility (190 day lifetime limit) Inpatient: $150 Copay per day (days 1-5) in-network, PRESCRIPTION DRUG BENEFITS per admission; authorized services only. Inpatient psychiatric care: 190 day lifetime limit. Alcohol and Preferred Value Network Pharmacy* substance abuse: $150 Copay per day (days 1-5) (up to 31-Day supply)in-network, per admission. $10 Generic copayPRESCRIPTION DRUG BENEFITS$30 Preferred brand copay Retail Pharmacy (up to 30-Day supply) $50 Non-preferred brand copay $5 Preferred generic copay$50 Specialty drugs$30 Non-preferred generic or preferred brand copayPreferred Value Network Pharmacy* $45 Non-preferred brand copay (up to 90-day supply) 25% $25 Generic copay Coinsurance for specialty drugs (limited to a 30-Day supply, max. $150 per prescription)$75 Preferred brand copay 30-day mail order supply also available with $5 $125Non-preferred brand copaypreferred generic copay. All other copays same as $125Specialty drugs retail 30-day supply.Express Scripts Mail Order (up to 90-Day Supply)$20 Generic copay Retail up to 90-Day Supply$60 Preferred brand copay $15Preferred generic copay$100Non-preferred brand copay $90Non-preferred generic or preferred brand copay $135Non-preferred brand copay$100Specialty drugs Coverage Mail Order up to 90-Day SupplyPrescription coverage is provided through the$0Preferred generic copaycoverage gap and generally stays the same as the$60Non-preferred generic or preferred brand copaycopays listed above. $90Non-preferred brand copayNon-Medicare Part D drugs are not covered (for example, lifestyle drugs for ED). Medicare Part B drugs: use UnitedHealthcare Vaccinations Medicare Advantage ID card.Flu shots and shots to prevent pneumococcalVaccinationsinfections are covered under Part B. Contact Humana Flu shots and shots to prevent pneumococcal infec- customer service for more information about vaccines tions are covered under Part B. Contact UnitedHealth- and other Part B services.care Medicare Advantage customer service for more information on vaccines and other Part B services. Important Pharmacy NotesImportant Pharmacy Notes Once your true out-of-pocket cost reaches $6,550 your Once your true out-of-pocket cost reaches $6,550, yourcopay may be reduced. Once you meet this cost copay may be reduced. Once you meet this costthreshold, you pay the greater of 5% coinsurance or threshold, you pay the greater of 5% coinsurance or$3.70 for generics/multi source drugs, $9.20 for brand $3.70 for generics/multi source drugs, $9.20 for brandname drugs, but never more than the normal copay for name drugs, but never more than the normal copay forthat drug tier based on the number of days prescribed that drug tier based on the number of days prescribed(e.g., 30 days).(e.g., 30 days).CTPF 2021 HEALTH INSURANCE HANDBOOKCTPF 2021 HEALTH INSURANCE HANDBOOK43'