b'Plan Comparisons: Medicare-Eligible MembersUnitedHealthcare Group Medicare Advantage PPO with Express Scripts Medicare (PDP) for CTPFHumana Group Medicare HMOMedicare Advantage plan with Part D Pharmacy Medicare 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 Preferred Value Network Pharmacy* psychiatric care: 190 day lifetime limit. Alcohol and (up to 31-Day supply)substance abuse: $150 Copay per day (days 1-5) in-network, per admission. $10 Generic copay $30 Preferred brand copay PRESCRIPTION DRUG BENEFITS$50 Non-preferred brand copay$50 Specialty drugsRetail Pharmacy (up to 30-Day supply) Preferred Value Network Pharmacy* $5 Preferred generic copay (up to 90-day supply) $30 Non-preferred generic or preferred brand copay$25 Generic copay $45 Non-preferred brand copay$75 Preferred brand copay 25% Coinsurance for specialty drugs (limited to a $125Non-preferred brand copay 30-Day supply, max. $150 per prescription) $125Specialty drugs 30-day mail order supply also available with $5Express Scripts Mail Order (up to 90-Day Supply) preferred generic copay. All other copays same as $20 Generic copay retail 30-day supply. $60 Preferred brand copay$100Non-preferred brand copay Retail up to 90-Day Supply $100Specialty drugs $15Preferred generic copay Coverage $90Non-preferred generic or preferred brand copay$135Non-preferred brand copayPrescription coverage is provided through the coverage gap and generally stays the same as the copays listed above. Mail Order up to 90-Day SupplyNon-Medicare Part D drugs are not covered (for$0Preferred generic copayexample, lifestyle drugs for ED).$60Non-preferred generic or preferred brand copayMedicare Part B drugs: use UnitedHealthcare $90Non-preferred brand copayMedicare Advantage ID card. VaccinationsVaccinations Flu shots and shots to prevent pneumococcalFlu shots and shots to prevent pneumococcalinfections are covered under Part B. Contact Humana infections are covered under Part B. Contact UnitedHealthcare Medicare Advantage customercustomer service for more information about vaccines service for more information on vaccines and otherand other Part B services.Part B services.Important Pharmacy Notes Important Pharmacy NotesOnce your true out-of-pocket cost reaches $8,000,After your yearly out-of-pocket drug costs (including your copay will be reduced. Once you meet this costdrugs purchased through your retail pharmacy and threshold, the plan pays the full cost for your coveredthrough mail order) reach $8,000, you have a $0 Part D drugs. If your plan covers additional drugs notcopayment. normally covered by Medicare, you may have a cost share for such drugs covered under an enhanced benefit.*Non-preferred network copays are $5 more than stated copays 20 CTPF 2024 MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2024 MEDICARE HEALTH INSURANCE HANDBOOK'