b'Plan Comparisons: Medicare-Eligible MembersCigna Surround Group Supplement Plan AARP Medicare Supplement Insurance with Express Scripts Medicare (PDP) (mirrors Plan G) Plan F (UnitedHealthcare) with Express Scripts Available to Medicare recipients who turned 65Medicare (PDP) for CTPF on or after 2020 (or Part A effective date on or afterAvailable to Medicare recipients who turned 65 1/1/2020). prior to 2020. BEHAVIORAL HEALTH SERVICES BEHAVIORAL HEALTH SERVICES(Medicare covered services only)(Medicare covered services only)(Part B deductible applies)Outpatient: 100% after Medicare paysOutpatient: 100% after Medicare pays Inpatient: 100% after Medicare paysInpatient: 100% after Medicare pays PRESCRIPTION DRUG BENEFITSPRESCRIPTION DRUG BENEFITS Preferred Value Network Pharmacy* Preferred Value Network Pharmacy*(up to 31-Day supply)(up to 31-Day supply) $10Generic copay$10Generic copay $30Preferred brand copay$30Preferred brand copay $50Non-preferred brand copay$50Non-preferred brand copay $50Specialty drugs$50Specialty drugs Preferred Value Network Pharmacy* Preferred Value Network Pharmacy*(up to 90-Day Supply)(up to 90-Day Supply) $25Generic copay$25Generic copay $75Preferred brand copay$75Preferred brand copay $125Non-preferred brand copay$125Non-preferred brand copay$125Specialty drugs$125Specialty drugsExpress Scripts Mail Order (up 90-Day Supply)Express Scripts Mail Order (up 90-Day Supply) $20 Generic copay$20 Generic copay $60 Preferred brand copay$60 Preferred brand copay $100Non-preferred brand copay$100Non-preferred brand copay$100Specialty drugs$100Specialty drugsCoverageCoverage Prescription coverage is provided through the Prescription coverage is provided through thecoverage gap and generally stays the same as the coverage gap and generally stays the same as thecopays listed above.copays listed above.Non-Medicare Part D drugs are not covered (forNon-Medicare Part D drugs are not covered (for example, lifestyle drugs for ED).example, lifestyle drugs for ED). Medicare Part B drugs, including diabetic supplies, areMedicare Part B drugs, including diabetic supplies, are processed by your medical plan.processed by your medical plan. VaccinationsVaccinations Flu shots and shots to prevent pneumococcalFlu shots and shots to prevent pneumococcal infections are covered under Part B. Contact yourinfections are covered under Part B. Contact your Medicare drug plan for more information aboutMedicare drug plan for more information about vaccines. vaccines.Important Pharmacy Notes Important Pharmacy NotesOnce your true out-of-pocket cost reaches $8,000, yourOnce your true out-of-pocket cost reaches $8,000,copay will be reduced. Once you meet this costyour copay will be reduced. Once you meet this cost threshold, the plan pays the full cost for your coveredthreshold, the plan pays the full cost for your covered Part D drugs. If your plan covers additional drugs notPart D drugs. If your plan covers additional drugs not normally covered by Medicare, you may have a costnormally covered by Medicare, you may have a cost share for such drugs covered under an enhancedshare for such drugs covered under an enhanced benefit. benefit.*Non-preferred network copays are $5 more than stated copays CTPF 2024 MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2024 MEDICARE HEALTH INSURANCE HANDBOOK 21'