b'Plan Comparisons: Medicare-Eligible MembersUnitedHealthcare Group Medicare AdvantageHumana Group Medicare HMOPPO with Express Scripts Medicare (PDP) for CTPFwith Part D Pharmacy Medicare Advantage planMedicare Advantage plan PLAN 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. Includes several benefits and programs notCONTACT INFORMATIONcovered by Medicare.CONTACT 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 card1-866-396-8810 Customer Service8 a.m.8 p.m., local time | 7 days a week www.humana.com1-877-365-7949 NurseLineHOW TO ENROLLRetiree.UHC.com/ctpf | uhcvirtualretiree.com/ctpfExpress Scripts Group number: CTPFRX Complete CTPF Form 350 (available in the center of this 1-800-864-1416 Customer Servicewww.Express-Scripts.com/medd/ctpf book or online at www.ctpf.org) Return with required HOW TO ENROLL documentation to CTPF.Complete CTPF Form 350 (available in the center of thisSERVICE AREAbook or online at www.ctpf.org). Return with requiredChicago (Cook, DuPage, Kane, Kankakee, Kendall, Lake, documentation to CTPF. McHenry & Will counties) SERVICE AREA FOREIGN TRAVELNationwide; All 50 states, the District of Columbia and theForeign travel emergency benefits available. Limited to 5 US Territories. emergency Medicare-covered services.FOREIGN TRAVEL PHYSICIAN SELECTIONUrgent and emergency benefits available. Select a PCP from the listing at www.humana.comPHYSICIAN SELECTION LIFETIME MAXIMUM Choose any provider who accepts Medicare. No lifetime maximum except inpatient mental health (see LIFETIME MAXIMUMbehavioral health services).No lifetime maximum OUT-OF-POCKET MAXIMUM OUT-OF-POCKET MAXIMUM$2,500 per individual, per calendar year. Excludes Part D $1,500 (Includes $175 deductible) pharmacy, extra services, & the plan premium.Annual Medical Out-of-Pocket Maximum combined forANNUAL PLAN YEAR DEDUCTIBLE IN and OUT of network. NoneANNUAL PLAN YEAR DEDUCTIBLESPECIAL DEDUCTIBLES $175 NoneSPECIAL DEDUCTIBLES None HOSPITAL SERVICESHOSPITAL SERVICES Inpatient$150 Copay, per day, for first five days of each Inpatientadmission, authorized services only100% after deductible Skilled Nursing Facility (non-custodial)No copay days Skilled Nursing Facility (non-custodial)1-20, no 3-day hospital stay required; $25 Copay per day, 100% after deductible days 21-100, per benefit period.0% coinsurance per day, days 1-20;100% days 21-100 after deductible1616 CTPF 2025 MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2025 MEDICARE HEALTH INSURANCE HANDBOOK'