b"Plan Comparisons: Medicare-Eligible MembersUnitedHealthcare Group Medicare Advantage PPOwith 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 Initial Coverage stage and generally stays the same as the copays listed above. For 2025, you will stay in this stage until the total cost of yourMail Order up to 90-Day SupplyPart D drugs reaches $2,000. Once you reach this limit, you move on to the Catastrophic Coverage stage. Most members$0Preferred generic copaywill not reach the Catastrophic Coverage stage. $60Non-preferred generic or preferred brand copayNon-Medicare Part D drugs are not covered (for example,$90Non-preferred brand copaylifestyle drugs for ED). Medicare Part B drugs: use UnitedHealthcareMedicareVaccinations Advantage ID card.Flu shots and shots to prevent pneumococcalVaccinationsinfections are covered under Part B. Contact Humana Flu shots and shots to prevent pneumococcalcustomer service for more information about vaccines infections are covered under Part B. Contact and other Part B services.UnitedHealthcare Medicare Advantage customer service for more information on vaccines and other Part B services. Important Pharmacy NotesImportant Pharmacy Notes When the member's cost share plus the costs incurred Once your true out-of-pocket cost reaches $2,000,for Part D drugs reimbursed through insurance or a your copay will be reduced. Once you meet this cost threshold,group health plan reaches $2,000, you have a $0 the plan pays the full cost for your covered Part D drugs. If yourcopayment.plan covers additional drugs not 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 2025 MEDICARE HEALTH INSURANCE HANDBOOK CTPF 2025 MEDICARE HEALTH INSURANCE HANDBOOK"