Page 5 - Cover Letter and Medicare Evaluation for Andrea Masters

1) CDPHP $0 Medicare Rx HMO Plan. This is one of eight 5-star Advantage plans
sponsored by the Capital District Physicians” Health Plan. It has no co-payments for
office visits to a primary care doctor, and the co-pays for a visit to a specialist range
between zero and $40. This plan’s extra benefits – especially its dental coverage –
appear to be slightly better than those of the Highmark plan described below.

Among this plan’s strengths is a network of 10,000 providers (doctors, therapists,
hospitals, etc.). One weakness is its $7,500 out-of-pocket (OOP) limit for medical
services -- a high number for an HMO plan (on average, PPO’s have higher OOP
limits for network services). This plan’s benefit summary is in Appendix C2.

2) The Highmark Blue Shield Freedom Nation PPO Plan. This is one of three 5-star
Highmark plans in your area, and many of its in-network benefits are similar to those
of the CDPHP plan above. Co-payments for in-network primary care visits are $0-$5
and $36 for in-network visits to specialists. The plan’s OOP limit for network services
is $7,550, or $50 higher than in the CDPHP plan above.

But that limit jumps to $11,300 when out-of-network services are included. So, if
you were to see an out-of-network doctor, you would pay 40% of cost and that
payment would count only toward the higher limit. This plan has $15 co-pays for
most preventive dental services (whether in the plan’s dental network or not) and it
also sells dental supplements for additional premiums of $13 and $24 a month. This
plan’s benefit summary is in Appendix C3.

Rx Drug Plan Coverage

As mentioned, even though you do not take prescription drugs, you will need to sign up Part D
coverage to avoid late-enrollment penalties. If you enroll in either of the Advantage plans in
your evaluation, Part D coverage is bundled with the plan’s medical benefits. But if you get a
Medigap policy, you will also need to enroll in a stand-alone drug plan. The stand-alone drug
plan that has the lowest premiums is the SilverScript Smart Rx plan with a $7.20 monthly
premium. CVS is a preferred pharmacy in this plan (CVS owns SilverScript). You can enroll in this
plan, whose benefit summary is in Appendix D, by calling (833) 526-2445.

CVS is not a preferred pharmacy in either of the Advantage plans in your evaluation, although it
could be that that the CDPHP does not have any preferred pharmacies, as is true for a few
plans. When a plan does have preferred pharmacies, you will often get the best pricing there.
Each plan’s preferred pharmacies (if any) are shown on page 4 of the evaluation.

Weighing the Options

In deciding which type of coverage to choose, you might factor in how much risk you are willing
to take. Even though the two Advantage plans in your evaluation have no premiums, they have
more out-of-pocket risk. In an unlikely worst case, you could spend twice as much in either of

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