Page 5 - Cover Letter and Evaluation for Sue Marx

This plan also has a $750 health plan deductible, an amount that is included in the
minimum-cost calculations on page 3 of the evaluation. Most of the PPO plans in your
area have a health plan deductible, some higher than this plan’s and others lower. It
makes sense to also consider a plan’s health care premiums when evaluating the
deductible. This plan’s health care premiums, for example, are only $7.70 a month
(about $92 a year), whereas some of the other PPO plans have lower deductibles but
premiums that are much higher. This plan’s benefit details are shown in Appendix B2.

2) UPMC for Life HMO Premier Rx Advantage Plan: Sponsored by UPMC, this plan has
more than 4,500 providers. It has no fixed costs – no premiums and no deductibles for
either health or Rx drug coverage. An HMO is the most restrictive type of managed care
plans. As you may know, most of them require that you get a referral before you see a
specialist and they do not cover out-of-network costs except in medical emergencies.

As a tradeoff for accepting these restrictions, people in HMO plans generally have the
lowest premiums and deductibles (they are zero in this plan). HMO’s are best suited for
people who do not use a large number of medical services and who do not see
specialists frequently (and thus do not need many referrals). This plan’s benefit details
are shown in Appendix B3

Rx Drug Plan Coverage

The first page of Appendix C1 lists your Rx drugs, dosages and monthly quantities as they were
entered in the Medicare web site’s Plan Finder, which uses this information to find the lowest-
cost plans (either Advantage or stand-alone) for a set of drugs.

As you are aware, Humira, an expensive brand-name drug, is the primary reason for your high
prescription drug costs. In all four of the drug plans that are compared on page 4 of the
evaluation, Humira is in the plans’ specialty tier, which is the highest cost tier. Also, when you
take a specialty tier drug you pay a percentage of the drug’s cost, and if Humira raises its prices
this year your co-insurance payment will increase. All four plans also indicate that your
physician’s prior authorization may be required before the plan will cover Humira, even though
it is included in their formularies. Also, three of the plans indicate that prior authorizations will
be needed for amitriptyline.

If a plan does request a prior authorization for a drug, your physician may need to justify your
need for the drug. In some instances the plan may recommend a less expensive substitute drug
that’s also on its formulary. Prior authorizations are fairly common in Part D plans, and in most
cases they do not present a significant obstacle to getting the drug(s) you need. But you should
be aware that the plan may request it.

You indicated on your questionnaire that you prefer to get mail-order refills. In some plans,
however, your costs will be substantially reduced if you are willing to get monthly refills at a
local pharmacy. Each plan’s costs for both refill schedules – mail-order and monthly -- are

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