Page 5 - 2020 Cover Letter and Evaluation for Donna Yacoe

1) Humana Gold Plus HMO Plan: This Advantage plan appears to be a good choice for
several reasons – its $3,400 out-of-pocket limit for Medicare-covered services in
network is low, and the most you can pay if you are hospitalized in a network hospital is
$350. Also, your total drug costs for methotrexate are $2 a month – or $4 total for the
last two months of this year at $24 for all next year, assuming you get your refills at CVS.
This plan has good benefits for dental and vision care. Benefit summaries for 2020 and
the last two months of this year are shown in Appendices C1 and C2.

2) Memorial Hermann HMO Plan. This likewise appears to be a strong plan. Its out-of-
pocket limit for medical services is $500 higher than the Humana plan’s, and its dental
and vision benefits may be slightly less comprehensive. Its drug costs are identical to
those of the Humana plan’s -- $2 a month this year and next if you get your
prescriptions filled at a CVS pharmacy. This plan’s benefit summaries for 2020 and for
the last two months of 2019 are shown in Appendices D1 and D2.

One other factor you may want to consider is the network size of each plan – that is, the
number of providers in the plan’s network (providers can be doctors, medical groups, skilled
nursing facilities, and so on). Usually, the larger the network the better.

Unfortunately, I don’t have an easy way of finding this out because as of October 1 the
Medicare Plan Finder no longer includes this information (I have suggested that they include it
in the future, as they have always done before). But if you call either of the plans, you might ask
the person you speak with if he/she knows how large the provider network is.

Because these are both HMO plans, it’s important to have access to a wide range of specialists
(you’ll have more choices). In an urban area like Harris County, these plans should have
networks of one thousand or more providers.

Rx Drug Plan Coverage

As already noted, both Advantage plans in your evaluation have low costs for methotrexate (I
estimated that you take 26 tablets a month). Because neither plan has a drug premium, your
total costs will be your monthly $2 co-payments.

The benefit summaries of both these Advantage plans indicate that they may require a “prior
authorization” from your doctor before they will cover methotrexate. If a plan requests a prior
authorization for a drug, your physician may need to justify your need for it. In some cases, the
plan may recommend a substitute drug that’s also on its formulary. Prior authorizations are
common in Part D plans, and usually they do not present a significant obstacle to getting the
drug(s) you want.

If you decide to get a Medigap policy, you will need to get a Medicare prescription drug plan,
also called a stand-alone drug plan. There are two of these stand-alone plans that are probably
the two lowest-cost options for 2020 (I say “probably” because the new Medicare Plan Finder

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