Page 6 - Cover Letter and Evaluation for Margaret Rockey

through the plan because your purchase will not count toward the plan’s deductible or
coverage limits.

Another option is to ask the plan that you enroll in to cover Qnasi. People frequently ask for
formulary exceptions, although there’s no way to know their rate of success (plans aren’t
required to disclose that information). When you request a formulary exception, your
physician will need to support the request and explain to the plan why you need Qnasi instead
of a different drug that is on the plan’s formulary and that is used to treat the same condition.
A separate attachment explains this process in more detail. If you decide to request a formulary
exception for Qnasi and would like help in understanding the process, you can probably get no-
cost assistance from the Arizona State Health Insurance Program (SHIP) at (800) 432-4040.

The estimates of your drug costs, including the full price for Onasi, are shown on pages 3 and 4
of the evaluation and are for the last 7 months of this year. These are estimates, of course, and
will not exactly match what you’ll spend. For one thing, most of your drugs have co-insurance
payments at various coverage phases. As you know, with co-insurance you will pay a
percentage of the drug’s costs, e.g., 25%. And so, when a pharmaceutical company raises a
drug’s price during the year, your co-insurance payments will also increase.

Something else to keep in mind is that the costs shown for mail-order refills vs. monthly refills
at a local pharmacy are not directly comparable. The reason is that if you continue to get mail-
order refills, you will have approximately a two-month supply of your drugs on hand at the end
of the year.

Of the plans compared in your evaluation, the lowest-cost option for the Rx drugs that you take
is the WellCare Medicare Rx Select Prescription Drug Plan (PDP). For the last seven months of
this year, this plan’s estimated costs for mail-order refills is $2,726, and you will have a two-
month supply of drugs at the start of 2021 (this assumes you order all your drugs on a quarterly
basis beginning June 1). You would get this plan only if you also decide to get a Medigap policy.
This plan’s enrollment number is (866) 859-9084 and its benefit summary is in Appendix D

As for the two Advantage plans compared in the evaluation, their costs for your Rx drugs are
roughly $1,000 more for the last seven months. Both plans’ estimated costs for your Rx drugs
are shown on page 4 of the evaluation and are also included in the plans’ benefit summaries in
Appendices C2 and C3.

Summary

In general, Medigap policies have high premiums and low out-of-pocket risks. The opposite is
true for Advantage plans, most of which have low premiums but high risk. As an example, the
Advantage PPO plan in your evaluation has no premiums and no deductible for health coverage
but it has a high $6,000 out-of-pocket limit for medical services.

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