Page 5 - Cover Letter and Evaluation for Patricia Stelter -- PDF version

similar in many respects. Both have zero premiums and deductibles for health coverage and
zero co-payments for office visits to network primary care doctors.

One important difference between Medigap policies and Advantage plans is that many
Advantage plans, including these two, have some benefits for hearing, dental, and vision
coverage. You can see the details of each plan’s coverage for these services in the appendices.
And you might check with your dentist and optometrist to see they accept the plan.

If you enroll in either of these PPO plans, you will save money by using only network providers
(emergencies are exceptions). When you go to an out-of-network provider, you can pay up to
50% of the cost, depending on the service. Even though PPO plans provide you with some
coverage for out-of-network services, they can be expensive choices if you don’t remain in the
network for most or all of your services.

Here are brief descriptions of these plans, whose benefit summaries are in the appendices.

• The Aetna Medicare Value PPO Plan. For a PPO, this plan has a fairly low out-of-
pocket limit of $3,950 for network medical services but a much higher $8,250
limit for in- and out-of-network services combined. And its out-of-network costs
for many medical services are 50% of cost. This plan’s co-payments for office
visits to network specialists are $20 less than in the AARP Medicare Advantage
Walgreens PPO Plan. This plan’s benefit summary is in Appendix C2.

• The AARP Medicare Advantage Walgreens PPO Plan. This plan’s out-of-pocket
limit for network medical services is not as good as the Aetna plan’s, but its OOP
limit for combined in- and out-of-network services is lower. As noted, its co-
payments for office visits to network specialists is a steep $45.This plan’s benefit
summary is in Appendix C3.

Rx Drug Plan Coverage

The one drug you take – Tirosint – is not covered by any of the lower-cost plans. It’s possible
that it may be covered by a high-premium plan, but even if it is, your total drug costs, including
premiums, will be higher than in the plans in your evaluation.

When a plan does not cover drug, it is called a “non-formulary” drug, and a plan can charge
whatever it chooses for that drug. In all the plans in your evaluation, monthly co-payments for
Tirosint are about $160 a month, or about $1,920 a year. But there’s no benefit to getting a
non-covered drug through your plan unless its price is competitive. That’s because your
purchases do not apply to the plan’s deductible or coverage phases.

One option is to request a formulary exception. If your request is approved, the plan will cover
the drug for at least the remainder of the plan year (and in some cases for several years). It’s
likely that if you request a formulary exception, your physician will need to write a letter

5