Page 6 - Cover Letter and Evaluation for Patricia Stelter -- PDF version

justifying your need for Tirosint instead of a similar drug that’s used to treat the same condition
and that is covered by the plan. Part D plans are required to cover at least two drugs in each
therapeutic class.

If your request for a formulary exception is approved, your co-payment amounts next year will
drop by $60-$80 a month, depending on the plan (your co-payments in the Advantage plans
will be $100 a month and about $80 a month in the stand-alone plans). To request a formulary
exception, you will first need to enroll in a plan. Then ask the plan for the form that’s used to
request the formulary exception – it should be e-mailed to you shortly after. If the request is
denied, you can appeal.

You can request a formulary exception as soon as you are enrolled in the plan – you do not
have to wait until your coverage begins. You can also request a transition refill to get you
started while your request is being considered. You should be able to get a transition refill for a
30-day supply so long as your current insurance covers Tirosint. If it does not, then you may not
qualify for the transition refill. Attached to this cover letter are explanations of formulary
exceptions and transition refills.

If you enroll in either of the Advantage plans in your evaluation, you can enroll effective
December 1 and then continue in that plan during 2021. The only design difference between
these two plans is that the Aetna Medicare Value PPO plan does not have a Rx drug deductible
while the AARP Medicare Advantage Walgreens PPO Plan has an annual $250 deductible in
2020 and again in 2021. This difference in deductibles could make the AARP plan more
expensive if your formulary exception is approved. But as long as a drug isn’t covered, the
presence or lack of a deductible does not affect your costs.

If you get a Medigap policy, the SilverScript SmartRx Prescription Drug plan, which will have a
$7.30 monthly premium next year – is the lowest-cost option. Since this will be a new plan in
2021, you would need to enroll in a different plan for the month of December and then during
December switch to the SilverScript plan effective January 1. The lowest-premium plan for the
month of December is the Wellcare Wellness Rx Plan, which has a $13.20 monthly premium
this year. The Wellcare plan is the second lowest-cost option next year. Both these plans’ 2021
costs are compared on page 4 of your evaluation, where their phone numbers are also shown.

Summary

As you can see from the costs shown on pages 2-4 of your evaluation, your fixed (or minimum)
costs (premiums + deductibles) are much higher with Medigap policies + stand-alone drug plans
than they are with the Advantage plans. If you get a formulary exception approved, these fixed
costs will be $750 or more lower, depending on the plan.

In a worst-case, your costs could be higher with the Advantage plans because their out-of-
pocket limits exceed any amounts you would reasonably pay with a Medigap policy. So, with a
Medigap policy you pay higher premiums in exchange for greater flexibility in choosing

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