2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Windsor Medicare Extra Diamond Plan (HMO) | ||||
Location: | Baxter, Arkansas Click to see other locations | ||||
Plan ID: | H5698 - 069 - 0 Click to see other plans | ||||
Member Services: | 1-800-316-2273 TTY users 1-866-460-7617 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Windsor Medicare Extra Diamond Plan (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $160.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Rx Gap Coverage? | Some Generics | ||||
Total Number of Formulary Drugs: | 2,525 drugs | Browse the Windsor Medicare Extra Diamond Plan (HMO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $5.00 | $10.00 | $39.00 | $65.00 | 33% |
• Number of Drugs per Tier: | 203 | 1174 | 331 | 591 | 226 |
Plan's Pharmacy Search: | http://www.windsorextra.com | ||||
Number of Members enrolled in this plan in (H5698 - 069): | 279 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$160 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$3 400 out-of-pocket limit. | |||||
All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
15% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.windsorextra.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from Windsor Medicare Extra Diamond Plan (HMO) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and Windsor Medicare Extra Diamond Plan (HMO) approves the exception you will pay Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
The plan covers some formulary generics (10%-64% of formulary generic drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Windsor Medicare Extra Diamond Plan (HMO). | |||||
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Separate Office Visit cost sharing of $0 to $15 may apply. | |||||
Vision Services | |||||
$150 plan coverage limit for eye wear every year. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
Plan offers additional comprehensive dental benefits. | |||||
$250 plan coverage limit for dental benefits every year. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$160 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$3 400 out-of-pocket limit. | |||||
All plan services included. | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
For hospital stays: | |||||
Days 1 - 5: $75 copay per day | |||||
Days 6 - 60: $0 copay per day | |||||
Days 61 - 90: $100 copay per day | |||||
$100 copay for each additional hospital day. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 7: $175 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 10: $0 copay per day | |||||
Days 11 - 100: $50 copay per day | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$0 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$0 copay for each in-area network urgent care Medicare-covered visit. | |||||
$15 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
$15 copay for each Medicare-covered visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
$15 copay for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$15 copay for each Medicare-covered individual therapy visit. | |||||
$10 copay for each Medicare-covered group therapy visit. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$15 copay for Medicare-covered individual visits. | |||||
$10 copay for Medicare-covered group visits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
$0 to $300 copay [or 10% of the cost] for each Medicare-covered ambulatory surgical center visit. | |||||
$0 to $300 copay [or 10% of the cost] for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$25 copay for Medicare-covered emergency room visits. | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$15 copay for Medicare-covered Occupational Therapy visits. | |||||
$15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$0 copay for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered items. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
0% to 20% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Separate Office Visit cost sharing of $0 to $15 may apply. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Separate Office Visit cost sharing of $0 to $15 may apply. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
Separate Office Visit cost sharing of $0 to $15 may apply. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $0 to $15 may apply. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
$0 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
Prescription Drugs | |||||
15% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.windsorextra.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from Windsor Medicare Extra Diamond Plan (HMO) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and Windsor Medicare Extra Diamond Plan (HMO) approves the exception you will pay Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
The plan covers some formulary generics (10%-64% of formulary generic drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Windsor Medicare Extra Diamond Plan (HMO). | |||||
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 5: Specialty Tier Drugs | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
Plan offers additional comprehensive dental benefits. | |||||
$250 plan coverage limit for dental benefits every year. | |||||
Hearing Services | |||||
$0 copay for hearing aids. | |||||
$500 plan coverage limit for hearing aids every year. | |||||
Vision Services | |||||
$150 plan coverage limit for eye wear every year. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Separate Office Visit cost sharing of $0 to $15 may apply. | |||||
Health/Wellness Education | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |