** Cost ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$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 ** |
Over-the-Counter Items |
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. |
Transportation |
$0 copay for up to 24 one-way trip(s) to plan-approved location every year |
** Important Information ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$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 |
Plan covers 90 days each benefit period. |
You will not be charged additional cost sharing for professional services |
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 of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. |
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. |
You will not be charged additional cost sharing for professional services |
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. Your plan will pay for a consultative visit before you select hospice. |
** Outpatient Care ** |
Doctor Office Visits |
0% or 20% of the cost for each primary care doctor visit for Medicare-covered benefits.* |
0% or 20% of the cost for each in-area network urgent care Medicare-covered visit* |
0% or 20% of the cost for each specialist visit for Medicare-covered benefits.* |
Chiropractic Services |
0% or 20% of the cost 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 |
0% or 20% of the cost for each Medicare-covered visit* |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
0% or 20% of the cost for each Medicare-covered individual therapy visit* |
0% or 20% of the cost for each Medicare-covered group therapy visit* |
0% or 20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist* |
0% or 20% of the cost for each Medicare-covered group therapy visit with a psychiatrist* |
0% or 20% of the cost for Medicare-covered partial hospitalization program services* |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered individual therapy visits* |
0% or 20% of the cost for Medicare-covered group visits* |
Outpatient Services/Surgery |
Authorization rules may apply. |
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* |
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered ambulance benefits.* |
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. |
Emergency Care |
0% or 20% of the cost (up to $65) for Medicare-covered emergency room visits* |
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. |
Urgently Needed Care |
0% or 20% of the cost for Medicare-covered urgently-needed-care visits* |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered Occupational Therapy visits* |
0% or 20% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered items* |
Prosthetic Devices |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered items* |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-management training* |
0% or 0% to 20% of the cost for Diabetes monitoring supplies* |
0% or 20% of the cost for Therapeutic shoes or inserts* |
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of 0% or 20% of the cost may apply* |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
0% of the cost for Medicare-covered lab services* |
0% of the cost for Medicare-covered diagnostic procedures and tests* |
0% or 20% of the cost for Medicare-covered X-rays* |
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
0% or 20% of the cost for Medicare-covered therapeutic radiology services* |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 20% of the cost may apply* |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 20% of the cost may apply* |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services* |
0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services* |
0% or 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services* |
Preventive Services and Wellness/Education Programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam) |
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. Please contact plan for details. |
This plan does not cover supplemental education/wellness programs. |
Kidney Disease and Conditions |
0% or 20% of the cost for renal dialysis* |
0% or 0% to 20% of the cost for kidney disease education services* |
Outpatient Prescription Drugs |
$0 annual deductible for Part B-covered drugs.* |
0% or 20% 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 have limited incomes live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service) providers. |
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). 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 you the plan and Medicare. |
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 Comp Plus Plan (HMO SNP) 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. |
You pay a $0 annual deductible. |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: A $0 copay or A $1.10 copay or A $2.60 copay For all other drugs either: A $0 copay or A $3.30 copay or A $6.50 copay. |
You can get drugs the following way(s): |
one-month (30-day) supply |
three-month (90-day) supply |
60-day supply |
Not all drugs are available at this extended day supply. Please contact the plan for more information. |
You can get drugs the following way(s): |
one-month (31-day) supply |
You can get drugs the following way(s): |
one-month (30-day) supply |
three-month (90-day) supply |
60-day supply |
Not all drugs are available at this extended day supply. Please contact the plan for more information. |
After your yearly out-of-pocket drug costs reach $4 700 you pay a $0 copay. |
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 Comp Plus Plan (HMO SNP). |
You can get drugs the following way: |
one-month (30-day) supply |
Depending on your income and institutional status you will be reimbursed by Windsor Medicare Extra Comp Plus Plan (HMO SNP) up to the plan's cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either: A $0 copay or A $1.10 copay or A $2.60 copay For all other drugs purchased out-of-network either: A $0 copay or A $3.30 copay or A $6.50 copay. |
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed in full for drugs purchased out-of-network. |
Dental Services |
$0 copay for Medicare-covered dental benefits* |
$0 copay for the following preventive dental benefits: |
up to 2 oral exam(s) every year |
up to 2 cleaning(s) |
up to 1 dental x-ray(s) every year |
Plan offers additional comprehensive dental benefits. |
$500 plan coverage limit for dental benefits every year |
Hearing Services |
$0 copay for hearing aids. |
0% or 20% of the cost for Medicare-covered diagnostic hearing exams* |
$10 copay for up to 1 supplemental routine hearing exam(s) every year |
$500 plan coverage limit for hearing aids every year. |
** Additional Benefits ** |
Vision Services |
0% or 20% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.* |
0% or 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.* |
$10 copay for up to 1 supplemental routine eye exam(s) every year |
0% of the cost for glasses |
0% of the cost for contacts |
0% of the cost for lenses |
0% of the cost for frames |
$200 plan coverage limit for eye wear every year. |
If the doctor provides you services in addition to eye exams separate cost sharing of 0% or 20% of the cost may apply* |
Over-the-Counter Items |
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. |
Transportation |
$0 copay for up to 24 one-way trip(s) to plan-approved location every year |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
You will not be charged additional cost sharing for professional services |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
** Outpatient Care ** |
Doctor Office Visits |
0% or 20% of the cost for each primary care doctor visit for Medicare-covered benefits.* |
0% or 20% of the cost for each in-area network urgent care Medicare-covered visit* |
0% or 20% of the cost for each specialist visit for Medicare-covered benefits.* |
Outpatient Services/Surgery |
Authorization rules may apply. |
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* |
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered ambulance benefits.* |
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered items* |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
Authorization rules may apply. |
0% of the cost for Medicare-covered lab services* |
0% of the cost for Medicare-covered diagnostic procedures and tests* |
0% or 20% of the cost for Medicare-covered X-rays* |
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
0% or 20% of the cost for Medicare-covered therapeutic radiology services* |
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 20% of the cost may apply* |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 20% of the cost may apply* |
** Additional Benefits ** |
Over-the-Counter Items |
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. |
Transportation |
$0 copay for up to 24 one-way trip(s) to plan-approved location every year |