Frequently Asked Questions
- What are the differences between the Windsor Medicare Extra plans?
- Will I need a referral to go to a specialist?
- Is there a limit on the number of drugs a plan will cover in a given year?
- Will I be able to use more than one Medicare Advantage or Medicare prescription drug plan?
- When and how often can I switch my Medicare Advantage or Medicare prescription drug plan?
- How do I pay for my coverage? Can it be deducted from my Social Security or my retirement check?
- What if the drug I need requires “prior authorization?”
- What does the term “extra help” mean when you are talking about Medicare prescription drug coverage?
- If I am not certain whether or not I qualify, should I apply for extra help paying for my prescription drug coverage?
- What information do I need to apply for the extra help?
- What is the difference between PDP and MAPD?
- What is the difference between Basic Alternative and Enhanced Alternative Coverage?
- What do I do if I have a medical emergency?
- Do I get an EOB (Explanation of Benefits) for pharmacy claims?
- When will I receive my ID card?
- Who qualifies for the Part D benefit?
- What are Medicare Parts A, B, C, and D?
- How can I get help with my premiums?
- How much will Medicare prescription drug coverage cost?
- What is creditable coverage?
- What if I have a limited income?
- Can I change plans when I want to?
- How do I pay for my coverage?
- What does the term "extra help" mean when you are talking about Medicare Advantage with prescription drug coverage?
- If I am not certain whether or not I qualify, should I apply for extra help?
- What information do I need to apply for the extra help?
- When is the enrollment period?
- Will I be able to enroll in more than one Medicare prescription drug plan?
- What if I turn age 65 and it’s not during an open enrollment period? Can I choose to enroll in a Medicare Advantage with prescription drug plan?
- When is my premium due?
- What is the coverage gap (donut hole)?
- How do I know if I am in the coverage gap?
- What is a “coverage determination”?
- What is a Prior Authorization?
- What is a Quantity Limit?
- What is a Step Therapy?
- What is an Exception?
- How do I request an exception?
- How does my physician submit a coverage determination request?
- How long does a coverage determination take to complete?
- What is an Expedited Request?
- How will I be notified of the decision?
- The pharmacy could not fill my prescription; what do I need to do?
- When can I refill a prescription?
- What if my doctor has changed the dosage on my medication?
- What if my medication was lost/stolen?
- What is a formulary?
- Can the formulary change throughout the year? Will I be notified? What if the medication I am taking is removed?
- How and when will I be notified of negative changes to the formulary?
- How and when will I be notified of positive changes to the formulary?
- What are “tiers”?
- My drug plan covers generic drugs. Are they as good as brand name drugs?
- What if I need a drug that isn’t on the formulary or is covered at a higher cost?
- What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
- Is there a limit on the number of drugs a plan will cover in a given year?
- Are there certain pharmacies I can go to?
- How do I find a network pharmacy in my area?
- How do I fill a prescription at a network pharmacy?
- How do I fill a prescription through a mail order pharmacy?
- What if I cannot fill my prescription at a network pharmacy?
- What if I am out of the country? Will you cover my prescription if filled outside the US?
- How do I submit a paper claim?
- What is a coinsurance?
- What is a co-payment?
- What is a deductible?
What are the differences between the Windsor Medicare Extra plans?
Windsor Medicare Extra plans vary by premium price, co-payment, co-insurance, and the number and type of Extras covered. Because Windsor Medicare Extra realizes that one plan does not fit all needs, we give you a choice with a variety of plans. There is a plan for every eligible Medicare beneficiary, regardless of individual income or health status.
In addition to Windsor’s Medicare Extra Advantage plans, Windsor Medicare Extra also offers Drug plans only (Part D plans) in Alabama, Arkansas, Mississippi, South Carolina, and Tennessee. For Tennessee residents (all Tennessee counties), there is even a Private Fee for Service plan called TN Choice.
Will I need a referral to go to a specialist?
No. You’ll never need a referral to see a specialist. In fact, you can even choose a specialist, such as a cardiologist, pulmonologist, or endocrinologist, as your primary physician. You’re not limited to a general practitioner or internist.
Is there a limit on the number of drugs a plan will cover in a given year?
No. There is no limit on the amount of drugs that can be covered. However, each Medicare prescription drug plan has a list of the specific prescription drugs that it will cover (called a formulary), and not all plans will cover exactly the same drugs.
If your doctor thinks you need a drug that is not on the plan’s list, you can ask the plan for an "exception" to its list. Plans may cover both generic and brand-name prescription drugs. These drugs must be approved by the FDA (Food and Drug Administration) as safe and effective.
Will I be able to use more than one Medicare Advantage or Medicare prescription drug plan?
No. You are only able to join, and get coverage under, one Medicare Advantage or Medicare prescription drug plan at a time.
When and how often can I switch my Medicare Advantage or Medicare prescription drug plan?
Generally if you join a Medicare Advantage or Medicare Prescription Drug Plan, you can only change plans under certain circumstances. You can choose to switch your current plan from November 15 through December 31 of every year.
Enrollment is generally for the calendar year. In certain cases, if you move or enter a nursing home, for example, you can switch your plan at other times.
If you have both Medicare and Medicaid, you can change plans at any time.
How do I pay for my coverage? Can it be deducted from my Social Security or my retirement check?
In general, there are three ways to pay Medicare prescription drug plan premiums:
- Give us permission to deduct the premium automatically from a bank account
- Have the premium deducted every month from Social Security Benefits, similar to premiums for Medicare Part B
- Pay us directly by mailing a check or money order each month
What if the drug I need requires “prior authorization?”
If the pharmacist tells you that the drug requires prior authorization (PA), you should contact Windsor Medicare Extra to find out about the PA requirement. Then ask your doctor if you meet this requirement.
Windsor Medicare Extra has a PA form that your doctor can complete and submit to the plan. Since a request for PA is a coverage determination request, when you or your doctor submit evidence to Windsor Medicare Extra to show that you meet the PA requirement, we must notify you of our decision no later than 72 hours from the time it is received or 24 hours from the time we received your request if your case is "expedited." If Windsor Medicare Extra decides you don’t meet the PA requirement, you can appeal.
In some cases, your doctor may think you wouldn’t meet the PA requirement but still need the drug. In those cases, you can ask Windsor Medicare Extra for an "exception" not to apply the PA requirement. Again, you would have the right to appeal if we deny this request.
Whenever you ask for any type of exception, your doctor will need to provide a statement to Windsor Medicare Extra to support this request. You should contact Windsor to find out what information we need. If Windsor approves your exception request, it’s good for at least the remainder of the plan year, with the condition that you remain enrolled in the plan, that your doctor continues prescribing the drug, and that the drug continues to be safe and effective for treating your illness or condition.
What does the term “extra help” mean when you are talking about Medicare prescription drug coverage?
Medicare prescription drug coverage and Medicare Advantage plans with prescription drug coverage are available to everyone with Medicare, regardless of your income and resources, health status, or current prescription expenses. There is "extra help" (also called a "low-income subsidy") available to assist Medicare enrollees who have limited income and resources pay for prescription drug coverage.
If you qualify for this, you can receive financial help paying for your Medicare prescription drug plan’s or Medicare Advantage plan with prescription drug coverage monthly premium, as well as for some of your prescriptions. The amount of extra help will be based on your income and resources. You can apply or get more information about this program by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778). This information is also available by visiting www.socialsecurity.gov.
If I am not certain whether or not I qualify, should I apply for extra help paying for my prescription drug coverage?
Yes, because there is no risk or cost to apply. And, if you qualify, you will receive extra help paying for the annual deductible, premiums, and co-payments for Medicare prescription drug coverage.
You can apply or get more information about extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778). This information is also available by visiting www.socialsecurity.gov/prescriptionhelp.
What information do I need to apply for the extra help?
In order to complete the application, you will need your Social Security number and financial information for you and your spouse (if married and living together). That financial information includes information about deposits in bank accounts, income from pensions, investments or annuities, and face value of life insurance policies. However, you should apply even if you think you don’t have all of this information.
You can apply or get more information about extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.socialsecurity.gov/prescriptionhelp.
What is the difference between PDP and MAPD?
MAPD: Medicare Advantage Prescription Drug Plans are health plan options that are part of the Medicare program. If you join one of these plans, you generally get all your Medicare-covered health care through that plan. This coverage can include prescription drug coverage. Medicare Advantage Plans include:
- Medicare Health Maintenance Organization (HMOs)
- Preferred Provider Organizations (PPO)
- Private Fee-for-Service Plans
- Medicare Special Needs Plans
When you join a Medicare Advantage Plan, you use the health insurance card that you get from the plan for your health care. In most of these plans, generally there are extra benefits and lower co-payments than in the Original Medicare Plan. However, you may have to see doctors that belong to the plan or go to certain hospitals to get services. To join a Medicare Advantage Plan, you must have Medicare Part A and Part B. You will have to pay your monthly Medicare Part B premium to Medicare. In addition, you might have to pay a monthly premium to your Medicare Advantage Plan for the extra benefits that they offer. If you join a Medicare Advantage Plan, your Medigap policy won’t work. This means it won’t pay any deductibles, co-payments, or other cost-sharing under your Medicare Health Plan. Therefore, you may want to drop your Medigap policy if you join a Medicare Advantage Plan. However, you have a legal right to keep the Medigap policy.
PDP: These stand-alone plans add prescription drug coverage to the Original Medicare Plan. If you wish to receive the Medicare prescription drug benefit but do not want to enroll in a Medicare Advantage plan, you may want to consider a stand-alone Prescription Drug Plan. The plan is called "stand-alone" because it is not attached to a Medicare Advantage plan. It simply provides name brand and generic prescription drug coverage, with none of the extra healthcare benefits of Medicare Advantage plans.
What is the difference between Basic Alternative and Enhanced Alternative Coverage?
Basic Alternative Coverage refers to the alternative coverage that is the actuarial equivalent to defined standard prescription drug coverage. Enhanced Alternative Coverage refers to alternative coverage that exceeds defined standard coverage by offering supplemental benefits. Enhanced alternative coverage includes basic prescription drug coverage and supplemental benefits.
What do I do if I have a medical emergency?
Get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room. You do not need to get permission first from your Primary Provider or other plan provider. Make sure your Primary Provider knows about your emergency, because he or she will need to be involved in following up on your emergency care. You or someone else should call to tell your Primary Provider about your emergency care as soon as possible, preferably within 48 hours.
Do I get an EOB (Explanation of Benefits) for pharmacy claims?
You will receive a pharmacy EOB monthly.
When will I receive my ID card?
We send out ID Cards once a week. You have to be accepted by CMS, so at the most unless there is some problem with your enrollment, about two weeks from the receipt date by the plan.
Who qualifies for the Part D benefit?
Anyone currently enrolled in Medicare is eligible for Medicare Part D.
What are Medicare Parts A, B, C, and D?
- Medicare Part A typically pays for your inpatient hospital expenses.
- Medicare Part B typically covers your outpatient healthcare expenses, including doctor fees.
- Medicare Part C also known as Medicare Advantage (formerly Medicare+Choice) offers a choice of options including Medicare managed care plans (like Medicare HMOs and PPOs) and Medicare private fee-for-service plans.
- Medicare Part D is the outpatient prescription drug benefit resulting from the Medicare Modernization Act of 2003 that went into effect on January 1, 2006.
How can I get help with my premiums?
If you are not getting the extra help automatically, it is easy to apply. Here’s how: Get an application or apply over the phone by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778), or Apply online at www.socialsecurity.gov. After you apply, Social Security will review your application and send you a letter to let you know if you qualify for the extra help. You will need to enroll in a Medicare-approved prescription drug plan to get this extra help.
How much will Medicare prescription drug coverage cost?
Medicare prescription drug coverage premiums will vary based on your geographic region and the plan that you choose.
What is creditable coverage?
Beneficiaries who have other sources of current drug coverage – through a current or former employer or union, for example – may stay in that plan and choose not to enroll in the Medicare prescription drug plan. If their other coverage is at least as good as the new Medicare drug benefit (and therefore considered “creditable coverage”), then the beneficiary can continue to get the high quality care they have now as well as avoid higher payments later if they later sign up for the Medicare drug benefit. Coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard prescription drug coverage under Medicare Part D, as demonstrated through the use of generally accepted actuarial principles and in accordance with CMS actuarial guidelines. In general, the actuarial equivalence test measures whether the expected amount of paid claims under the entity’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Part D benefit.
What if I have a limited income?
If you have Medicare and have limited income and resources, you may qualify for special financial assistance to help you pay for your Medicare prescription drug plan, or Medicare Advantage plan with prescription drug, costs. The amount of assistance you qualify for will depend on your income and resources.
Can I change plans when I want to?
Congress designed Medicare prescription drug coverage and Medicare Advantage coverage to work on an annual enrollment cycle. This means that each year, you will have the option to stay in your existing plan or change plans between November 15 and December 31. You may also have another opportunity during the year to switch plans, under limited circumstances. For example, if you move out of your plan’s service area, you’ll have an opportunity to choose another plan that serves your new area.
How do I pay for my coverage?
In general, there are three ways to pay Medicare Advantage plan premiums:
- Give us permission to deduct the premium automatically from a bank account
- Have the premium deducted every month from Social Security Benefits, similar to premiums for Medicare Part B
- Pay us directly by mailing a check or money order each month
What does the term "extra help" mean when you are talking about Medicare Advantage with prescription drug coverage?
Medicare Advantage with prescription drug coverage is available to everyone with Medicare, regardless of your income and resources, health status, or current prescription expenses. There is also "extra help" (also called a "low-income subsidy") to help people with Medicare who have limited income and resources pay for their coverage. If you qualify for extra help, you will get help paying for your plan’s monthly premium, and for some of the costs you would normally pay for your prescriptions. The amount of extra help you get will be based on your income and resources. You can apply for extra help by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778) or visiting www.socialsecurity.gov.
If I am not certain whether or not I qualify, should I apply for extra help?
Yes, because there is no risk or cost to apply. And, if you qualify, you will get extra help paying for the annual deductible, premiums, and co-payments for Medicare Advantage with prescription drug coverage.
What information do I need to apply for the extra help?
You will need your Social Security number and financial information for you and your spouse (if married and living together), including information on deposits in bank accounts, income from pensions, investments or annuities, and face value of life insurance policies to complete the application. However, you should apply even if you think you don’t have all of this information.
When is the enrollment period?
Each year, the annual enrollment period is November 15th through December 31st. For MA, MA-PD and PFFS plans there is also an open enrollment period each year from January 1 through March 31. The open enrollment period gives an enrollee one more election to make a plan change during that time frame. PDP enrollees may not change to another PDP after December 31st unless they have a special election period. PDP enrollees may choose a MA type plan during the open enrollment period.
Will I be able to enroll in more than one Medicare prescription drug plan?
No, you will only be able to join, and get coverage under, one Medicare prescription drug plan at a time.
What if I turn age 65 and it’s not during an open enrollment period? Can I choose to enroll in a Medicare Advantage with prescription drug plan?
Absolutely! When you turn age 65, you are eligible to enroll in a Medicare Advantage with prescription drug plan.
When is my premium due?
If you have chosen to direct bill as your payment method we will bill you at the end of each month for the next month. Premiums are due and payable by the 10th day of the month. If you have chosen to have you premium deducted from your bank account that will occur within the first week of each month.
What is the coverage gap (donut hole)?
The coverage gap is the period during which you are responsible for all prescription drug costs until insurance coverage begins again. The duration of the coverage gap continues until your out of pocket expenses are greater than $3,850 for 2007 and $4,050 for 2008.
How do I know if I am in the coverage gap?
You receive an EOB every month and the EOB will show how much money you have spent and how much the plan has spent with the combined total and balance left before the coverage gap.
What is a “coverage determination”?
The following are the utilization management tools requiring coverage determination to be requested that are currently utilized by Windsor Pharmacy Department:
- Prior Authorization
- Quantity Limits
- Step Therapy
- Exceptions
What is a Prior Authorization?
Prior authorization is required for coverage of the medication before the beneficiary goes to the pharmacy. This applies to certain drugs which the Windsor P&T Committee decides can be used only in specific circumstances.
What is a Quantity Limit?
Quantity Limits are established to promote safe, appropriate, and cost-effective use of specific classes of medications. All Quantity Limits will be listed on the formulary as an established number of units per 30 days. The system will count all units received within the therapeutic class and will only allow payment of the quantity established. The process used to establish the limit of the identified drug is the current approved Food and Drug Administration (FDA) dosing. Prescribers may request an exception to our Quantity Limits by completing a Part D Coverage Determination Form.
What is a Step Therapy?
Step Therapy drugs are established through utilization review or the Windsor P&T Committee recommendations. When step therapies are established, they are coded in the pharmacy claims processing system. The code mandates a certain drug within a therapeutic class be tried before obtaining a different drug within the same class.
What is an Exception?
There are two types of exceptions. A Formulary Exception should be requested to obtain a Part D drug that is not included on a plan sponsor’s formulary. For formulary exceptions, the physician’s supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee’s condition because all covered Part D drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be ineffective, or the alternative listed on the formulary or required to be used in accordance with step therapy has been or is likely to be ineffective. A Tiering Exception should be requested to obtain a non-preferred drug at the cost-sharing terms applicable to drugs in the preferred tier. For tiering exceptions, the physician’s supporting statement must indicate that the preferred drug would not be as effective as the requested drug for treating the enrollee’s condition; the preferred drug would have adverse effects for the enrollee, or both.
How do I request an exception?
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician’s supporting statement.
How does my physician submit a coverage determination request?
You or your physician should submit a Coverage Determination Request Form. If a Coverage Determination Form is not available, all information may be given orally. This form is located on the website or you can request one having your physician call the Pharmacy Department.
How long does a coverage determination take to complete?
There are two types of coverage determination requests: Standard and Expedited. There are specific time frames for each type of request. For Standard Requests, as expeditiously as the enrollee’s health condition requires, but no later than 72 HOURS after receipt of the request/supporting statement. For Expedited Requests, as expeditiously as the enrollee’s health condition requires, but no later than 24 HOURS after receipt of the request/supporting statement.
What is an Expedited Request?
An expedited request means that you or your physician feels that waiting for a standard decision could seriously harm your health or your ability to function.
How will I be notified of the decision?
You will receive the determination in the mail. We will also fax a copy to your physician.
The pharmacy could not fill my prescription; what do I need to do?
First, try to find out from your pharmacist why the prescription couldn’t be filled. The pharmacist may be able to give you this information and may be able to give you or recommend another drug you can use, such as a generic version. If you disagree with the information provided by the pharmacist, the pharmacist will provide you with a notice about your right to contact your plan to find out why the drug isn’t covered, and your right to request an “exception”. You can also review your plan materials or visit the plan’s website for information about how to request an exception. Once you know why your prescription can’t be filled, you should contact your doctor and give her/him this information. Then, you will need to work with your doctor to either:
- Find another drug that is covered by the plan.
- Provide additional information to the plan so that you can get your prescription filled.
- Request an exception.
When can I refill a prescription?
Network pharmacies cannot dispense refill medications to beneficiaries until the beneficiary has used at least 75% of the original supply. This edit is in place to eliminate stock-piling, sharing medications and to alert pharmacist to a potential compliance issue. If the medication was lost or stolen, the beneficiary will be responsible for 100% of the drug cost.
What if my doctor has changed the dosage on my medication?
If the dose has increased, the pharmacist can obtain an early refill override from the pharmacy claims processor.
What if my medication was lost/stolen?
If the medication was lost or stolen, you will be responsible for 100% of the drug cost.
What is a formulary?
A formulary is a list of specific drugs a Medicare prescription drug plan will cover. Medicare plans must cover all types of drugs required by Medicare, but within each type it can limit which specific drugs it will cover. It may also charge different cost-sharing amounts for different drugs within a type of drug.
Can the formulary change throughout the year? Will I be notified? What if the medication I am taking is removed?
Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or improve the safety of your drugs.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
How and when will I be notified of negative changes to the formulary?
You will be notified of all negative formulary changes 60 days prior to the change. The notification will be on your Explanation of Benefits (EOB).
How and when will I be notified of positive changes to the formulary?
If the Windsor P&T Committee recommends adding Medicare Part D eligible drugs or removing current prior authorizations, quantity limits and/or step therapies, or moving a drug to a lower cost-sharing tier for the member, we must notify providers and beneficiaries of the "positive" changes. All "positive" drug changes will be implemented in the system immediately with at least a 30-day notification sent to beneficiaries and providers.
What are “tiers”?
Tier One – this tier contains ALL Part D eligible generic drugs. This tier is open to all drugs that are identified as generic medications in First Data Bank. The beneficiary co-payments for tier one drugs ranges from $0 to $10 per 30 day supply depending on the beneficiaries plan.
Tier Two – this tier contains all Part D eligible drugs that are Preferred Brands. These drugs are identified and recommended by the Windsor P&T Committee. The beneficiary co-payment for tier two drugs range from $0 to $35 per 30 day supply depending on the beneficiaries plan.
Tier Three – this tier contains all Part D eligible drugs that are Non-Preferred Brands. These drugs are identified and recommended by the Windsor P&T Committee and brand drugs that have generics available. The beneficiary co-payment for tier three drugs range from $0 to $50 per 30 day supply depending on the beneficiaries plan.
Tier Four – this tier contains all Part D eligible drugs that are Specialty Products. These drugs are identified and recommended by the Windsor P&T Committee and which are typically prescribed by a specialist, have unique uses, or may require special dosing or administration, and are generally more costly than other drugs. The beneficiary co-payment for tier four drugs range from $0 to 33% per 30 day supply depending on the beneficiaries plan. Most drugs on this tier require a Coverage Determination or Prior Authorization.
Before prescribing a non-preferred drug (Tier 3) for a Windsor Medicare Extra beneficiary, we ask that prescribing physicians consider formulary alternatives which are on Tier ONE or Tier TWO. Beneficiaries will reach the coverage gap more rapidly when non-formulary drugs are prescribed. This means members must pay the entire cost of the drug until catastrophic levels are reached.
My drug plan covers generic drugs. Are they as good as brand name drugs?
Yes. Today, almost half of all prescriptions in the United States are filled with generic drugs. The U.S. Food and Drug Administration ensures that a generic drug is the same as a brand-name drug in dosage, safety, strength, quality, the way it works, the way it is taken, and the way it should be used. Generic drugs use the same active ingredients as brand-name drugs and work the same way. This means they have the same risks and benefits as the brand-name drugs. Creating a drug costs a lot of money. Since generic drug makers don’t develop a drug from scratch, the costs to bring the drug to market are less. But they must show that their product performs in the same way as the brand-name drug.
What if I need a drug that isn’t on the formulary or is covered at a higher cost?
You should ask your doctor if you can switch to a drug that is on the formulary. If your doctor thinks that you need the drug that is not on the formulary, you or your doctor will have to ask for an exception from the plan. Your doctor will have to send the plan information about why you need that particular drug and then the plan will decide to cover it for you or not. If the plan decides that it will not cover it, you can appeal the decision to try to get the plan to cover that drug for you.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary three-month 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first three-month 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
Is there a limit on the number of drugs a plan will cover in a given year?
No. There is no limit on the amount of drugs that can be covered. However, each Medicare prescription drug plan will have a list of the specific prescription drugs that it will cover (called a formulary), and not all plans will cover exactly the same drugs. If your doctor thinks you need a drug that is not on the plan’s list, you can ask the plan for an "exception" to its list. Plans may cover both generic and brand-name prescription drugs. These drugs must be approved by the FDA (Food and Drug Administration) as safe and effective.
Are there certain pharmacies I can go to?
Yes, you must go to a “network pharmacy.” A network pharmacy is a pharmacy where beneficiaries obtain prescription drug benefits provided by Windsor. There are more than 55,000 pharmacies across the country that are part of the Windsor network. In most cases, your prescriptions are covered under Windsor only if they are filled at a network pharmacy or through our mail order pharmacy service. Once you go to one, you are not required to continue going to the same pharmacy to fill your prescription, you can go to any of our network pharmacies. We will fill prescriptions at non-network pharmacies under certain circumstances.
How do I find a network pharmacy in my area?
To find a pharmacy near you in the pharmacy directory, you should first locate the type of pharmacy you need. The three types of pharmacies include retail, mail order and long term care. The directory is then arranged in alphabetical order by county, then by city, and finally then by zip code. We have also indicated if the pharmacy is open 24 hours a day and if the pharmacy will accept 90 day supply maintenance prescriptions. Or, you can call our Member Services department.
How do I fill a prescription at a network pharmacy?
To fill your prescription at a network pharmacy, you must show your Windsor Medicare Extra Member ID card. If you do not have your ID card with you when you fill your prescription, you may have to pay the full cost of the prescription (rather than paying just your co-payment). If this happens, you can ask us to reimburse you for our share of the cost by submitting a claim to us. To find out how to submit a claim, look in your Evidence of Coverage or call our Member Services department.
How do I fill a prescription through a mail order pharmacy?
To get order forms and information about filling your prescriptions by mail, call ProCare Rx at 800-662-0586. Please note that you must use the Windsor Medicare Extra mail order service. Prescription drugs that you get through any other mail order service are not covered. You can use the mail order service to fill prescriptions for what we call "maintenance drugs." These are drugs that you take on a regular basis, for a chronic or long-term medical condition. The formulary list tells you which drugs we consider to be maintenance drugs. These are the only drugs available through our mail order service. When you order prescription drugs by mail, you must order at least a 60-day supply, and no more than a 90-day supply of the drug. You are not required to use mail order prescription drug services to obtain an extended supply of maintenance medications. Instead, you have the option of using a retail pharmacy in our network to obtain a supply of maintenance medications. Some retail pharmacies may agree to accept the mail order reimbursement rate for an extended supply of medications for up to 90 days per dispensing, which may result in no out-of-pocket payment difference to you. Please look in the Evidence of Coverage or call our Member Services for more information. Mail Order maintenance prescriptions will be shipped within three business days after receipt of the prescription by the mail order pharmacy, ProCare Rx, unless there is additional information or requirements needed to fill your prescriptions. Generally, if there is a delay filling your prescription it should be resolved and shipped to you within five business days. If a mail order prescription is delayed due to a stock issue, the mail order pharmacy will immediately advise you of the shortage and contact a local pharmacy to fill the prescription.
What if I cannot fill my prescription at a network pharmacy?
Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call our Member Services department to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy’s price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.
Getting coverage when you travel or are outside of your Windsor’s Service Area: In the United States, Windsor Plans have over 55,000 pharmacies in the network. All major chains (Walgreens, Eckerd’s, Kroger, CVS, ect.) and most independent pharmacies are in our network. Please remember that if you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. If needed, we may issue a vacation supply override as long as the drug is a maintenance medication. Additionally you will be able to order your prescription drugs ahead of time through our mail order pharmacy service, ProCare Rx by calling 800-662-0586. Regardless of where you are traveling, you may always call our Member Services Department (number is on the back of your Windsor ID Card) to locate a network pharmacy in the area you are traveling.
Other times you can get your prescription covered if you go to an out-of-network Pharmacy: We will cover your prescriptions at an out-of-network pharmacy if at least one of the following applies:
- If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
- If you are trying to fill a prescription drug that is not regularly stocked at accessible network retail or mail-order pharmacies (including high cost and unique drugs).
* If you are getting a Medicare Part D vaccine that is medically necessary.
What if I am out of the country? Will you cover my prescription if filled outside the US?
No, we cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.
How do I submit a paper claim?
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. When you return home, simply submit your claim and your receipt to the following address:
Windsor Medicare Extra
Attention: Rx Paper Claims
7100 Commerce Way, Suite 285
Brentwood, TN 37027
Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage or call our Member Services department.
What is a coinsurance?
The sharing of charges by Windsor and you for covered services received by you, usually stated as a percentage of the allowed amount.
What is a co-payment?
The fixed-dollar amount that is due and payable by you at the time a covered service is provided.
What is a deductible?
The specific dollar amount that you must pay before benefits are payable for the remaining covered services. The deductible does not include co-payments, coinsurance, charges in excess of the allowed amount, amounts exceeding any maximum and expenses for non-covered services.
