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Coverage and benefits
Get a quick overview of the plan benefits and costs and find more detailed information about additional benefits and programs.
Compass Rose Medicare Advantage Plan (PPO)
Benefits and costs
| Benefits and costs |
Compass Rose Medicare Advantage Plan |
|---|---|
|
Compass Rose Medicare Advantage Plan |
|
| Part B premium reduction |
$125 per month |
| Part B premium reduction | |
|
$125 per month |
|
| Annual medical deductible |
None |
| Annual medical deductible | |
|
None |
|
| Annual out-of-pocket maximum |
None |
| Annual out-of-pocket maximum | |
|
None |
|
| Office and clinic visits |
$0 copay for primary care, specialist or Virtual Visit/Telemedicine |
| Office and clinic visits | |
|
$0 copay for primary care, specialist or Virtual Visit/Telemedicine |
|
| Hospital services (inpatient) |
$0 copay |
| Hospital services (inpatient) | |
|
$0 copay |
|
| Hospital services (outpatient) |
$0 copay |
| Hospital services (outpatient) | |
|
$0 copay |
|
| Ambulance services |
$0 copay |
| Ambulance services | |
|
$0 copay |
|
| Emergency room |
$0 copay |
| Emergency room | |
|
$0 copay |
|
| Urgent care |
$0 copay |
| Urgent care | |
|
$0 copay |
|
| Durable medical equipment |
$0 copay |
| Durable medical equipment | |
|
$0 copay |
|
| Prosthetics |
$0 copay |
| Prosthetics | |
|
$0 copay |
|
| Diabetic supplies (test strips, lancets, glucose monitors) |
$0 copay |
| Diabetic supplies (test strips, lancets, glucose monitors) | |
|
$0 copay |
|
| Preventive services |
$0 copay |
| Preventive services | |
|
$0 copay |
|
| Routine podiatry |
$0 copay - 6 visits per year |
| Routine podiatry | |
|
$0 copay - 6 visits per year |
|
| Massage therapy |
$0 copay $60 allowance per visit |
| Massage therapy | |
|
$0 copay $60 allowance per visit |
|
| Hearing aid allowance |
$0 copay - $2,400 allowance for unlimited aids every 3 years. Allowance is combined for both ears. You must contact UnitedHealthcare hearing prior to using your hearing aid allowance. Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered. |
| Hearing aid allowance | |
|
$0 copay - $2,400 allowance for unlimited aids every 3 years. Allowance is combined for both ears. You must contact UnitedHealthcare hearing prior to using your hearing aid allowance. Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered. |
|
| Dental |
Class 1 Preventive & Diagnostic (P&D): $0 copay Class 2 Minor: 20% copay Class 3 Major: 50% copay Deductible (P&D not included): $50 Annual Plan Year Maximum (P&D not included): $1,000 Out-of-network reimbursement schedule: Maximum Allowable Charge |
| Dental | |
|
Class 1 Preventive & Diagnostic (P&D): $0 copay Class 2 Minor: 20% copay Class 3 Major: 50% copay Deductible (P&D not included): $50 Annual Plan Year Maximum (P&D not included): $1,000 Out-of-network reimbursement schedule: Maximum Allowable Charge |
|
| Vision |
Routine Eye Exam Refraction: $0 copay – 1 per 12 months Eyeglasses Allowance: $130 every 12 months Contact Lens Allowance (in lieu of glasses): $175 every 12 months |
| Vision | |
|
Routine Eye Exam Refraction: $0 copay – 1 per 12 months Eyeglasses Allowance: $130 every 12 months Contact Lens Allowance (in lieu of glasses): $175 every 12 months |
|
| Prescription drug coverage |
Part D Retail Copay (up to a 30-day supply) Note: 90-day Retail supply for Tiers 1-3 is available for the same copay amount as Mail Order; Tier 4 is limited to a 30-day supply
Tier 1: Generic $1 copay Tier 2: Preferred Brand $25 copay Tier 3: Non-Preferred Brand $75 copay Tier 4: Specialty Tier – Limited to a 30-day supply 25% ($100 maximum)
Part D Preferred Mail Order Copay * (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply)
Tier 1: Generic $2 copay Tier 2: Preferred Brand $50 copay Tier 3: Non-Preferred Brand $150 copay Tier 4: Specialty Tier – Limited to a 30-day supply 25% ($100 maximum) *UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. |
| Prescription drug coverage | |
|
Part D Retail Copay (up to a 30-day supply) Note: 90-day Retail supply for Tiers 1-3 is available for the same copay amount as Mail Order; Tier 4 is limited to a 30-day supply
Tier 1: Generic $1 copay Tier 2: Preferred Brand $25 copay Tier 3: Non-Preferred Brand $75 copay Tier 4: Specialty Tier – Limited to a 30-day supply 25% ($100 maximum)
Part D Preferred Mail Order Copay * (up to a 90-day supply for Tiers 1-3; Tier 4 is limited to a 30-day supply)
Tier 1: Generic $2 copay Tier 2: Preferred Brand $50 copay Tier 3: Non-Preferred Brand $150 copay Tier 4: Specialty Tier – Limited to a 30-day supply 25% ($100 maximum) *UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. |
Important Information about your Part D Vaccine and Insulin Coverage
What You Pay for Vaccines – Our plan covers most adult Part D vaccines at no cost to you.
What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan. Refer to your plan materials.
Preventive services
The following preventive services are covered under your plan for a $0 copay when you visit your primary care provider:
- Annual Wellness Exam
- Annual Routine Physical
- Screenings for certain Cancers (Prostate, colorectal, breast cancer)
- Screening for diabetes
- Smoking and Tobacco Use Cessation
For more information about these preventive services, please call the Customer Service number on your member ID card.