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)
2022 materials
Benefits and costs
Benefits | Compass Rose Medicare Advantage Plan (PPO) |
---|---|
Annual medical deductible | None |
Annual out-of-pocket maximum | None |
Office and clinic visits | $0 copay for primary care, specialist or Virtual Visit/Telemedicine |
Hospital services (inpatient) | $0 copay |
Hospital services (outpatient) | $0 copay |
Ambulance services | $0 copay |
Emergency room | $0 copay |
Urgent care | $0 copay |
Durable medical equipment | $0 copay |
Prosthetics | $0 copay |
Diabetic supplies (test strips, lancets, glucose monitors) | $0 copay |
Preventive services | $0 copay |
Routine podiatry | $0 copay - 6 visits per year |
Massage therapy | $60 allowance per visit |
Hearing aid allowance | $0 copay - $2,400 allowance for unlimited aids every 3 years. Allowance is combined for both ears. |
Dental | Class 1 Preventive & Diagnostic (P&D): 100% Class 2 Minor: 80% Class 3 Major: 50% Deductible (P&D not included): $50 Annual Calendar 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 24 months Contact Lens Allowance (in lieu of glasses): $175 every 24 months |
Prescription drug coverage | Part D Retail Copay (up to a 30-day supply) Tier 1: Generic $1 copay
Tier 1: Generic $2 copay * UnitedHealthcare’s pharmacy benefit manager is OptumRX. Mail order prescriptions will be through OptumRX. |
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.
Disclaimer
Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the costsharing that applies to out-of-network services.