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 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)
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. 

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.