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.