To search for a covered drug on our formulary, click on the link below. You can also download a copy of the formulary by clicking on your specific plan's PDF version. If you have any questions, we’re here to help.
PDF documents can be downloaded and then viewed with Adobe Reader. Get Adobe Reader by clicking here.
Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might:
In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. If we make any such change to our Formulary during the year, and you are taking the drug affected by the change, we will notify you of the change at least 60 days in advance. However, if a drug is recalled from the market, we will remove the drug from our Formulary immediately and notify you about the change as soon as possible.
Changes to our Formulary (both additions and deletions) are also listed on this website in the following document.
Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. If you qualify, you get help paying for Ultimate Health Plans’ monthly premium (because our premium includes coverage for both medical services AND prescription drugs). If you get Extra Help, your Ultimate Health Plans premium will be less than if you didn’t get Extra Help. Extra Help also helps pay your yearly deductible and prescription copayments. If you don’t already get Extra Help, you should see if you qualify. Call:
Medicare uses data from states and Social Security to determine the level of Extra Help (also called the low-income subsidy) for which a person may qualify. If Medicare doesn’t have the right information, its systems may show incorrect copayment levels, or they may not show that an eligible person qualifies for Extra Help. This discrepancy may happen when the state hasn’t successfully reported a person’s Medicaid or institutionalized status. Ultimate Health Plans must use "Best Available Evidence" (BAE) to correct information about a person’s level of Extra Help. Once we get BAE documentation, we can’t charge a person more than the maximum cost sharing for that person’s level of Extra Help. If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us. For more information on our process, please refer to the Evidence of Coverage, Chapter 2, Section 7, Information about programs to help people pay for their prescription drugs.
You can also download the document below for detailed information on how to use Best Available Evidence to correct your LIS status.
To view and download materials related to the CMS Best Available Evidence (BAE) policy, please click on the following link: CMS Website BAE Page for Policy and Guidance
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.
|Your level of extra help||Monthly Premium for Premier by Ultimate (HMO)*||Monthly Premium for Premier Plus by Ultimate (HMO)*||Monthly Premium for Advantage Care by Ultimate (HMO C-SNP)*||Monthly Premium for Advantage Care CHF by Ultimate (HMO)*||Monthly Premium for Advantage Care COPD by Ultimate (HMO)*||Monthly Premium for Advantage Plus by Ultimate (Full) (HMO D-SNP)*||Monthly Premium for Advantage Plus by Ultimate (Partial) (HMO D-SNP)*|
*This does not include any Medicare Part B premium you may have to pay.
To download the Ultimate Health Plans’ LIS Premium Summary Sheet, including information on how to find out if you qualify, please click on the following link.
You will see the PBM's name and logo on many of the forms we use to communicate about your prescription drug benefits. The PBM processes and pays prescription drug claims on behalf of Ultimate Health Plans. They also develop and maintain our drug list, contract with pharmacies, and negotiate discounts and rebates with drug manufacturers on our behalf.
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work medically just as well as a higher cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.
We hope that your drug coverage will work well for you, but it’s possible that you might have a problem. If your drug is not on the Drug List or is restricted, here are things you can do (please see the Evidence of Coverage, Chapter 5: Using the plan’s coverage for your Part D prescription drugs, for more detailed information):
If you and your provider want to ask for an exception, Chapter 9, Section 6.4 of the Evidence of Coverage tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. You will also need to fill out the form below. This form can be used to request the following types of requests:
Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change which is defined as when enrollees:
Ultimate Health Plans will provide the member with a written notice after Ultimate Health Plans covers the Transition Supply. This notice will explain the steps they can take to request an exception and how to work with their doctor to decide if they should switch to an appropriate drug that Ultimate Health Plans covers.
For more information, please refer to the Evidence of Coverage, Chapter 5 Section 5.2: What can you do if your drug is not on the Drug List or if the drug is restricted in some way?
Ultimate Health Plans provides a Medication Therapy Management Program (MTMP) to help members improve the way they use their medicines so that they get the most benefit out of their medicines and reduce the risk for harmful drug events and interactions. This program is not a benefit but part of the pharmacy medication management program. It is offered at no cost to eligible Members. This program is managed and conducted by licensed pharmacists. MTMP Services including Comprehensive Medication Reviews provide members (or designees) with medication reviews and care plans along with member and provider education on specific drug therapy topics. This service is available to Ultimate Health Plans members who meet the MTMP eligibility criteria. For complete information on the Medication Therapy Management Program, please click on the link below.
To obtain MTM service documents, please call 1-800-311-7517 (TTY 711) 24 hours a day, 7 days a week. To download a blank Personal Medication List, please click on the link below.
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