1-844-891-2121 (TTY 711)

Ultimate Health Plans provides a comprehensive formulary which is a list of covered Part D drugs. Please note the formulary may change throughout the year. An updated comprehensive formulary is posted monthly. To search for a covered drug on our formulary, click on the Prescription Drug link below. Please select your plan name or number to begin your search. You can also download a copy of the formulary by clicking on your plan’s PDF version.Get Adobe Reader by clicking here.

Prescription Drug List

Find covered drugs using our online search tool



Find covered drugs and utilization management tools by downloading the drug list.


  • Important Message About What You Pay for Vaccines Effective 1/1/2023 - Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
  • Important Message About What You Pay for Insulin Effective 1/1/2023 - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
Formulary Addendum

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:

  • Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
  • Move a drug to a higher or lower cost-sharing tier.
  • Add or remove a restriction on coverage for a drug.
  • Replace a brand name drug with a generic drug.

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.

Preferred Diabetic Products

Ultimate Health Plans provides coverage for Diabetic Supplies. Traditional blood glucose monitors (BGM), test strips, lancet devices, lancets, and glucose control solutions are covered through Part B for a $0 cost-share. Below we have outlined the coverage for these products and other helpful information.

  • Freestyle (Abbott) and OneTouch (Johnson & Johnson) traditional BGM and test strips are the preferred diabetic products.
  • Freestyle and OneTouch products can be obtained through your retail or mail-order pharmacy.
  • Other brands of glucose monitors and test strips (including generic products) are available through the plan’s in-network Durable Medical Equipment (DME) providers, which can be found in the Provider & Pharmacy Directory or by visiting https://www.chooseultimate.com/Home/FindDoctor
  • Traditional BGM, blood glucose test strips, lancet devices and lancets, and glucose-control solutions are covered through Part B for a $0 cost-share.
  • Continuous glucose monitors (CGM) i.e., Freestyle Libre, Dexcom, and supplies are not available at retail pharmacies. However, they are available through the plan’s in-network DME providers and require prior authorization.
Medicare’s Extra Help Program

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:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
  • The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
  • Your State Medicaid Office. (See Section 6 of Chapter 2 of the Evidence of Coverage for contact information.)

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

Monthly Plan Premium for People who get Extra Help from Medicare

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)*
100% $0 $0 $0 $0 $0 $0 $0
75% $0 $0 $0 $0 $0 $0 $0
50% $0 $0 $0 $0 $0 $0 $0
25% $0 $0 $0 $0 $0 $0 $0

*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.

OptumRx Member Portal

OptumRx’s name and logo will appear on forms we use to communicate about your prescription drug benefits. OptumRx processes prescriptions, maintains our drug list and negotiates discounts and rebates with drug manufacturers. To locate network pharmacies, search for drugs on the prescription drug list, or download the home delivery mail order and prescription request forms click on the link below. You will also find educational videos regarding home delivery, formulary, and exception requests.

OptumRx Logo
Special Rules Apply to Some Prescriptions Drugs

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.

Prior Authorizations and Exceptions

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):

  • You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
  • You can change to another drug.
  • You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

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:

  • To request a prior authorization for a prescription drug that requires it.
  • To request a prior authorization for a drug designated as a high-risk medication.
  • To request that we cover a non-formulary drug.
  • To request that we waive quantity limit on a drug.
  • To request that a drug be covered at a lower tier.
  • To request that we waive the requirement to try an alternative drug “step therapy” first.
Transition Policy

Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change which is defined as when enrollees:

  • Enter a Long-Term-Care (LTC) facility from a hospital or other setting.
  • Leave a Long-Term-Care (LTC) facility and return to the community.
  • Are discharged from a hospital to a home.
  • End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan Formulary.
  • Revert from hospice status to standard Medicare Part A and Part B benefits; and
  • Are discharged from a psychiatric hospital with a medication regimen that is highly individualized.

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?

If your drug is not on the Drug List or is restricted, here are options:

  • You may be able to get a temporary supply of the drug.
  • You can change to another drug.
  • You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
You may be able to get a temporary supply

Under certain circumstances, the plan must provide a temporary supply of a drug that you are already taking. This temporary supply gives you time to talk with your provider about the change in coverage and decide what to do.
To be eligible for a temporary supply, the drug you have been taking must no longer be on the plan’s Drug List OR is now restricted in some way.

  • If you are a new member, we will cover a temporary supply of your drug during the first 90 days of your membership in the plan.
  • If you were in the plan last year, we will cover a temporary supply of your drug during the first 90 days of the calendar year.
  • This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
  • For those members who have been in the plan for more than 90 days and reside in a long-term care facility and need a supply right away:
    We will cover one 31-day emergency supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply.
  • For those members who have been in the plan for more than 90 days and experience a level of care change (from one treatment setting to another): You may have an unplanned transition, such as a move from a hospital to a long-term care facility. If this happens and you need a drug that is not on our formulary or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a resident of a longterm care facility) when you go to a network pharmacy. This gives you time to talk to your doctor about other treatment options. After your first one-month supply in such situations, you are required to use the plan's formulary exception process. A level of care change is defined as when enrollees:
    • Enter a Long-Term-Care (LTC) facility from a hospital or other setting.
    • Leave a Long-Term-Care (LTC) facility and return to the community.
    • Are discharged from a hospital to a home.
    • End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered) and must revert to coverage under their Part D plan Formulary.
    • Revert from hospice status to standard Medicare Part A and Part B benefits; or
    • Are discharged from a psychiatric hospital with a medication regimen that is highly individualized.

For questions about a temporary supply, call Member Services.
During the time when you are using a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You have two options:

1) You can change to another drug

Talk with your provider about whether there is a different drug covered by the plan that may work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you.

2) You can ask for an exception

You and your provider can ask the plan to make an exception and cover the drug in the way you would like it covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception. For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions.

If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells you 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.

Medication Therapy Management

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.

  • Drug Management Program and Quality Assurance: Our goal is to ensure that our members receive safe, high-quality, cost-effective medication therapy. To achieve this goal, we use a Pharmacy and Therapeutics committee, whose goal is to improve the quality of care for Ultimate Health Plans members. To find out more about how Ultimate Health Plans ensures that your drugs are appropriate, medically necessary, and not likely to result in adverse medical effects, please click on the following link:
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