Welcome

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.

When formulary updates are available, they can be found on our website.

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, yearly deductible, and prescription copayments. This "Extra Help" also counts toward your out-of-pocket costs. If you automatically qualify for "Extra Help" Medicare will mail you a letter. You will not have to apply. If you do not automatically qualify you may be able to get "Extra Help" to pay for your prescription drug premiums and costs. To see if you qualify for getting "Extra Help", 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 8 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
• Your State Medicaid Office. (See Chapter 2, Section 6 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. This Extra Help can inclide assistance paying monthly premiums and may reduce or elimate copayments. 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 prescriptions drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare.

If you get extra help, your monthly plan premium will be $0 for any of the plan(s) below. (This does not include any Medicare Part B premium you may hanve to pay).

• Premier by Ultimate (HMO)
• Advantage Care by Ultimate (HMO C-SNP)
• Advantage Care CHF by Ultimate (HMO C-SNP)
• Advantage Care COPD by Ultimate (HMO C-SNP)
• Advantage Plus by Ultimate (Full) (HMO D-SNP)
• Advantage Plus by Ultimate (Partial) (HMO D-SNP)

Ultimate Health Plans premium includes coverage for both medical services and prescription drug coverage. 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.

If you get extra help from Medicare to help pay for your Medicare prescriptions drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare.

If you get extra help, your monthly plan premium will be $0 for any of the plan(s) below. (This does not include any Medicare Part B premium you may hanve to pay).

• Premier by Ultimate (HMO)
• Advantage Care by Ultimate (HMO C-SNP)
• Advantage Care COPD by Ultimate (HMO C-SNP)
• Advantage Plus by Ultimate (Full) (HMO D-SNP)
• Advantage Plus by Ultimate (Partial) (HMO D-SNP)

Ultimate Health Plans premium includes coverage for both medical services and prescription drug coverage. 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.

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.

Ultimate Health Plans has a process for you to get your prescription drugs that are not on the formulary. If you are not able to get your prescription drug because it is not on the formulary or it requires prior authorization because of quantity limits or step therapy requirements, we can help. Please click below for additional information.

• As of 1/1/2023, Our plan covers most Part D vaccines at no cost to our members. Call Member Services for more information.
• As of 1/1/2023, Members 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.

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:

Safe Disposal of your Medications

Do you have unused or expired medications and need a safe way to dispose of them? Before you throw them away, here is some information you should know.

For safety reasons, unused or expired medications should be disposed of as soon as possible.

• Don't flush prescriptions and over the counter medications down the drain or toilet unless the label or patient information tells you to.
• Do bring unwanted or expired prescriptions and over-the-counter medications to a drug disposal program. To find a nearby pharmacy or authorized site to dispose of your medications, please visit Controlled Substance Public Disposal Locations . You will enter your zip code and a list of locations in your area will be displayed.

For additional information about safe disposal visit Drug Disposal: Drug Take Back Options .

Members can request Deterra disposal kits at any time and can receive 2 kits per request by calling OptumRx member services: 800-311-7517. Members do not need to use Optum Home Delivery to request the kits.

Dispose Medications at Home

You can also dispose of expired medication properly at home by following these steps:

• Take your prescribed medications out of the original packaging.
• Mix drugs with an undesirable substance, such as used coffee grounds or cat litter.
• Pour mixture into an empty plastic container with a lid or a bag that can be sealed.
• Remove all personal information from the medication container, including the Rx number, using permanent marker.

Lastly, place the sealed container with the medication mixture in the trash.

Drug Recall Alerts

Stay informed about the latest drug recalls by the FDA. The Drug Recall Alert keeps you informed of prescription drugs that have recently been recalled by the U.S. Food and Drug Administration (FDA). If you are taking a medication that has been recalled, you should:

• Discontinue use of the recalled prescription drug.
• Contact your provider if you have experienced any adverse reactions.
• Check your prescription label for the lot number and expiration date to determine if your medication is part of the recall.
• Contact your pharmacy that filled the medication.
• Any adverse reactions from the use of the prescription drug should be reported to the FDA by calling 1-800-FDA-0178.

Recent Recalls

For an immediate list of recalled drugs please visit the link below.

https://www.fda.gov/drugs/drug-safety-and-availability/drug-recalls

Potential for Contract Termination

Ultimate Health Plans is an HMO with a Medicare contract and a contract with the state Medicaid program. Enrollment in Ultimate Health Plans depends on contract renewal. This contract renews each year. Ultimate Health Plans is required to notify beneficiaries that it is authorized by law to refuse to renew its contract with the Centers for Medicare & Medicaid Services (CMS), that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment. In addition, the plan may reduce its service area and no longer offer services in the area where you reside. In the event this happens, you will receive advance notice.