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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 assist people with limited income and resources in paying their prescription drug costs. If you qualify, Extra Help can lower or eliminate your:

• Monthly plan premium
• Yearly deductible
• Prescription drug copayments

This assistance also counts toward your out-of-pocket costs.

How to Qualify:

If you automatically qualify, Medicare will send you a letter — no application is needed.

If you do not automatically qualify, you may still be eligible and can apply for Extra Help.

To see if you qualify, contact any of the following:

• Medicare: 1-800-MEDICARE (1-800-633-4227)

  TTY users: 1-877-486-2048 (24 hours a day, 7 days a week)

• Social Security: 1-800-772-1213 (Monday-Friday, 8 a.m. to 7 p.m.)

  TTY users: 1-800-325-0778

• Your state Medicaid Office: 1-888-419-3456

  TTY users: 1-800-955-8771

  (See Evidence of Coverage, Chapter 2, Section 6, for additional contact information)

What If Medicare Has Incorrect Information?

Medicare uses data from Social Security and your state to determine your level of Extra Help (also known as the Low-Income Subsidy, or LIS). This information may not always be up to date. For example, if your Medicaid or institutional status hasn't been properly reported, Medicare may show incorrect copayment levels or fail to show that you qualify.

What We Can Do to Help

Ultimate Health Plans follows Medicare’s Best Available Evidence (BAE) policy to ensure you are charged the correct amount. Once we receive valid BAE documentation, we will adjust your copayment level so you do not pay more than the maximum allowed based on your level of Extra Help.

If you believe you're eligible for Extra Help and are paying too much for prescriptions:

• You can request assistance from us to obtain documentation of your proper copayment level or
• You may submit documentation you already have that shows your correct copayment level.

For more details on this process, refer to your Evidence of Coverage, Chapter 2, Section 7: Information about programs to help people pay for their prescription drugs.

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 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 want your prescription drug coverage to meet your needs. However, sometimes you may find that a drug is not on our Drug List (formulary) or has certain restrictions. If this happens, here are your options (see Evidence of Coverage, Chapter 5: Using the plan’s coverage for your Part D prescription drugs, for more details):

• Temporary supply (in certain situations): You may be able to receive a short-term supply of the drug. This gives you and your provider time to either switch to another drug or submit a request to have your drug covered. For more details, see the Transition Policy section below.
• Switch to another drug: Your provider may prescribe a different medication that is on our Drug List.
• Request an exception: You and your provider can ask the plan to cover your drug or remove restrictions.

If you and your provider decide to request an exception, see Evidence of Coverage, Chapter 9, Section 6.4 for instructions. This section explains the Medicare-required procedures and timelines for handling your request promptly and fairly.

You will also need to complete the form below. This form can be used for the following types of requests:

• Prior authorization for a drug that requires it.
• Prior authorization for a drug designated as a high-risk medication.
• Coverage of a non-formulary (not on the Drug List) drug
• Wavier of a quantity limit on a drug.
• Request to cover a drug at a lower cost-sharing tier.
• Waiver of the requirement to try an alternative drug (“step therapy”) first.

Ultimate Health Plans has a process to help you receive a temporary supply of your prescription drug if it is not on our Drug List (formulary) or if it has coverage restrictions such as prior authorization, quantity limits, or step therapy requirements. A temporary supply gives you and your provider time to review your options, such as switching to another covered drug or requesting an exception to continue your current medication. Please click the link below to review the information and see if you qualify for a temporary supply under our Transition Policy.

• Vaccines: Starting January 1, 2023, our plan covers most Part D vaccines at no cost to members. For details, please contact Member Services.
• Insulin (effective January 1, 2023): Members pay no more than $35 for a one- month supply of each insulin product covered by our plan, regardless of the cost-sharing tier.
• Insulin (effective January 1, 2026): Members will pay no more than 25% of the cost, up to a maximum of $35 for a one-month supply of each insulin product covered by our plan, regardless of the cost-sharing tier.

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.