1-844-891-2121 (TTY 711)

Below, please find Ultimate Health Plans’ most accessed documents and forms. If you can’t find what you’re looking for or if you need help, please call Member Services at 1-888-657-4170 (TTY 711) and we’ll be happy to assist you.

PDF documents can be downloaded and then viewed with Adobe Reader click here.

The Evidence of Coverage (EOC) booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. Chapter 4 of the EOC focuses on your covered services and what you pay for your medical benefits. It includes a Medical Benefits Chart that lists your covered services and shows how much you will pay for each covered service as a member of Ultimate Health Plans. It also has information about medical services that are not covered and explains limits on certain services.


The Evidence of Coverage (EOC) booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. Chapter 4 of the EOC focuses on your covered services and what you pay for your medical benefits. It includes a Medical Benefits Chart that lists your covered services and shows how much you will pay for each covered service as a member of Ultimate Health Plans. It also has information about medical services that are not covered and explains limits on certain services.

The Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please access the “Evidence of Coverage” document above.