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. Get Adobe Reader by clicking here.

The Evidence of Coverage 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 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.

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.

Over The Counter (OTC) Medicines and Supplies
Quality Program

Ultimate Health Plans maintains a Quality Program to improve quality of care and member health outcomes. The Quality Program provides the framework for how we monitor the quality of care and services that our members receive. Through this program, we develop clinical initiatives and process improvements. On an annual basis, Ultimate Health Plans measures the program's effectiveness.

Quality Monitoring

Ultimate Health Plans analyzes many different types of data, including member clinical data (such as claims, lab results, and diagnoses) as well as member and provider appeals and grievances. Ultimate also monitors its internal processes.

Ultimate Health Plans annually measures the quality of care and services its members receive through the use of HEDIS® (Healthcare Effectiveness Data and Information Set) measures. Ultimate Health Plans also conducts annual member surveys to determine what members think about the health plan, their physicians, and their own health. This survey is called the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We also look at member responses to the Medicare Health Outcomes Survey (HOS), which tells us how its members feel about their health.

Ultimate Health Plans also monitors measures of patient safety on an annual basis. Ultimate maintains programs to improve patient safety, such as through medication reconciliation and the use of high-risk medications.

Quality Improvements

Ultimate Health Plans uses the Quality Program to implement ongoing, continuous quality improvement projects and interventions. Examples of quality projects may include:

  • Flu shot clinics
  • Reminder calls to members when they are due for specific care, such as a mammogram or colonoscopy
  • Member incentive programs
  • Provider education
Measuring and Reporting Quality

One of the ways that you can determine how well we are doing is by looking at our Medicare Star Rating. Every year, Medicare evaluates plans based on a 5-star rating system. This system is based on the health plan’s quality and performance. You can find information about our current star rating below.

Ultimate Health Plans is evaluated by the National Committee for Quality Assurance (NCQA) every three years. You can review our report card here: https://reportcards.ncqa.org/#/health-plan/Hp_3_1_001G000001uwtBdIAI

Ultimate Health Plans also establishes internal goals and benchmarks in an annual quality work plan. Quality monitoring information is reported to the Quality Management Steering Committee. This committee reports to the Ultimate Health Plans Board of Directors.

For more information about this program, please contact Member Services at 1-888-657-4170 (TTY: 711).

Prior Authorization for Medical Care

Some services are covered by our plan only if your Primary Care Physician (PCP) or other provider gets permission from Ultimate Health Plans first. This is called a Prior Authorization.

Prescription Drug Forms
  • Reimbursement: If you paid out of pocket for a covered medication, send us your request for payment, along with your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Mail your request for payment together with any bills or receipts to us with the contact information provided below:

    OptumRx Direct Member Reimbursements

    P.O. Box 650287

    Dallas, TX 75265-0287

    You must submit your claim to us within 12 months of the date you received the service, item, or drug.

  • Prescription Drug Determination Requests
    The Prescription Drug Determination Request Form can be used for the following:
    • 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.
  • Appeals for Part D Prescription Drug Benefits: To file an appeal (request for redetermination) for a Medicare prescription drug denial please have your provider complete the form below:
Assessment of New Medical Technology

UHP has a formal process to evaluate and address new developments in technology and new applications of existing technology. We consider including new technology in our benefit plans to keep pace with changes and to ensure our members have equitable access to safe and effective care. To learn more about this formal process, please click on the link below:

Appointment of Representative

You can appoint someone to represent you in formal matters, such as appeals or grievances, by completing the form below:

Permission of Share Information (PSI)

Use this form if you want Ultimate Health Plans to share the information we have about you with another person or organization, such as a family member, friend, or other relative; someone who helps take care of you; or a social worker or health-care advocacy group.

Care Transition

If you're a new member, help us better understand your health needs and transition your care by completing and returning the form below:

Direct Member Reimbursement

To ask us for reimbursement on covered expenses you paid out of pocket for please download the form below and ask for your provider's help to complete it.

Advance Directives

Every competent adult has the right to make decisions concerning his or her own health, including the right to choose or refuse medical treatment. When a person becomes unable to make decisions due to a physical or mental change, such as being in a coma or developing dementia (like Alzheimer’s disease), they are considered incapacitated. To make sure that an incapacitated person’s decisions about health care will still be respected, the Florida legislature enacted legislation pertaining to health care advance directives (Chapter 765, Florida Statutes). The law recognizes the right of a competent adult to make an advance directive instructing his or her physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make his or her own decisions; and/or to indicate the desire to make an anatomical donation after death.

Medicare law gives you the right to file a complaint with the Agency for Health Care Administration (AHCA) if you are dissatisfied with our process for handling Advance Directives.

To complete an advance directive, simply download the information and complete the forms in the document below. Make sure that your primary care doctor, attorney and the significant persons in your life know that you have an advance directive, and give them a copy. You may also want to keep a card or note in your purse or wallet that states that you have an advance directive and where it is located.

If you change your advance directive, make sure your health care provider, attorney and the significant persons in your life have the latest copy. To download advance directives information and forms, please click on the following link:

Emergency Preparedness

If there is an emergency, do you know:

  • What you and your family will do?
  • What to have on hand?
  • What to take with you?
  • Where to go, if necessary?
  • What you would do with your pets?

Clinical Practice Guidelines

These Preventive Care Guidelines address routine health exams, diagnostic checkups, counseling and immunizations recommended for adults. Discuss these general guidelines with your doctor to stay as healthy as possible throughout the year.

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