Out-of-Network Coverage | Ultimate Health Plans

It is important to know which providers and pharmacies are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services, and you must get your prescriptions filled at one of our network pharmacies if you want our plan to cover (help you pay for) them. Please click on "Find a Doctor or Pharmacy" on the menu at the right hand side of this webpage to access Ultimate Health Plans’ most up to date Provider and Pharmacy Directory.

There are three exceptions when you may receive care from an out-of-network provider:

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in Chapter 3 of the Evidence of Coverage.
If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. If an out-of-network provider is used, authorization should be obtained from Ultimate Health Plans prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider. For information about getting approval to see an out-of-network doctor, see Section 2.4 in Chapter 3 of the Evidence of Coverage.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

What is covered if you have a medical emergency?

You may get covered emergency medical care whenever you need it, anywhere in the world. Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. For more information, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage. If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over. After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If your emergency care is provided by out-of-network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow.

Getting "urgently-needed" care

"Urgently needed care" is a non-emergency, unforeseen medical illness, injury, or condition, that requires immediate medical care. Urgently needed care may be furnished by in-network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. The unforeseen condition could, for example, be an unforeseen flare-up of a known condition that you have. For complete information on how we cover "urgently needed care" both from in-network and out-of-network providers (including any limitations), please see section 3.2 in Chapter 3 of the Evidence of Coverage.

When can you use a pharmacy that is not in the plan’s network?

We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

If you are traveling within the U.S., but outside of the plan’s service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within the Evidence of Coverage and a network pharmacy is not available. Prior to filling your prescription at an out-of-network pharmacy, call Member Services to find out if there is a network pharmacy in the area where you are traveling. If there are not network pharmacies in that area, Member Services may be able to make arrangements for you to get your prescription from an out-of-network pharmacy. See Section 3.5 of Chapter 5. Using the plan’s coverage for your Part D prescription drugs for more information on when you can use a pharmacy that is not in the plan’s network.
If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost. 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 at:
OptumRx P.O. Box 650287 Dallas, TX 75265-0287
For complete details on how to ask the plan to pay you back (including any steps you must follow) please see the Evidence of Coverage, Section 2.1 of Chapter 7. Asking us to pay our share of a bill you have received for covered medical services or drugs.

Evidence of Coverage

Can be found in the Documents and Forms section of this website.

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