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:
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.
"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.
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: