***Coronavirus, COVID-19**** There is an Emergency Declaration in place for
the State of Florida and Nationally. Please click here
to learn how Ultimate Health Plans provides benefits during an Emergency.
Below, please find Ultimate Health Plans’ most accessed forms and resources. If you can’t find what you’re looking
for or if you need help, please call Member Services and we’ll be happy to assist you.
Prior Authorization for Medical Care
Some services are covered by our plan only if your PCP or other provider gets permission from Ultimate
Health Plans first. This is called a Prior Authorization.
The PDF documents can be downloaded and then viewed with Adobe Reader.
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
or fax your request for payment together with any bills or receipts to us with the contact information provided below:
P.O. Box 407
Boys Town, NE 68010
You must submit your claim to us within 12 months of the date you received the service, item, or drug.
- Coverage Determinations or Exceptions: Request a coverage determination or exception to our drug formulary by
having your provider complete one of the forms below:
- 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.
Communicate Your Health Needs
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.
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:
Take Action BEFORE an Emergency to Stay Safe DURING a Crisis
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?
Adult Preventive 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.