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 Plan Documents

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Welcome to Ultimate Health Plans. Below, please find frequently referenced plan documents.

Evidence of Coverage

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


Annual Notice of Change


Summary of Benefits

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


To order OTC products online, click here.

Quality Management Program



This page was last modified: 1/13/2021 3:22:16 AM

Ultimate Health Plans is an HMO plan with a Medicare contract. Enrollment in Ultimate Health Plans depends on contract renewal. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Ultimate Health Plans does not collect any member information through this website.


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