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  Prior Authorization

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Quick Reference Guide (QRG)

The QRG serves as a handy and valuable resource for information to help serve your patients who have become Ultimate Health Plans’ Members. You can find information on the following topics:

  • Frequently Used Contact Information for Ultimate Health Plans
  • Claims
  • Pharmacy and Prescription Drugs
  • Laboratory Services
  • Other Contracted Networks (Vision, Hearing, Dental, Behavioral Health)
  • Gym Membership and Locations
  • Over-the-Counter (OTC) Benefit
  • Referrals
  • Case Management
  • Prior Authorization
  • Grievances and Appeals
  • Patient Communication and UHP’s Commitment to Quality Care

Prior Authorization for Medical Care

Prior Authorization List
To view a list of services requiring prior authorization please click on the following link:

Timeframes for Authorization Requests

Ultimate Health Plans processes authorization requests according to the following general time frames, which comply with Medicare guidelines:

  • Standard- decision within 14 calendar days from the date of request.
  • Expedited- decision within 72 hours from the date of the request (including weekends and holidays). Conditions meeting criteria for expedited review include an imminent or serious threat to the health of the Member, including, but not limited to, severe pain, potential loss of life, limb or major bodily function. Please, only submit authorizations for expedited review if you can support that the above criteria applies to your request.

NOTE: Please ensure that your authorization request includes adequate documentation and/or information to medically support the request. If the information submitted is not adequate, the determination will be based upon the available information and/or lack of medical information. To expedite the process and to ensure appropriateness of the decision, it is very important that relevant clinical information be submitted with the request.

Request for Extensions:
Ultimate may extend the decision time frame up to 14 calendar days. This extension is allowed if the enrollee requests the extension or if the provider or Ultimate can justify a need for additional information and documents how the delay is in the best interest of the enrollee.

Prior Authorization for Prescription Drugs

Request prior authorization for prescription drug that requires it by completing this form on behalf of your patient.


Drug Transition Policy

Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change. We will provide the member with a written notice after we cover the Transition Supply. This notice will explain the steps they can take to request an exception and how to work with their doctor to decide if they should switch to an appropriate drug that we cover.

This page was last modified: 6/17/2020 12:30:58 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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