Below, please find Ultimate Health Plans’ most accessed documents and forms. If you can’t find what you’re looking for or if you need help, please call Member Services at 1-888-657-4170 (TTY 711) and we’ll be happy to assist you.

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

The Evidence of Coverage (EOC) 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.

Over-the-Counter (OTC) Medicines and Supplies
Quality Program

Ultimate Health Plans maintains a Quality Program to improve quality of care and member health outcomes. The Quality Program provides the framework for how we monitor the quality of care and services that our members receive. Through this program, we develop clinical initiatives and process improvements. Ultimate Health Plans measures the program's effectiveness on an annual basis.

Quality Monitoring

Ultimate Health Plans analyzes many different types of data, including member clinical data (such as claims, lab results, and diagnoses) as well as member and provider appeals and grievances. Ultimate Health Plans also monitors its internal processes.

Ultimate Health Plans annually measures the quality of care and services its members receive through the use of the Healthcare Effectiveness Data and Information Set (HEDIS®). Ultimate Health Plans also conducts annual member surveys to determine what members think about the health plan, their physicians, and their own health. This survey is called the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We also look at member responses to the Medicare Health Outcomes Survey (HOS), which tells us how its members feel about their health.

Ultimate Health Plans also monitors measures of patient safety on an annual basis. Ultimate Health Plans maintain programs to improve patient safety, such as through medication reconciliation and the use of high-risk medications.

Quality Improvements

Ultimate Health Plans uses the Quality Program to implement ongoing, continuous quality improvement projects and interventions. Examples of quality projects may include:

  • Flu shot clinics
  • Reminder calls to members when they are due for specific care, such as a mammogram or colonoscopy
  • Member incentive programs
  • Provider education
Measuring and Reporting Quality

One of the ways that you can determine how well we are doing is by looking at our Medicare Star Rating. Every year, Medicare evaluates plans based on a 5-star rating system. This system is based on the health plan’s quality and performance. You can find information about our current star rating below.

Ultimate Health Plans is evaluated by the National Committee for Quality. You can review our report card by clicking here.

Ultimate Health Plans also establishes internal goals and benchmarks in an annual quality work plan. Quality monitoring information is reported to the Quality Management Steering Committee. This committee reports to the Ultimate Health Plans Board of Directors.

For more information about this program, please contact Member Services at 1-888-657-4170 (TTY 711).

Health Risk Assessment (HRA)

One of our main goals is to help you get healthy and stay healthy. The information you provide on this questionnaire helps us do this. It includes basic questions about your health and lifestyle.

Prior Authorization Form

Some services are covered by our plan only if your Primary Care Physician (PCP) or other provider gets permission from Ultimate Health Plans first. This is called a Prior Authorization.

Pharmacy Mail Order
Prescription Drug Determination Requests
Assessment of New Medical Technology

Ultimate Health Plans 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 open the document 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 to 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 another relative; someone who helps take care of you; and social worker or healthcare advocacy group.