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We look forward to serving you. We want your experience with us to be great. We promise to serve and care for you in the same way we would want our family to be treated.
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.
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.
The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Participation is voluntary.
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.
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.
You can appoint someone to represent you in formal matters, such as appeals or grievances, by completing the form below:
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.
If you're a new member, help us better understand your health needs and transition your care by completing and returning the form below.
You must submit your claim to us within 12 months of the date you received the service, item, or drug.
Life Planning provides you with the opportunity to evaluate and communicate your values, goals, and preferences through advance care planning regarding your medical care. Life Planning is communicated through advance directives.
Every competent adult has the right to make decisions concerning their own health, including the right to choose or refuse medical treatment. The law recognizes the right of a competent adult to make an advance directive instructing their physician to provide, withhold, or withdraw life-prolonging procedures; to designate another individual to make treatment decisions if the person becomes unable to make their own decisions; and/or to indicate the desire to make an anatomical donation after death.
By law, hospitals, nursing homes, home health agencies, hospices, and health maintenance organizations (HMOs) are required to provide their patients with written information concerning health care advance directives. The state rules that require this include 58A-2.0232, 59A-3.254, 59A- 4.106, 59A-8.0245, and 59A-12.013, Florida Administrative Code. This written information can be found below.
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.
What is an Advance Directive?
An advance directive is a written or oral statement about how you want medical decisions made should you not be able to communicate them yourself. Various people make advance directives when they are diagnosed with a life-threatening illness. Others put their wishes into writing while they are healthy, often as part of their estate planning.
Types of life planning advance directives include:
To download advance directive information and forms, please click on the following link.
Your health, safety, and well-being are important to us. During an emergency, it’s important you and your family are prepared and have the information on what to do before, during, and after public health emergencies. Visit https://www.floridahealth.gov/programs-and-services/emergency-preparedness-and-response/index.html for tools and resources to help you and your loved ones prepare for any disaster.
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.
Use the Social Worker Referral Form if you want an Ultimate Health Plans Social Worker to contact you for community resource needs such as housing, food, transportation, etc.