Prescription Drug Information

Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the year, the plan might make many kinds of changes to the Drug List. For example, the plan might:

• Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective.
• Move a drug to a higher or lower cost-sharing tier.
• Add or remove a restriction on coverage for a drug.
• Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the plan’s Drug List. If we make any such change to our Formulary during the year, and you are taking the drug affected by the change, we will notify you of the change at least 60 days in advance. However, if a drug is recalled from the market, we will remove the drug from our Formulary immediately and notify you about the change as soon as possible.

Changes to our Formulary (both additions and deletions) are also listed on this website in the following document.

Ultimate Health Plans provides coverage for Diabetic Supplies. Traditional blood glucose monitors (BGM), test strips, lancet devices, lancets, and glucose control solutions are covered through the Part B benefit.

Preferred Product:

OneTouch® (Johnson & Johnson) traditional BGM and test strips are the preferred diabetic products. OneTouch® products can be obtained through your local in-network retail or mail-order pharmacy.

Coinsurance:

All plans - Premier, Advantage Care, Advantage Plus (except for Premier Plans 046 and 047)

• 0% Coinsurance for diabetic monitors, lancets, and test strips when ordered through in-network retail or mail order service.

Premier Plans 046 and 047

• 0% Coinsurance for diabetic monitors, lancets, and test strips when ordered through mail order service.
• 20% Coinsurance for diabetic monitors, lancets, and test strips when ordered through in-network retail.

Other Options:

Other non-preferred brands of glucose monitors and test strips (including generic products) are available through the plan’s in-network Durable Medical Equipment (DME) providers, which can be found in the Provider & Pharmacy Directory or by visiting https://www.chooseultimate.com/Home/FindDoctor

Continuous glucose monitors (CGM), i.e., Freestyle Libre, Dexcom, and supplies, are not available at retail pharmacies. However, they are available through the plan’s in-network DME providers and require prior authorization.

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. If you qualify, you get help paying for Ultimate Health Plans’ monthly premium (because our premium includes coverage for both medical services AND prescription drugs). If you get Extra Help, your Ultimate Health Plans premium will be less than if you didn’t get Extra Help. Extra Help also helps pay your yearly deductible and prescription copayments. If you don’t already get Extra Help, you should see if you qualify. Call:

• 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
• The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778; or
• Your State Medicaid Office. (See Section 6 of Chapter 2 of the Evidence of Coverage for contact information.)

Medicare uses data from states and Social Security to determine the level of Extra Help (also called the low-income subsidy) for which a person may qualify. If Medicare doesn’t have the right information, its systems may show incorrect copayment levels, or they may not show that an eligible person qualifies for Extra Help. This discrepancy may happen when the state hasn’t successfully reported a person’s Medicaid or institutionalized status. Ultimate Health Plans must use "Best Available Evidence" (BAE) to correct information about a person’s level of Extra Help. Once we get BAE documentation, we can’t charge a person more than the maximum cost sharing for that person’s level of Extra Help. If you believe you have qualified for Extra Help and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us. For more information on our process, please refer to the Evidence of Coverage, Chapter 2, Section 7, Information about programs to help people pay for their prescription drugs.

You can also download the document below for detailed information on how to use Best Available Evidence to correct your LIS status.

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

OptumRx’s name and logo will appear on forms we use to communicate about your prescription drug benefits. OptumRx processes prescriptions, maintains our drug list and negotiates discounts and rebates with drug manufacturers. To locate network pharmacies, search for drugs on the prescription drug list, or download the home delivery mail order and prescription request forms click on the link below. You will also find educational videos regarding home delivery, formulary, and exception requests.

To access OptumRx page click here