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2020 PROVIDER & PHARMACY DIRECTORY · PDF file You may choose your PCP from the Provider and Pharmacy Directory. You may also view the most up-to-date Provider and Pharmacy Directory

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  • H2962_Combined PPD v120_C

    2020 PROVIDER & PHARMACY DIRECTORY

    This directory is current as of 11/02/2020.

    please call our Member Services Department at 1-888-657-4170, Monday through Sunday 8 a.m. to 8 p.m.

    Federal holidays. TTY users should call 711.

    09/2020

    This document may be available in other formats such as large print or other alternate formats. If you need

    Citrus

    Hernando

    Pasco

    Pinellas

    SumterMarion

  • i

    Section 1 – Introduction _________________________________________________________ i

    Table of Contents – Preface

    What is the service area for Ultimate Health Plans? _____________________________ iii

    How do you find Ultimate Health Plans providers and pharmacies in your area? ______ iii

  • ii

    Section 1 – Introduction

    This directory provides a list of Ultimate Health Plans’ network providers. To get detailed information about your health care coverage, please see your Evidence of Coverage (EOC).

    This booklet provides a list of our network pharmacies. To get a complete description of your prescription coverage, including how to fill your prescriptions, please review the Evidence of Coverage and Acclaim by Ultimate (HMO)’s, Acclaim Plus by Ultimate (HMO)’s, Advantage Care by Ultimate (HMO C-SNP)’s, Ascend Plus by Ultimate (HMO)’s, Elite by Ultimate (HMO)’s, Premier by Ultimate (HMO)’s and Premier Plus by Ultimate (HMO)’s formulary.

    How to access our plan’s providers and pharmacies You will have to choose one of our network providers who are listed in this directory to be your Primary Care Provider (PCP). Generally, you must get your health care coverage from your PCP. Your PCP is a physician who meets state requirements and is trained to give you medical care. Your PCP serves as your medical home, and you will get your routine or basic care from your PCP. The types of providers that may act as a PCP are: General Practice, Family Practice, and Internal Medicine physicians.

    You may choose your PCP from the Provider and Pharmacy Directory. You may also view the most up-to-date Provider and Pharmacy Directory online at www.ChooseUltimate.com. If you require assistance in choosing your PCP, contact Member Services (phone numbers can be found on the cover of this booklet).

    The network providers listed in this directory have agreed to provide you with your health care services. You may go to any of our network providers listed in this directory; however, some services may require a referral. Your PCP will coordinate and provide you referrals for certain covered services you get as a member of our plan. In some cases, you may get covered services from non-network providers. Please refer to your Evidence of Coverage for more information.

    Some provider services require a prior authorization. In addition to providing you referrals to a specialist when needed, your PCP (or specialist in some cases) will obtain prior authorization (approval in advance) from Ultimate Health Plans for certain services and items, such as elective hospital admissions, MRI/PET scans, etc. For a complete list of the services that may require Ultimate Health Plans’ approval in advance, please refer to your Evidence of Coverage.

    Your PCP selection may limit the specialists you can see. If there are specific specialists you want to use, find out whether your PCP sends patients to these specialists, as your PCP may only refer patients to certain participating providers. Please check first to be sure your PCP can refer you to an in-network specialist, or hospital you may want to use. If you have been going to one network provider, you are not required to continue going to that same provider.

    We call the pharmacies on this list our “network pharmacies” because we have made arrangements with them to provide prescription drugs to Plan members. In most cases, your prescriptions are covered under our plan only if they are filled at a network pharmacy or through our mail order pharmacy service. Once you go to one pharmacy, you are not required to continue going to the same pharmacy to fill your prescription but can switch to any other of our network pharmacies. We will fill prescriptions at non-network pharmacies under certain circumstances as described in your Evidence of Coverage.

    All network pharmacies may not be listed in this directory. Pharmacies may have been added or removed from the list after this directory was printed. This means the pharmacies listed here may no longer be in our network, or there may be newer pharmacies in our network that are not listed. This list is current as of 11/02/2020. For the most current list, please contact us. Our contact information appears on the front and back cover pages.

  • iii

    You can get prescription drugs shipped to your home through our network mail order delivery program. For more information, please contact us or see the mail order section of this Provider and Pharmacy Directory.

    If you have questions about any of the above, please see the first and last cover pages of this directory for information on how to contact us.

    Services that don’t require approval in advance Referrals from your PCP are not required for emergency care or urgently needed care. There are also some other kinds of care you can get without having approval in advance from your PCP, such as preventive services, routine women’s health care covered dermatology, podiatry and chiropractic services, covered mental health services, flu shots and vaccinations.

    What to do if you get a bill from a non-contracted provider There may be times when you get a bill from a non-contracted provider for the full cost of medical care you have received. You should send this bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider our share of the cost directly. You will be responsible for paying your share of the cost. For more information on situations in which you may need to ask us for reimbursement or to pay a bill you have received from a provider (including where to send your request for payment), see chapter 7 of your Evidence of Coverage (Asking us to pay our share of a bill you have received for covered medical services or drugs).

    Getting Care if you have a medical emergency A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

    You may get covered emergency medical care whenever you need it, anywhere in the world. If you have a medical emergency, get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. You do not need to get approval or a referral first from your PCP.

    If you have an emergency, we will talk with the doctors who are giving you emergency care to help manage and follow up on your care. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over. After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your follow-up care will be covered by our plan. If your emergency care is provided by out of network providers, we will try to arrange for network providers to take over your care as soon as your medical condition and the circumstances allow.

    What if you are outside the plan’s service area when you have an urgent need for care? When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. Our plan does not cover urgently needed care or any other non- emergency care if you receive the care outside of the United States.

    You must use network providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers, neither Medicare nor Ultimate Health Plans will be responsible for the costs.

  • iv

    What is the service area for Ultimate Health Plans? The counties in our service area are listed below.

    The service area for Premier by Ultimate is Hernando County. The service area for Premier Plus by Ultimate is Citrus, Hernando and Pasco Counties. The service area for Elite by Ultimate is Citrus and Pasco Counties. The service area for Acclaim by Ultimate and Acclaim Plus by Ultimate is Pinellas County. The service area for Ascend Plus by Ultimate is Marion and Sumter Counties. The service area for Advantage Care by Ultimate is Citrus, Hernando and Pasco Counties.

    How do you find Ultimate Health Plans providers and pharmacies that serve your area?

    Find Doctors, Hospitals, Skilled Nursing Facilities, Outpatient Mental Health and Ancillary Providers Ultimate Health Plans’ providers are listed by specialty in Section 2. The PCPs are listed first, followed by specialists listed by specialty type in alphabetical order (Cardiology, Chiropractic, Endocrinology), then hospitals, skilled nursing facili