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Premier by Ultimate (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Premier by Ultimate (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Premier by Ultimate (HMO) in 2025, please refer to our full plan details page.
Premier by Ultimate (HMO) is a HMO plan offered by Ultimate Healthcare Holdings, LLC available for enrollment in 2025 to people living in Counties: CIT, HER, IDR, PAS, STL. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Premier by Ultimate (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Premier by Ultimate (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Premier by Ultimate (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $174.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $1900.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Premier by Ultimate (HMO) plan has an "Enhanced Alternative" drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you may pay a $0 copay for preferred generic drugs at a standard pharmacy. Standard generic drugs have a $30 copay, while preferred brand drugs have a $70 copay. Non-preferred drugs have a 33% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Premier by Ultimate (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient services with varying copays. The plan also includes coverage for emergency services, primary care, hearing, vision, dental, and home infusion services. Some services, such as ambulance, dialysis, and medical equipment, involve coinsurance or copays, while home health services and skilled nursing facilities have no copay for some days. Be aware that this plan does not cover many additional benefits, such as annual physicals, podiatry, and more.
Inpatient Hospital See details
Inpatient Hospital benefits, including services not usually covered by Medicare plans, are covered. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $60 copay for days 1-5, and no copay for days 6-90, and also have 1 additional day per benefit period.
Outpatient Services See details
Outpatient Services are covered by Premier by Ultimate (HMO). Outpatient Hospital Services and Observation Services have a $75 copay, Ambulatory Surgical Center (ASC) Services have a $25 copay, and both Individual and Group Sessions for Outpatient Substance Abuse have a $15 copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Premier by Ultimate (HMO) plan, but requires prior authorization and a doctor referral. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services include coverage for ground and air ambulance services, as well as transportation services to plan-approved health-related locations. Ground ambulance services have a $150 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered, but the plan covers 20 one-way trips per year to plan-approved health-related locations.
Emergency Services See details
Emergency Services, including urgently needed services and worldwide emergency coverage, are covered by Premier by Ultimate (HMO). Emergency services have a $75 copay, urgently needed services have a $10 copay, and worldwide emergency coverage has a $100 copay, while worldwide urgent coverage and worldwide emergency transportation are not covered.
Primary Care See details
Premier by Ultimate (HMO) covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $20 copay, physician specialist services with a $10 copay, mental health specialty services with a $10 copay for individual and group sessions, physical therapy and speech-language pathology services with a $20 copay, and opioid treatment program services with 20% coinsurance. This plan does not cover podiatry services, and routine chiropractic care.
Preventive Services See details
Preventive Services, including Medicare-covered services, additional preventive services, kidney disease education services, and other preventive services, are covered. However, the plan does not cover annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, enhanced disease management, telemonitoring services, and counseling services.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Hearing exams and routine hearing exams are covered once per year, and fitting/evaluation for hearing aids is covered once per year. Prescription hearing aids are covered up to $1,000 per year, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
The Premier by Ultimate (HMO) plan covers vision services, including routine eye exams with one visit per year, and eyewear with a combined maximum benefit of $200 per year, and upgrades with a copay of $30-$50. The plan also covers contact lenses, eyeglasses (lenses and frames) with one pair per year, eyeglass lenses with one pair per year, and eyeglass frames with one frame per year.
Dental Services See details
Dental services include coverage for oral exams (2 visits), dental x-rays (2 per year), prophylaxis (cleaning) (1 every six months), and fluoride treatments (1 every six months). Orthodontic, endodontics, prosthodontics (removable, fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Premier by Ultimate (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Premier by Ultimate (HMO) plan and require prior authorization and a doctor referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices and Medical Supplies with 20% coinsurance. Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with copays between $25 and $75, and lab services with no copay and up to 20% coinsurance. Therapeutic Radiological Services have a 20% coinsurance, and Diagnostic Radiological Services have a copay of up to $100. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered under the Premier by Ultimate (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. A referral and authorization are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Premier by Ultimate (HMO), but require prior authorization and a doctor's referral. For days 1-20, there is no copay, days 21-40 have a $150 copay, and days 41-100 have no copay. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes a meal benefit for chronic illnesses, but does not cover acupuncture, over-the-counter items, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, or Self-Directed Personal Assistance Services.
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