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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 2026, 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 Lake, Marion, and Sumter counties. This plan received an overall rating of 4 out of 5 stars in 2026.
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 $185.00. 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 $2500.00 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 features a $0 prescription drug deductible, meaning your coverage begins immediately without any out-of-pocket deductible costs. For Tier 1 preferred generic and Tier 2 generic drugs, there is no copay for a 1-month or 3-month supply at standard pharmacies, and standard mail-order fills for a 3-month supply also have no copay. This plan offers excellent cost savings for those relying on common generic medications. For Tier 3 preferred brand drugs, you will pay a $30 copay for a 1-month supply and a $90 copay for a 3-month supply at standard pharmacies, though you can save with a $60 copay for a 3-month standard mail order. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs carrying a 35% coinsurance for standard pharmacy and mail-order fills, and Tier 5 specialty drugs requiring a 33% coinsurance for a 1-month standard pharmacy supply.
Additional Benefits
Premier by Ultimate (HMO) provides comprehensive medical coverage with affordable out-of-pocket costs, featuring no copays for primary care visits, home health services, and annual preventive care. Specialized services like specialist visits, urgent care, and cardiac rehabilitation require a low copay of just $10, while inpatient hospital stays cost a $170 daily copay for the first five days and no copay thereafter. Emergency room visits carry a $120 copay, and ground ambulance services require a $200 copay, both with no coinsurance. This plan also features robust supplemental benefits, including dental, routine vision, and routine hearing exams with no copay or coinsurance, alongside a $400 annual eyewear allowance and up to $1,000 per ear for prescription hearing aids. Patients can also benefit from no copay on up to 20 one-way transportation trips per year and an $80 monthly allowance for over-the-counter items. For specialized medical needs, diagnostic lab work and x-rays have no copay, while durable medical equipment and dialysis require a 20% coinsurance.
Inpatient Hospital See details
Premier by Ultimate (HMO) partially covers inpatient hospital acute and psychiatric services with no coinsurance, requiring a $170 daily copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization and referrals are required, while additional days, non-Medicare-covered stays, and upgrades are not covered.
Outpatient Services See details
Premier by Ultimate (HMO) covers outpatient services with no coinsurance, featuring copays of $75 to $150 for outpatient hospital services, $150 per stay for observation services, and $25 for ambulatory surgical center services. Outpatient substance abuse sessions require a $20 copay with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Premier by Ultimate (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization and a referral are required to receive this care.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Premier by Ultimate (HMO), with ground ambulance services requiring a $200 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay. Transportation services are partially covered, providing up to 20 one-way trips per year to plan-approved locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Premier by Ultimate (HMO) covers emergency services with a $120 copay and no coinsurance, and urgently needed services with a $10 copay and no coinsurance, with both copays waived if admitted to the hospital within 24 hours. Worldwide emergency services are covered up to a $50,000 maximum with a $100 copay and no coinsurance, though worldwide urgent care and emergency transportation are not covered.
Primary Care See details
Premier by Ultimate (HMO) covers primary care, physical therapy, and speech-language pathology with no copay and no coinsurance. Specialist visits, occupational therapy, mental health, and psychiatric services require a $10 copay and no coinsurance, while opioid treatment has no copay and 20% coinsurance; chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Premier by Ultimate (HMO) with no copay and no coinsurance for covered benefits, though some services require referrals or prior authorization. Covered options include health education, fitness benefits, and kidney disease education, while annual physical exams, in-home safety assessments, personal emergency response systems, and medical nutrition therapy are not covered.
Hearing Services See details
Premier by Ultimate (HMO) covers hearing services with no copay and no coinsurance, which includes one routine hearing exam and one fitting evaluation per year. Prescription hearing aids are partially covered with no copay or coinsurance up to $1,000 per ear annually, but OTC hearing aids and inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
Vision services are partially covered by Premier by Ultimate (HMO) with no deductibles, offering one routine eye exam annually with no copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no coinsurance and a $400 annual allowance for contacts or one pair of eyeglasses, though lens upgrades require a $30 to $50 copay.
Dental Services See details
Dental services are partially covered by Premier by Ultimate (HMO) with no copay and no coinsurance for all covered services, although prior authorization is required for some procedures. Covered benefits include oral exams, cleanings, x-rays, fluoride, restorative care, periodontics, and oral surgery, while other diagnostic or preventive services, endodontics, prosthodontics, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Premier by Ultimate (HMO) with no copay, though prior authorization is required. Medicare Part B insulin drugs require a $35 copay and no coinsurance, while Medicare Part B chemotherapy and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under Premier by Ultimate (HMO) with no copay and a 20% coinsurance. Both prior authorization and a referral are required to receive these services.
Medical Equipment See details
Medical Equipment is covered by Premier by Ultimate (HMO) with no copay, though durable medical equipment, prosthetic devices, and medical supplies require a 20% coinsurance and prior authorization. Diabetic equipment features no copay and no coinsurance, but diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Premier by Ultimate (HMO) covers diagnostic and radiological services, requiring prior authorization and referrals. Lab services and outpatient X-rays are offered with no copay, while diagnostic tests carry a $25 to $150 copay, diagnostic radiology starts at a $25 copay, and therapeutic radiology requires a 20% coinsurance.
Home Health Services See details
Premier by Ultimate (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization and a referral are required to receive care.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Premier by Ultimate (HMO) with a $10 copay and no coinsurance, subject to prior authorization. Although some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Premier by Ultimate (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and days 41 through 100, and a $150 daily copay for days 21 through 40. Prior authorization and referrals are required for these services, and additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Premier by Ultimate (HMO) partially covers other services with no copay and no coinsurance, which includes chronic illness meal benefits and up to $80 monthly for over-the-counter items via reimbursement. Acupuncture and other additional services are not covered under this plan.
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