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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 Orange, Osceola and Seminole counties. 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 $170.00. 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 $2900.00 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. During the initial coverage phase, you will pay a $0 copay for preferred generic drugs at standard pharmacies, a $35 copay for standard generic drugs, and an $85 copay for preferred brand drugs. For non-preferred drugs, you will pay 33% coinsurance. After your yearly out-of-pocket drug costs reach $2,000, you pay nothing for Part D covered drugs.
Additional Benefits
The Premier by Ultimate (HMO) plan offers comprehensive coverage, including inpatient hospital stays with a $175 copay for days 1-5, and no copay for days 6-90, along with outpatient services, and emergency care. The plan also provides coverage for a variety of services such as primary care, preventive services with no copay, hearing, vision, and dental services. This plan includes additional benefits like ambulance and transportation services, home health services with no copay, and home infusion services. There are some cost-sharing requirements, such as copays for outpatient services, specialist visits, and various therapies, and coinsurance for services like air ambulance, dialysis, and durable medical equipment.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a copay of $175 for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services and observation services with a $195 copay, ambulatory surgical center (ASC) services with a $50 copay, and outpatient substance abuse services with a $10 copay for individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by Premier by Ultimate (HMO) with a $55 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Premier by Ultimate (HMO), with prior authorization required for all ambulance services. Ground ambulance services have a $175 copay, while air ambulance services have a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered for 12 one-way trips per year, using rideshare services, bus/subway, van, medical transport, or other methods. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, 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. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Premier by Ultimate (HMO) plan covers Primary Care Physician Services, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $20 copay, Physician Specialist Services with a $15 copay, Mental Health Specialty Services with a $15 copay, Other Health Care Professional with a $15 copay, Psychiatric Services with a $15 copay, Physical Therapy and Speech-Language Pathology Services with a $20 copay, Additional Telehealth Benefits, and Opioid Treatment Program Services with 20% coinsurance. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Premier by Ultimate (HMO) plan covers preventive services, including Medicare-covered preventive services with no copay, and additional preventive services like health education and smoking cessation counseling. 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, readmission 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 includes coverage for hearing exams, with no deductible and no coinsurance, as well as routine hearing exams and fitting/evaluation for hearing aids, each covered once per year. Prescription hearing aids are covered up to $1,000 per year, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Premier by Ultimate (HMO) covers vision services, including routine eye exams once per year, and eyewear with a combined maximum benefit of $200 per year. Contact lenses are covered, and eyeglasses (lenses and frames) are covered once per year. Upgrades have a copay of $30-$50.
Dental Services See details
The Premier by Ultimate (HMO) plan covers a variety of dental services, including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, and oral and maxillofacial surgery. Endodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay. 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, but require prior authorization and a doctor's 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 Prosthetics/Medical Supplies with 20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a maximum 20% coinsurance and a copay up to $195, Lab Services with no copay and a maximum 20% coinsurance, Diagnostic Radiological Services with a copay between $25 and $195, and Therapeutic Radiological Services with a maximum 20% coinsurance, while Outpatient X-Ray Services have no copay. Prior authorization and a doctor referral are required for all services.
Home Health Services See details
Home Health Services are covered under the Premier by Ultimate (HMO) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by Premier by Ultimate (HMO). Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Premier by Ultimate (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20 and days 41-100, but there is a $150 copay for days 21-40. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Premier by Ultimate (HMO) plan covers a meal benefit for chronic illnesses, but 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, and Self-Directed Personal Assistance Services are not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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