Drug Coverage Determination

Certain drugs require a coverage determination. If your drug requires this action, you, your appointed representative, or your prescribing physician or other prescriber will need to request and receive approval in order for SOLIS Health Plans (HMO) to cover your drug.

Why is a drug coverage determination required?

SOLIS has placed this requirement on selected high-risk or high-cost medications. We want to make sure these medications do not affect with others you take or add to your costs unnecessarily. Coverage determination conditions are established by our Pharmacy and Therapeutics Committee with involvement from providers, manufacturers, peer-reviewed literature, research, and other experts.

To request a drug coverage determination, you, your appointed representative, or your prescribing physician or other prescriber can contact SOLIS in one of the following ways:

• Ask your prescribing physician or other prescriber to submit the request for you

Your prescribing physician or other prescriber may call our Pharmacy Coverage Determination Review team at 1-833-615-9259and request a coverage determination request over the phone. We are available to take your prescriber’s call Monday to Friday, 8 a.m. to 5p.m.

Alternatively, your prescribing physician or other prescriber can submit a coverage determination request form for you. Your prescriber may call the Pharmacy Coverage Determination Review team at the number provided above and request a coverage determination form specifically designed for the drug that is being requested and submit the completed form to us by fax at 1-855-668-8552. This form will include specific questions to ensure all required information is obtained for the review. Your physician can also submit the request for you online by filling out the Coverage Determination Request Form, which is a general form. This form may require for the Pharmacy Coverage Determination Review team to contact your prescriber to obtain additional information that is specific to the drug that is being requested.

For process or status questions, your prescribing physician or other prescriber may call the Pharmacy Coverage Determination Review team at the number listed above.

• Fax or mail the form - You can download a copy of the form below and fax or mail it to SOLIS

Coverage Determination Request Form

Fax number: 1-855-668-8552

Mailing address:

SOLIS Health Plans

Attention: Pharmacy coverage determination review team

PO Box 1039

Appleton, WI 54912-1039

Note: You can also access the Drug Determination Request Form at the CMS part D webpage link below: Part D Coverage Determination Request Form (for use by enrollees and providers)