Utilization Management
Solis Health Plans Utilization Management Department is committed to ensuring that decisions regarding care for our members is based on appropriateness and does not use incentives to encourage barrier to care and service.
Note: Once completed, fax to 833-210-8141
Service Authorization for a Member
Part D Prior Authorization Criteria
This program requests prior approval before receiving a member’s medication to make sure they’re getting a prescription drug that is suitable for the intended use and covered by the prescription benefit.
National Coverage Determinations
Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In some cases, CMS’ own research is supplemented by an outside technology assessment and/or consultation with the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC). In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors based on a local coverage determination (LCD).
