Utilization Management

The Utilization Management Department at Solis Health Plans 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. For our Affirmative Statement, please click here.

To request a Service Authorization for a member, please download our form here and fax to 833-210-8141.

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. You can find that criteria here:

2024 Part D Prior Authorization Criteria

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). To access NCD updates from CMS, click here.