SOLIS SPF 001 (HMO) Formulary



Below is the 2022 Formulary, or prescription drug list, from Solis Health Plans, Inc. for SOLIS SPF 001 (HMO)( H0982-001). A formulary is a list of prescription medications that are covered under Solis Health Plans, Inc.'s 2022 Medicare Advantage Plan in Florida.

This SOLIS SPF 001 (HMO) plan has a $0 drug deductible.

The Initial Coverage Limit (ICL) for this plan is $7000. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $7000 on covered drugs. (combined amount plus your deductible)

You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart.

In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. SOLIS SPF 001 (HMO) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.




Plan Name:SOLIS SPF 001 (HMO)
Plan ID: H0982-001
Formulary
Provider: Solis Health Plans, Inc.
Plan Year:2022
Premium:$0.00
Deductible:$0
Initial Coverage Limit:$7000
Coverage Area:Florida


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Bacitracin Zinc And Polymyxin B Sulfate
2NANNA7/7NN
Baclofen
1NA$0NANN
Balsalazide Disodium
2NANNANN
Balversa
5NA33%NA30/30YN
Balziva
2NANNANN
Baqsimi
3NA$0NA2/7NN
Baxdela
3NA$0NA60/30YN
Bcg Vaccine
3NA$0NANN
Benazepril Hydrochloride And Hydrochlorothiazide
2NANNANN
Benznidazole
3NA$0NAYN
Benztropine Mesylate
1NA$0NANN
Bepotastine Besilate
2NANNANN
Berinert
5NA33%NAYN
Betamethasone Dipropionate
2NANNA120/30NN
Betamethasone Valerate
2NANNA120/30NN
Betaxolol Hydrochloride
2NANNANN
Bethanechol Chloride
1NA$0NANN
Betimol
3NA$0NANN
Betoptic S
4NA$10NANN
Bexarotene
2NANNAYN
Bexsero
3NA$0NANN
Bicillin C-r 900/300
3NA$0NANN
Bicillin Cr
3NA$0NANN
Bicillin L-a
3NA$0NANN
Biktarvy
5NA33%NANN
Bisoprolol Fumarate
1NA$0NANN
Bisoprolol Fumarate And Hydrochlorothiazide
1NA$0NANN
Bivigam
5NA33%NAYN
Blephamide
4NA$10NANN
Blisovi 24 Fe
2NANNANN
Blisovi Fe 1.5/30
2NANNANN
Boostrix
3NA$0NANN
Bosulif
5NA33%NAYN
Braftovi
5NA33%NA180/30YN
Breo Ellipta
3NA$0NA60/30NN
Breztri
3NA$0NA1/30NN
Briellyn
2NANNANN
Brilinta
4NA$10NANN
Brimonidine Tartrate
2NANNANN
Briviact
4NA$10NAYN
Bromfenac Ophthalmic Solution 0.09%
2NANNA/365NN
Budesonide
2NANNANN
Bumetanide
2NANNANN
Buprenorphine
2NANNA4/28NN
Buprenorphine And Naloxone
1NA$0NA60/30NN
Buprenorphine Hcl
1NA$0NA90/30NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
1NA$0NA90/30NN
Bupropion Hydrochloride
1NA$0NANN
Buspirone Hydrochloride
1NA$0NANN
Butorphanol Tartrate
2NANNA10/30NN
Bydureon Bcise
3NA$0NA/28NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H0982-001

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $7000
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2022 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Q1 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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