SOLIS SPF 005 (HMO)
H0982 - 005 - 0
(4 / 5)
SOLIS SPF 005 (HMO) is a Medicare Advantage (Part C) Plan by Solis Health Plans.
This page features plan details for 2022 SOLIS SPF 005 (HMO) H0982 – 005 – 0 available in Orange MAPD.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
SOLIS SPF 005 (HMO) is offered in the following locations.
Plan Overview
SOLIS SPF 005 (HMO) offers the following coverage and cost-sharing.
| Insurer: | Solis Health Plans |
| Health Plan Deductible: | $0 |
| MOOP: | $3,400.00 |
| Drugs Covered: | Yes |
Ready to sign up for SOLIS SPF 005 (HMO) ?
Premium Breakdown
SOLIS SPF 005 (HMO) has a monthly premium of $0. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
SOLIS SPF 005 (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | |||
| 2 (Generic) | $0.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 2 (Generic) | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
SOLIS SPF 005 (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization required) (referral required) |
| Endodontics: | $0 copay (limits may apply) (authorization required) (referral required) |
| Extractions: | $0 copay (limits may apply) (authorization required) (referral required) |
| Non-routine services: | Not covered |
| Periodontics: | $0 copay (limits may apply) (authorization required) (referral required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) (referral required) |
| Restorative services: | $0 copay (limits may apply) (authorization required) (referral required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (referral required) |
| Dental x-ray(s): | $0 copay (limits may apply) (referral required) |
| Fluoride treatment: | $0 copay (limits may apply) (referral required) |
| Oral exam: | $0 copay (limits may apply) (referral required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0-90 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0-90 copay (referral required) |
| Lab services: | $0-90 copay (referral required) |
| Outpatient x-rays: | $0-90 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $75 copay per visit (always covered) |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $10 copay (authorization required) (referral required) |
| Routine foot care: | $10 copay (authorization required) (referral required) |
Ground ambulance
| $200 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered |
| Hearing aids: | $0 copay (limits may apply) (authorization required) (referral required) |
| Hearing exam: | $0 copay (referral required) |
Hospital coverage (inpatient)
| $50 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) (referral required) |
Hospital coverage (outpatient)
| $75 copay per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $3,400 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $50 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $20 copay (referral required) |
| Outpatient group therapy visit: | $20 copay (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $30 copay (referral required) |
| Outpatient individual therapy visit: | $30 copay (referral required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (referral required) |
Rehabilitation services
| Occupational therapy visit: | $10-40 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $10-40 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $160 per day for days 21 through 100 (authorization required) (referral required) |
Transportation
| $0 copay (referral required) |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization required) (referral required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization required) (referral required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization required) (referral required) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization required) (referral required) |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) (referral required) |
| Upgrades: | $0 copay (limits may apply) (authorization required) (referral required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (referral required) |
Ready to sign up for SOLIS SPF 005 (HMO) ?