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Prior Authorization Forms

Senior Whole Health requires you, or your physician, to get prior authorization for certain drugs. This means that you will need to get approval from Senior Whole Health before you fill your prescriptions. If you don't get approval, Senior Whole Health may not cover the drug.

The following document provides a list of drugs that require Prior Authorization.

2016

Effective November 1, 2016

Download the Senior Whole Health 2016 Prior Authorization Criteria (PDF).

2017

Download the Senior Whole Health 2017 Prior Authorization Criteria (PDF).


Download the Drug Coverage Determination Form (PDF) — 2016.

Download the Drug Coverage Determination Form (PDF) — 2017.


Last Updated 11/09/2016
H2224_2013_133 Approved 06/21/2013