Formulary

About the SWH Formulary | Download the Formulary | Using the Formulary | Changes in the Formulary |Prior Authorization Criteria | Prior Authorization Forms | Quantity Level Limits | Step Therapy

 

About the Senior Whole Health Formulary

Our formulary lists all of the drugs that we cover. Senior Whole Health generally covers all the drugs listed in our formulary as long as the drug is medically necessary. Prescriptions are filled at a network pharmacy or through our network mail order pharmacy service. For certain prescription drugs we have additional requirements for coverage or limits on our coverage.

The drugs on the formulary are selected by our plan with the help of a team of health care providers. We select the prescription therapies believed to be a necessary part of a quality treatment program, and both brand name drugs and generic drugs are included on the formulary.


Download the Formulary

2014

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2014 Comprehensive Formulary (PDF) — updated July 2014.

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2014 Comprehensive Formulary in SPANISH (PDF) — updated July 2014.

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2014 Over-the-Counter Formulary (PDF).

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Using the Senior Whole Health Formulary

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Medications. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the index that begins on page 88. The index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list.

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Changes in the Senior Whole Health Formulary

The Senior Whole Health Formulary is updated periodically throughout the year. 

Below is a list of changes to the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) Formulary, effective June 1, 2014.

Download the Medicare Part D Formulary Change Chart (PDF).

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Prior Authorization Criteria

Senior Whole Health requires prior authorization for certain drugs. Without approval, Senior Whole Health may not cover the drug. The following document provides a list of drugs that require Prior Authorization.

Download the 2014 Senior Whole Health Prior Authorization Criteria (PDF) — last updated July 2014.

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Prior Authorization Forms

Please call the Senior Whole Health Pharmacy Department at 617-252-6366 to have a form individualized to the patient faxed to you.

Drug Coverage Determination Form (PDF)

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Quantity Level Limits

For certain drugs, Senior Whole Health limits the amount of the drug that Senior Whole Health will cover. For example, Senior Whole Health provides 34 tablets per prescription for Abilify 10mg. This may be in addition to a standard one-month or three month supply. The following document provides a list of drugs that require Quantity Level Limits.

Download the 2014 Senior Whole Health Quantity Level Limits (PDF) — last updated July 2014.

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Step Therapy

In some cases, Senior Whole Health requires members to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat a member's medical condition, SWH may not cover Drug B unless the member tries Drug A first. If Drug A does not work, Senior Whole Health will then cover Drug B. The following document provides a list of drugs that require Step Therapy.

Download the 2014 Senior Whole Health Step Therapy Algorithms (PDF) — last updated July 2014.

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Last Updated 07/09/2014