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
Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2015 Comprehensive Formulary (PDF).
Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2015 Over-the-Counter & Enhanced RX Drug List (PDF).
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Using the Senior Whole Health Formulary
There are two ways to find your drug within the formulary:
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 and then look under the category name for your drug.
If you are not sure what category to look under, you should look for your drug in the index at the back of the formulary. 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 November 1, 2014.
Download the Medicare Part D Formulary Change Chart (PDF).
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 2015 Senior Whole Health Prior Authorization Criteria (PDF).
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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.
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.
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.