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Benefits
Prescription Drug Coverage Benefits
Once you've joined SWH you receive prescription drug coverage with $0 co-pays and deductibles. When you fill a prescription just show your identification card to the pharmacist.
| Prescription Drug Costs | |
|---|---|
| Initial Coverage | $0 |
| Annual Coverage Gap | $0 |
| Catastrophic Protection | $0 |
- You pay a $0 annual deductible.
- You pay a $0 premium because of your eligibility for MassHealth Standard coverage.
In addition to the drugs covered on the Medicare Part D formulary, SWH also covers some OTC (Over-the-Counter) medications and most of the Medicare excluded medications through your Medicaid benefit.
Prior Authorization Criteria
SWH requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from SWH before you fill your prescriptions. If you don’t get approval, SWH may not cover the drug. The following document provides a list of drugs that require Prior Authorization.
Download the 2012 SWH Prior Authorization Criteria (PDF)
To download the SWH Prior Authorization Criteria, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.
Contract Termination
If your prescription drug coverage is provided under a contract with Medicare, your coverage is not guaranteed beyond the end of the current contract year. In the event that Medicare or SWH terminates or chooses not to renew the contract between SWH and Medicare, as allowed by law, this may end your coverage. If this occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do so within the time period required by Medicare.
This plan is available to anyone aged 65 or older who is enrolled in MassHealth Standard.
The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement, for more information contact the plan.
Quantity Level Limits
For certain drugs, SWH limits the amount of the drug that SWH will cover. For example, SWH 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 2012 SWH Quantity Level Limits (PDF)
To download the SWH Quantity Level Limits, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.
Step Therapy
In some cases, SWH requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Senior Whole Health HMO of Massachusetts may not cover drug B unless you try Drug A first. If Drug A does not work for you, SWH will then cover Drug B. The following document provides a list of drugs that require Step Therapy.
Download the 2012 SWH Step Therapy Algorithms (PDF)
To download the SWH Step Therapy Algorithms, you must have Adobe Acrobat Reader installed. If you do not have Adobe Acrobat Reader installed on your computer, click here to download and install a free version of Adobe Acrobat Reader or click on the Adobe Acrobat Reader icon below.
Last modified: 12/22/2011