Drug Benefits

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Formulary

About the Senior Whole Health Formulary

We have a formulary that lists all of the drugs that we cover. SWH 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

2012
Download the Senior Whole Health of Massachusetts 2012 Abridged Formulary (PDF)

Download the Senior Whole Health of Massachusetts 2012 Comprehensive Formulary (PDF)

To download the formulary, 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.

To search an Adobe PDF file using Adobe Acrobat Reader, click on the "Search" icon (the button with the binoculars) on the Acrobat file toolbar or choose "Edit > Search" from the Acrobat menu. In the "Search PDF" window that opens, type in the word or phrase you are looking for and click on "Search".

The cursor will jump to the first place in the document that word or phrase appears and a search results box will also appear listing all the occurrences of that word or phrase. You can jump to any particular instance of the word or phrase by clicking on that item in the results box. You can also use the "Edit > Search Results > Next Result" or "Edit > Search Results > Previous Result" in the Acrobat menu to navigate forwards or backwards to the next item.

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 59. 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.

Changes in the Senior Whole Health Formulary

The SWH Formulary is updated periodically throughout the year. Below is a list of changes that have been made to Massachusetts' 2011 Formulary:

There are no changes at this time.

To download the formulary changes, 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.

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.

Prior Authorization Forms

Please call the SWH Pharmacy Department directly at 617-252-6366 to have a form individualized to the patient faxed to you.

Formulary Exceptions Sheet- Non Formulary Requests (PDF)

EPO New Start Prior Authorization Request Form (PDF)

EPO Renewal Prior Authorization Request Form (PDF)

To download the SWH Prior Authorization forms, 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.

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