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Formulary

About the Formulary | Using the Formulary | Download the Formulary | Changes in the Formulary | Prior Authorization Criteria | Prior Authorization Forms | Quantity Level Limits Step Therapy | Quality Assurance Policy & Procedures |  Medicare Part D Forms  | Information About Accessing Formulary

Formulary

About the Senior Whole Health Formulary

We have a formulary that 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 careproviders. 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.

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Using the Formulary

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

1.) Search by your medical condition.

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.

2.) Search by the drug name alphabetically.

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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Download the Formulary

2018 Formulary

Comprehensive Formulary

Effective November 1, 2018

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2018 Comprehensive Formulary (PDF).

 

Over-the-Counter (OTC) & Additional Coverage Drug List

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2018 Over-the-Counter (OTC) & Additional Coverage Drug List (PDF) in ENGLISH.

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2018 Over-the-Counter (OTC) & Additional Coverage Drug List (PDF) in LARGE PRINT, ENGLISH.

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2018 Over-the-Counter (OTC) & Additional Coverage Drug List (PDF) in SPANISH.

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2018 Over-the-Counter (OTC) & Additional Coverage Drug List (PDF) in LARGE PRINT, SPANISH.

Download the Senior Whole Health (HMO SNP) and Senior Whole Health NHC (HMO SNP) 2018 Over-the-Counter (OTC) & Additional Coverage Drug List (PDF) in PORTUGUESE.

2019 Formulary

Comprehensive Formulary

Download the Senior Whole Health Senior Care Options (SCO) 2019 Comprehensive Formulary (PDF).

Over-the-Counter (OTC) & Additional Coverage Drug List
Download the Senior Whole Health Senior Care Options (SCO) 2019 Over-the-Counter (OTC) & Additional Coverage Drug List (PDF).

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Changes in 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, 2018.

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

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Prior Authorization Criteria

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.

To request a prior authorization for a specific drug, you, your appointed representative or your prescriber should contact Senior Whole Health Member Services at 1-888-794-7268 (TTY/TDD 711).

Effective November 1, 2018

Download the Senior Whole Health 2018 Prior Authorization Criteria (PDF).

2019 Prior Authorization Criteria

Download the Senior Whole Health 2019 Prior Authorization Criteria (PDF).

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Prior Authorization Forms

To request a prior authorization for a specific drug, you, your appointed representative or your prescriber should contact Senior Whole Health Member Services at 1-888-794-7268 (TTY/TDD 711).

Download the Request for Prescription Drug Coverage Determination Form (PDF) in ENGLISH.

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Quantity Level Limits

For certain drugs, Senior Whole Health limits the amount of the drug that we 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.

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Step Therapy

In some cases, Senior Whole Health 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 may not cover drug B unless you try drug A first. If drug A does not work for you, Senior Whole Health will then cover drug B. The following document provides a list of drugs that require Step Therapy.

Effective November 1, 2018

Download the Senior Whole Health 2018 Step Therapy Algorithms (PDF).

2019 Step Therapy

Download the Senior Whole Health 2019 Step Therapy Algorithms (PDF).

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Quality Assurance Policies & Procedures

Medication therapy management programs

If you are a member of Senior Whole Health and Senior Whole Health NHC and take medications for different medical conditions, you may be eligible to receive free services through our Medication Therapy management program. This program helps you understand your medications and how to use them safely. You can talk with a pharmacist or other health professional and find out how to get the most benefit from your medications. You can ask questions about drug costs, drug reactions, or other problems. You will get your own action plan and medication list after the discussion. These can be shared with your doctors or other healthcare providers.

You may qualify if:
  1. You are being treated for at least three (3) conditions
  2. Take at least five (5) different medications and,
  3. Use medications that cost more than $3,967 for the year
Click here to learn more about our medication therapy management program.

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Medicare Part D Forms 

Online Request for Medicare Part D Prescription Drug Coverage Determination

Download the Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in ENGLISH.

If you are interested in filing an appeal of a denial of medications, please complete the applicable form below or have your physician complete the form.

Download the Request for Redetermination of Medicare Prescription Drug Denial (PDF).

Online Request for Medicare Part D Redetermination


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Information About Accessing Formulary (Drug List)

2018

Download important information about accessing the Senior Whole Health 2018 Formulary (Drug List) (PDF) in ENGLISH.

Download important information about accessing the Senior Whole Health 2018 Formulary (Drug List) (PDF) in SPANISH.

Download important information about accessing the Senior Whole Health 2018 Formulary (Drug List) (PDF) in PORTUGUESE.

Download important information about accessing the Senior Whole Health 2018 Formulary (Drug List) (PDF)
in LARGE PRINT, ENGLISH.

Download important information about accessing the Senior Whole Health 2018 Formulary (Drug List) (PDF) in LARGE PRINT, SPANISH.

2019

Download important information about accessing the Senior Whole Health 2019 Formulary (Drug List) (PDF) in ENGLISH.

Download important information about accessing the Senior Whole Health 2019 Formulary (Drug List) (PDF) in SPANISH.

Download important information about accessing the Senior Whole Health 2019 Formulary (Drug List) (PDF) in PORTUGUESE.

Download important information about accessing the Senior Whole Health 2019 Formulary (Drug List) (PDF)
 in CHINESE.

Download important information about accessing the Senior Whole Health 2019 Formulary (Drug List) (PDF) in LARGE PRINT, SPANISH.

Download important information about accessing the Senior Whole Health 2019 Formulary (Drug List) (PDF) in LARGE PRINT, CHINESE.

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Last Updated 11/22/2018
MA_SCO_2017_099 Approved 10/13/2016