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Prescription Drug Coverage

As a Senior Whole Health Member, you receive prescription drug coverage with $0 co-pays and deductibles. When you fill a prescription just show your identification card to the pharmacist.

  • You pay a $0 annual deductible.
  • You pay a $0 premium because of your eligibility for MassHealth Standard coverage.

Initial Coverage: $0 Prescription Drug Costs

Annual Coverage Gap: $0 Prescription Drug Costs

Catastrophic Protection: $0 Prescription Drug Costs

In addition to the drugs covered on the Medicare Part D formulary, Senior Whole Health also covers some Over-the-Counter (OTC) medications and most of the Medicare excluded medications through your Medicaid benefit.

Learn more about your prescription medications by using the tools available through our Pharmacy Benefit Manager, Express Scripts' website.

Click here to see your SWH Drug benefit and other information such as:*

  • determine your financial responsibility for a drug, based on pharmacy benefit;
  • order a refill for an existing and unexpired mail-order prescription;
  • find the location of an in-network pharmacy based on a proximity search by zip code;
  • determine potential drug to drug interactions;
  • determine a drug's common side effects and significant risks; and
  • determine the availability of generic substitutes.

* Please note: By clicking this link you will be leaving the Senior Whole Health website.


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


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.

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).


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 Senior Whole Health terminates or chooses not to renew the contract between Senior Whole Health 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.

Last Updated 11/22/2018
H2224_2014_112 Approved 01/13/2014