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Prior Authorization Forms

Senior Whole Health of New York requires you, or your physician, to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don't get approval, we 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 of New York 2018 Prior Authorization Criteria (PDF).

2019 Prior Authorization Criteria

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

Drug Determination Forms

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

Download the Drug Coverage Determination Form (PDF) in SPANISH.


Last Updated 11/22/2018
H5992_2015_099 Approved 10/16/2014