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1-877-353-0188 (Toll-free)
TTY/TDD 711
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1-877-353-0185 (Toll-free) 
TTY/TDD 711

Formulary

About the SWH Formulary | Using the Formulary | Download the Formulary | Changes in the Formulary | Prior Authorization Criteria | Prior Authorization Forms | Quantity Level Limits | Step Therapy | LIS Premium Summary Chart | Quality Assurance Policies & Procedures | Transition Policy | Medicare Part D Forms | Information About Accessing Formulary

About the Senior Whole Health Formulary

We have a formulary that lists all of the drugs that we cover. Senior Whole Health of New York 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 healthcare 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.

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Using the Senior Whole Health of New York Formulary

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

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.

Alphabetical Listing

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

Effective November 1, 2018

Download the Senior Whole Health of New York NHC (HMO SNP) 2018 Comprehensive Formulary (PDF) in ENGLISH.

Download the Senior Whole Health of New York NHC (HMO SNP) 2018 Comprehensive Formulary (PDF) in SPANISH.

2019 Formulary

Download the Senior Whole Health of New York NHC (HMO SNP) 2019 Comprehensive Formulary (PDF) in ENGLISH.

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Changes in the Senior Whole Health Formulary

The Senior Whole Health of New York Formulary is updated periodically throughout the year. 

Below is a list of changes to the Senior Whole Health of New York (HMO SNP) and Senior Whole Health of New York 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 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 Senior Whole Health of New York before you fill your prescriptions. If you don’t get approval, Senior Whole Health of New York 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 1-877-353-0185 (TTY/TDD 711).

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).

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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 1-877-353-0185 (TTY/TDD 711).

Drug Coverage Determination Form
 (PDF) in ENGLISH

Drug Coverage Determination Form (PDF) in SPANISH

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Quantity Level Limits

For certain drugs, Senior Whole Health of New York limits the amount of the drug that you can have by limiting how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. 

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Step Therapy

In some cases, Senior Whole Health of New York 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 of New York may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we 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 of New York 2018 Step Therapy Algorithms (PDF).

2019 Step Therapy

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

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LIS Premium Summary Chart

Please click on the link below to view a chart that shows you what your monthly plan premium will be if you get extra help from Medicare to help pay for your Medicare prescription drug plan costs.

2018

Download the Senior Whole Health of New York 2018 LIS Premium Summary Chart (PDF).

2019

Download the Senior Whole Health of New York 2019 LIS Premium Summary Chart (PDF). 


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Quality Assurance Policies & Procedures

Medication therapy management programs

If you are a member of Senior Whole Health of New York 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.
Learn more about medication therapy management.

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Transition Policy

New Senior Whole Health of New York members may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Members should talk to their doctors to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug. See Section 5 of the Evidence Of Coverage booklet under "What is an exception?" to learn more about how to request an exception. Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.

During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in Senior Whole Health of New York. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug. If you need a refill for the drug during the first 90 days of the new plan year, Senior Whole Health of New York will provide you with the opportunity to request a formulary exception in advance for the following year.

When a member goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover. In many cases, where it is clinically appropriate, we may approve the continuation of an important drug that you have been stabilized on. In those situations, you will receive an approval letter.

If a new member is a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days a new member is enrolled in Senior Whole Health (when the member is a resident of a long-term care facility). The total supply will be for a maximum of up to a 98-day supply on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of up to a 98-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If a new member who is a resident of a long-term-care facility has been enrolled in Senior Whole Health for more than 90 days and needs a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

Senior Whole Health and its pharmacy vendor will use multiple approaches to ease the transition of new enrollees who may be on drugs that are not part of the Senior Whole Health drug benefit or have other restrictions associated with them. This policy specifically applies to non-formulary drugs, drugs requiring step therapy, prior authorization or other rules that would limit the immediate access of continuation of an existing drug therapy by a new enrollee.

A temporary 30-day fill will automatically be processed at retail within the first 90 days of a beneficiary's enrollment. In a long term care setting, medications can be filled and refilled up to 90 days following an enrollment.

Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out of network, unless you qualify for out of network access.

Download the Pharmacy Transition Management (PDF).

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Medicare Part D Forms

Online Request for Medicare Part D Prescription Drug Coverage Determination

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

Request for Medicare Part D Prescription Drug Coverage Determination (PDF) in SPANISH

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.

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.

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Last Updated 11/28/2018
H5992_2017_099 Approved 11/04/2016