How can I join?
Call the New York Enrollment Broker:
1-855-600-FIDA (Toll-free)
TTY/TDD 1-888-329-1541
Participant Services:
1-844-861-FIDA (3432), TTY/TDD: 711

Drug List

About the SWH Drug List | Using the Drug List | Download the Drug List | Changes in the Drug List | Prior Authorization Criteria | Prior Authorization Forms | Step Therapy | Quality Assurance Policies & Procedures | Transition Policy | Medicare-Medicaid Prescription Forms | Information About Accessing Formulary

Formulary

About the SWH Whole Health FIDA Plan Drug List

We have a drug list that lists all of the drugs that we cover. SWH Whole Health FIDA Plan generally covers all the drugs listed in our drug list 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 drug list 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 drug list.

Each year, we will send you a copy of the Drug List, but some changes may occur during the year. To get the most up-to-date information about which drugs are covered, call Participant Services at 1-844-861-FIDA (3432), TTY/TDD: 711. We are open seven days (7) a week, 8 a.m. 8 p.m.

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Using the SWH Whole Health FIDA Plan Drug List

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

Medical Condition

The drugs in this drug list 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. 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. 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 Drug List

Effective November 1, 2018

Download the SWH Whole Health FIDA Plan 2018 Drug List (PDF) in ENGLISH.

Download the SWH Whole Health FIDA Plan 2018 Drug List (PDF) in SPANISH.

Download the SWH Whole Health FIDA Plan 2018 Drug List (PDF) in CHINESE.

2019 Drug List

Download the SWH Whole Health FIDA Plan 2019 Drug List (PDF) in ENGLISH.

Download the SWH Whole Health FIDA Plan 2019 Drug List (PDF) in SPANISH.

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Changes in the SWH Whole Health FIDA Plan Drug List

The SWH Whole Health FIDA Plan Drug List is updated once per month.

Below is a list of changes to the SWH Whole Health FIDA Plan Drug List, effective November 1, 2018.

Download the Medicare Part D Drug List Change Chart (PDF).

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Prior Authorization Criteria

SWH Whole Health FIDA Plan requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from SWH Whole Health FIDA Plan before you fill your prescriptions. If you don’t get approval, SWH Whole Health FIDA Plan 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, please have your prescriber contact SWH Whole Health FIDA Plan at 1-844-861-FIDA (3432), TTY/TDD: 711. We are open 8 a.m. - 8 p.m., seven (7) days a week.

Effective November 1, 2018

Download the SWH Whole Health FIDA Plan 2018 Prior Authorization Criteria (PDF).

2019 Prior Authorization Criteria

Download the SWH Whole Health FIDA Plan 2019 Prior Authorization Criteria (PDF).

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Prior Authorization Forms

To request a prior authorization for a specific drug, please have your prescriber contact SWH Whole Health FIDA Plan at 1-844-861-FIDA (3432), TTY/TDD: 711. We are open 8 a.m. - 8 p.m., seven (7) days a week.

The Prior Authorization Forms are appropriate for use by both SWH Whole Health Plan participants and providers.

Drug Coverage Determination Form (PDF) in ENGLISH

Drug Coverage Determination Form (PDF) in SPANISH

Drug Coverage Determination Form (PDF) in CHINESE

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Step Therapy

In some cases, SWH Whole Health FIDA Plan 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, SWH Whole Health FIDA Plan 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 SWH Whole Health FIDA Plan 2018 Step Therapy Algorithms (PDF).

2019 Step Therapy

Download the SWH Whole Health FIDA Plan 2019 Step Therapy Algorithms (PDF).

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Quality Assurance Policies & Procedures

Medication therapy management programs

If you are a member of SWH Whole Health FIDA 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 SWH Whole Health FIDA Plan participants may be taking drugs that aren't on our drug list or that are subject to certain restrictions, such as prior authorization or step therapy. Participants 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 your Participant Handbook to learn more about how to request an exception. Please contact Participant Services if your drug is not on our drug list, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our drug list next year and you need help switching to a different drug that we cover or requesting a drug list exception.

During the period of time participants are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-drug list drug if those participants need a refill for the drug during the first 90 days of new membership in SWH Whole Health FIDA Plan. If you are a current participant affected by a drug list 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, SWH Whole Health FIDA Plan will provide you with the opportunity to request a drug list exception in advance for the following year.

When a participant goes to a network pharmacy and we provide a temporary supply of a drug that isn't on our drug list, or that has coverage restrictions or limits (but is otherwise considered a Medicare-Medicaid prescription drug), we will cover up to a 90-day supply (unless the prescription is written for fewer days). After we cover the temporary 90-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 participant is a resident of a long term care facility (like a nursing home), we will cover a temporary 98-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 participant is enrolled in SWH Whole Health FIDA Plan (when the participant is a resident of a long-term care facility). If a new participant who is a resident of a long term care facility has been enrolled in SWH Whole Health FIDA Plan for more than 90 days and needs a drug that isn't on our drug list 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 participant pursues a drug list exception.

SWH Whole Health FIDA Plan and its pharmacy vendor will use multiple approaches to ease the transition of new participants who may be on drugs that are not part of the SWH Whole Health FIDA Plan drug benefit or have other restrictions associated with them. This policy specifically applies to non-drug list 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 participant.

A temporary up to 90-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 98 days following an enrollment.

Download the Pharmacy Transition Management (PDF).

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Medicare-Medicaid Prescription Forms

Online Request for Prescription Drug Coverage Determination

Request for Prescription Drug Coverage Determination
 (PDF) in ENGLISH

Request for Prescription Drug Coverage Determination (PDF) in SPANISH

Request for Prescription Drug Coverage Determination (PDF) in CHINESE

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 Redetermination

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Information About Accessing Drug List

2018

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

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

Download important information about accessing the SWH Whole Health 2018 Drug List (PDF) in CHINESE.

2019

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

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

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Last Updated 11/22/2018
H8851_2017_099 Pending CMS Review