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.

Updated March 1, 2020

Download the Senior Whole Health of New York 2020 Prior Authorization Criteria (PDF).

Updated April 1, 2020

Download the Senior Whole Health of New York 2020 Prior Authorization Criteria (PDF).

Drug Determination Forms

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

Standard Prior Authorization Request Form (PDF)


Last Updated 03/31/2020
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