Prior Authorization Forms

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 us before you fill your prescriptions. If you don't get approval, we may not cover the drug.

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

The following document provides a list of drugs that require Prior Authorization. The Prior Authorization Forms are appropriate for use by both SWH Whole Health Plan participants and providers.

Effective October 1, 2019

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

Last Updated 10/01/2019

H8851_2015_099 Approved 12/18/2014