Prescription Drug Coverage

Participants have a $0.00 co-pay for all their covered medications. 

  • You pay a $0 annual deductible.
  • You pay a $0 premium because of your eligibility for Medicaid coverage.
  Tier 1
Preferred Generic
Tier 2
Preferred Brand

Tier 3

Non-Part D Prescription Medications

Non-Part D OTC Medications
per prescription
per prescription
$0.00 per prescription $0.00 per prescription
per prescription
per prescription
$0.00 per prescription  $0.00 per prescription
Catastrophic $0.00 per prescription $0.00 per prescription $0.00 per prescription $0.00 per prescription

Learn more about your prescription medications by using the tools available through our Pharmacy Benefit Manager, Express Scripts' website.

Click here to see your SWH Drug benefit and other information such as:*

  • determine your financial responsibility for a drug, based on pharmacy benefit;
  • order a refill for an existing and unexpired mail-order prescription;
  • find the location of an in-network pharmacy based on a proximity search by zip code;
  • determine potential drug to drug interactions;
  • determine a drug's common side effects and significant risks; and
  • determine the availability of generic substitutes.
* Please note: By clicking this link you will be leaving the Senior Whole Health website.

Medicare/Medicaid Prescription Forms 

Online Request for Prescription Drug Coverage Determination

Request for Prescription Drug Coverage Determination

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

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 through your Interdisciplinary Team (IDT) 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.

Effective October 1, 2019

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

Contract Termination

If your prescription drug coverage is provided under a contract with Medicare, your coverage is not guaranteed beyond the end of the current contract year. In the event that Medicare or SWH Whole Health FIDA Plan terminates or chooses not to renew the contract between SWH Whole Health FIDA Plan and Medicare, as allowed by law, this may end your coverage. If this occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do so within the time period required by Medicare.

Last Updated 10/01/2019
H8851_2017_099 Pending CMS Review