Formulary

About the SWH Formulary | Download the Formulary | Using the Formulary | Changes in the Formulary |  Prior Authorization Criteria | Prior Authorization Forms | Quantity Level Limits | Step Therapy

 

About the Senior Whole Health of New York 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 health care 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.


Download the Formulary

2018 Formulary

Effective November 1, 2018

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

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

2019 Formulary

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

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

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Using the Senior Whole Health of New York Formulary

There are two ways to find a 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. Look for the category name in the list and then look under the category name for the drug.

Alphabetical Listing

You can also look for the 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 the drug. Next to the 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 the drug in the first column of the list.

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Changes in the Senior Whole Health of New York 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 NHC (HMO SNP) Formulary, effective November 1, 2018.

Download the Medicare Part D Formulary Change Chart (PDF).


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

Download the Medicare Part D Formulary Change Chart for SWH Whole Health FIDA Plan (PDF).

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Prior Authorization Criteria

Senior Whole Health of New York requires members to get prior authorization for certain drugs. Without approval, Senior Whole Health of New York may not cover the drug. The following document provides a list of drugs that require Prior Authorization.

Effective November 1, 2018

Download the Senior Whole Health of New York 2018 Prior Authorization Criteria (PDF).

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

2019 Prior Authorization Criteria

Download the Senior Whole Health of New York 2019 Prior Authorization Criteria (PDF).

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

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Prior Authorization Forms

Please call the Senior Whole Health of New York Pharmacy Department directly at 617-252-6366 to have a form individualized to the patient faxed to you.

Drug Coverage Determination Form (PDF) in English for Senior Whole Health of New York NHC (HMO SNP) Plan

Drug Coverage Determination Form (PDF) in Spanish for Senior Whole Health of New York NHC (HMO SNP) Plan

Drug Coverage Determination Form (PDF) in English for SWH Whole Health FIDA Plan

Drug Coverage Determination Form (PDF) in Spanish for SWH Whole Health FIDA Plan

Drug Coverage Determination Form (PDF) in Chinese for SWH Whole Health FIDA Plan

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Quantity Level Limits

For certain drugs, Senior Whole Health 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 members to first try certain drugs to treat their medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the member's medical condition, Senior Whole Health Plus of New York may not cover Drug B unless the member tries Drug A first. If Drug A does not work for the member, Senior Whole Health of New York 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 NHC 2018 Step Therapy Algorithms (PDF).

Download the SWH Whole Health FIDA 2018 Step Therapy Algorithms (PDF).

2019 Step Therapy

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

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

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Last Updated 11/28/2018