Pharmacy and Prescription Benefits
Senior Whole Health covers a comprehensive list of drugs chosen for their effectiveness. We choose these drugs with help from a team of doctors and pharmacists. Your drugs are covered when you show your member ID card at a network pharmacy whenever you get your prescriptions filled.
Senior Whole Health will generally cover any prescription drug listed in our formulary if:
- the drug is medically necessary,
- the prescription is filled at a Senior Whole Health network pharmacy,
- and other plan rules are followed.
What drugs does Senior Whole Health cover?
For the Prescription Drugs you may need:
Important Pharmacy & Prescription Benefits Documents
Changes to the Formulary
Wrap Around Drug List
Over-the-Counter (OTC) Catalog
Rx Mail Order Form
Prior Authorization Grid
Step Therapy Grid
Can the Formulary Change?
We may add or remove drugs from the formulary during the year. Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription. If we remove drugs from the formulary, or add prior authorizations, quantity limits and/or step therapy restrictions on a drug, and you are taking the drug affected by the change, we will notify you of the change at least 30 days before the date that the change becomes effective. However, if a drug is removed from our formulary because the drug has been recalled from the market, we will not give 30 day notice before removing the drug from the formulary. Instead, we will remove the drug from our formulary immediately and notify members about the change as soon as possible.
For more information on covered drugs and how to fill your prescriptions, including obtaining prescriptions at Out-of-Network Pharmacies (see above) and how to get a temporary supply of drugs as a new member, see Transition Policy (above). You can ask Senior Whole Health to make an exception to our coverage rules by completing the Coverage Determination Request form or the Drug Determination Request form (see Member Materials & Forms Page).
What is prior authorization?
For certain drugs, you or your provider need to get preapproval (or prior authorization) from Senior Whole Health before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
See the Prior Authorization Grid (above) for drugs that require prior authorization.
What is step therapy?
In some cases, we require that you first try certain drugs to treat your medical condition before we will cover another drug for that same condition. For example, if Drug A and Drug B both treat the condition but Drug A costs less, you may need to try Drug A first. If Drug A doesn’t work for you, we’ll then cover Drug B.
Can I get help managing my prescriptions (Medication Therapy Management MTM)?
Senior Whole Health’s Medication Therapy Management (MTM) program is a service provided at no cost. MTM is not considered a benefit and is offered to members that meet certain criteria. A pharmacist or other trained health care provider will review your prescription, over-the-counter (OTC) and supplement/herbal medications with you over the phone. The goal of MTM is to help you understand your medicines, resolve side effects and answer questions you may have about your medication.
How do I Qualify for MTM?
Senior Whole Health determines MTM eligibility on a quarterly basis using medical and pharmacy claims information. You qualify for MTM if you meet each of the three criteria below:
1. Have three or more of the following conditions:
- Chronic Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
2. Take at least six drugs from selected classes:
- Blood pressure medicines
- Alpha blockers
- Angiotensin II Receptor Blockers (ARBs)
- Beta Blockers
- Renin Inhibitor
- Calcium Channel Blockers
- Diabetes medicines
- Oral hypoglycemics
- Anticoagulants (blood thinners)
- Antihyperlipidemics (cholesterol-lowering medicines)
- Bronchodilators (for asthma or COPD)
- Inhaled Corticosteroids (for asthma or COPD)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Antianginal agents (chest pain medicines)
- Cardiac glycoside
3. Are likely to incur annual costs for covered Part D drugs equal to or greater than $4,696 in 2022.
In addition to the above criteria, you may also qualify if you are taking certain pain management medications.
Once you meet the criteria, you will be automatically enrolled in the MTM program and mailed a letter with information about the program and how to contact us. We may also call you to schedule an appointment to speak with a pharmacist.
What is discussed during my MTM consultation?
In the comfort of your own home, a pharmacist or other trained health care provider will help you:
- Review all your prescription, over-the-counter (OTC) and supplement/herbal medicines
- Discuss side affects you may have when taking certain medicines
- Answer questions you have about your medicine
- Suggest potential improvements to your medication regimen
- Make a list of your medicines with when and how you should take them
- Create goals for taking your medicine
MTM is performed over the phone and the appointment will last approximately 30 minutes. After the appointment, you will be mailed a Personal Medication List that you can share with your health care providers. You will also be mailed a Medication Action Plan that summarizes what was discussed during your MTM encounter. If the MTM provider has any concerns about your medications, such as drug interactions, your prescribing doctors will be made aware. We encourage you to participate in this Comprehensive Medication Review at least once a year and if possible, before your annual wellness visit with your doctor.
How do I contact Senior Whole Health to participate in MTM?
To participate in the Medication Therapy Management Program, please call (855) 658-0918, TTY/TDD 711, Monday – Friday, 7:00 a.m. – 6:00 p.m., MT.
Check the Member Materials and Forms to see all the standard benefits offered by Senior Whole Health.
Please note: Members can contact the plan for a printed copy of the most recent list of drugs or view the link above. You can contact our Pharmacy team at (888) 665-1328, TTY 711, 7 days a week, 8:00 am to 8:00 pm local time.