Pharmacy and Prescription Drugs

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.

Our drug list, called a Formulary lists brand name and prescription drugs we cover, along with any rules or restrictions that apply.
Formulary

Formulary (SCO)

We also cover many OTC (over-the-counter) medications when you have a prescription from your doctor.
Covered (over-the-counter) medications

We use Express Scripts to administer your pharmacy benefits.
Log into the Express Scripts* member portal to:

• Order refills for existing and unexpired mail-order prescriptions
• Learn about potential drug-to-drug interactions
• Understand your drugs common side effects or significant risks
• Find out the availability of generic substitutions
• Review your order history and claims balances
• Set up automatic refills

We use Express Scripts to administer your pharmacy benefits.

*By clicking this link you are leaving the Senior Whole Health website.

How do I find out if my drug is covered?

• Use the Express Scripts search tool to search for your drug by name
Express Scripts search tool*
*By clicking this link, you are leaving the Senior Whole Health website.

• Download the Senior Whole Health Formulary
Formulary

-Search by medical condition: drugs are grouped by the medical conditions they are used to treat. If you know what the drug is used for, look for the category name for your condition, then by drug name. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Medications.

-Search by drug name: use the Index at the book to look for the drug alphabetically. Then go to the page number listed beside the drug name to get information about the drug.

 

How do I know if there are rules or other requirements for getting the drug?

When you find your drug, any rules or special requirements are listed under the column titled Requirements/Limits with an indicator for the type of requirement.

There are generally three (3) types of requirements:

1. Prior Authorization: indicated by PA
2. Quantity Limits: indicated by QL
3. Step Therapy: indicated by ST

You may ask us to waive these requirements by requesting a Formulary Exception.

Learn more about requesting an exception.How do I ask the plan to waive prior authorizations, quantity limits or step therapy for my drug?  

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. Learn more about how to ask for prior authorization here. How do I request prior authorization
Medical pharmacy drugs (J-Code) requiring Prior Authorization List (updated May 1, 2021)
Senior Whole Health Part D Prior Authorization Criteria (updated August 1, 2021)

What are quantity limits?

Senior Whole Health limits the amount of certain medication you can receive within a certain time period. We do this to help ensure safe, cost-effective use of these drugs. For example, if it’s considered safe to take only one pill per day of a drug, we may limit the quantity you’re able to receive to 30 pills in a 30-day period.

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.

There is no step-therapy for Part D drugs in 2021.

 

What if I need a drug that’s not on the formulary?

There may be times when you need a drug that’s not on our formulary or one that is on our formulary but has restrictions. When this happens, you can:

• Talk to your doctor to decide if you should switch to another drug on our formulary.
• Request a formulary exception. Find out how to ask for an exception.
• You may be able to get a temporary supply (called a transition supply) of the drug.

Transition (or temporary) supply
In certain situations, we can provide a temporary supply of your drug. This applies to:

• New Senior Whole Health members within the first 90 days of membership
• Current members affected by an annual formulary change during the first 90 days of the new year
• You may request a formulary exception in advance for the following year

During the transition period, we will automatically process a 30-day refill of your drug. Quantity may be less if your prescription is written for less than a 30-day supply. Once we cover the temporary supply, we generally won’t cover the drug again under our transition policy. You’ll receive a written notice explaining the steps you can take to request an exception or to work with your doctor on finding another drug on our formulary. Learn more about requesting an exception.

For new members residing in long-term care facilities, we’ll cover more than one refill during the first 90 days of membership. If you’ve been enrolled for more than 90 days, we’ll cover a temporary 31-day emergency supply (unless the prescription is for fewer days) while you’re pursuing the formulary exception.

Read the Senior Whole Health Transition Policy

How much do I pay for my prescriptions?

You pay nothing for prescriptions filled at a plan pharmacy. As a Senior Whole Health member who qualifies for Medicaid, you’re entitled to “Extra Help” paying for prescription drugs. That means you have no deductible, no premiums and no copays.

We use Medicare’s Best Available Evidence policy to determine the amount of Extra Help members get.

What is Medicare’s Best Available Evidence Policy?

Individuals with Medicare who are also enrolled in Medicaid qualify for “Extra Help” paying for prescription drugs. This “Extra Help” is also called the Low-Income Subsidy (LIS). We use Medicare’s Best Available Evidence policy to determine the amount our dual-eligible members pay for prescription drugs.
You may review the entire policy here
If you believe you qualify for “Extra Help” or the Limited Income Supplement (LIS) and are paying an incorrect copay amount for your prescriptions, please contact Member Services.

Where can I get my prescriptions filled?

Our network includes many types of pharmacies and drugstores, including mail-order and specialty pharmacies.
You may download and view the Provider and Pharmacy Directory for your county located on the Member Materials pageThe provider network or the pharmacy network may change at any time. As our member, you will receive notice of changes when necessary.

For the most up-to-date list of providers and pharmacies:
• Use the Find a Provider search tool.

• Use the Express Scripts Pharmacy locator tool on the Express Scripts website to search for a network pharmacy near you. www.expressscripts.com*

You may also get your prescriptions delivered by mail.
Learn more* 

*By clicking this link, you are leaving the Senior Whole Health website.

Can I get help managing all my prescriptions?

Senior Whole Health offers a Medication Therapy Management (MTM) program for members with complex medical conditions. The program is free of charge and helps you safely manage all your medications.
The program is for individuals with three (3) or more chronic conditions who take at least eight (8) long-term drugs that cost more than $4,376 a year.
Learn about the MTM program and what it can do for you.

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 Senior Whole Health terminates or chooses not to renew this contract, as is allowed by law, your coverage may end. If this occurs, you will be able to choose another plan without having to pay a late enrollment penalty, as long as you’re within the time period required by Medicare.