Member Materials and Forms — 2021

On this page, you can find important documents related to your Senior Whole Health of Massachusetts health plan. Click the links below to download each document.

Annual Materials 2021

Summary of Benefits: A summary of what we cover and what you get from Senior Whole Health. For a complete list of covered services and exclusions, refer to your Evidence of Coverage.

Summary of Benefits Addendum: For SCO (MassHealth Medicaid only) members, this document provides additional information.

Evidence of Coverage (EOC): Your member handbook, or EOC, gives you detailed information about your benefits and services, and all the information you need on working with Senior Whole Health.

(SCO) EOC Addendum: For SCO (MassHealth Medicaid only) members, this document provides additional information.

Part D Formulary (August 2021)
This lists all of the drugs that we cover. The drugs on the formulary are selected by our plan with the help of a team of health care providers.

SCO Formulary (August 2021)
This lists all of the drugs that we cover in our SCO plan. The drugs on the formulary are selected by our plan with the help of a team of health care providers.

Annual Notice of Changes: Describes changes to your SWH plan coverage, costs or service area.

LIS Rider: Describes the extra help you get paying for your prescription drugs.

LIS Premium Summary:  This chart will show you what your monthly premium will be if you get extra help from Medicare to help pay for your Medicare prescription drug plan costs.

Pharmacy & Prescription Drug Materials 

Frequently Used  Forms

Online Request for Medicare Part D RedeterminationOnline Request for Medicare Part D Prescription Drug Coverage Prescription Coverage Determination Form (PDF) 
Medicare Reconsideration Request Form
Medicare Redetermination Request Form
Part D Formulary Change Chart (August 2021)
Part D Formulary (August 2021)

SCO Formulary (August 2021)
Prior Authorization Criteria  (August 2021)
Medical pharmacy drugs (J-Code) requiring Prior Authorization List (updated May 1, 2021)
Medication Therapy Management Program Overview 
Direct Reimbursement Claim Form
Appointment of Representative Form
Health Care Proxy Form
Request for Reconsideration of Medicare Prescription Drug Denial

Provider and Pharmacy Directories 

A list of network providers and pharmacies you may use to get care, services and prescription drugs.

Bristol and Plymouth counties (August 2021)
Hampden and Worcester counties (August 2021)
Middlesex and Essex counties (August 2021)
Norfolk and Suffolk counties (August 2021) 

2021 Behavioral Health Providers 
2021 Dental Health Providers

Other Member Materials

2021 Medicare Star Ratings: The Centers for Medicare & Medicaid Services (CMS) uses a five-star quality rating system to measure the experiences Medicare beneficiaries have with their health plan.
Behavioral Health Services 
Over-The-Counter (OTC) and Additional Coverage Drug List 
Non-Discrimination Notice

 

Health and Education Materials

Telehealth — sometimes called telemedicine — is the use of electronic information and telecommunication technologies to provide care when you and the doctor are not in the same place at the same time. If you have a phone or a device with internet access, you already have everything you need to get medical care or services through telehealth — you may be able to:

  • Talk to your doctor live over the phone or video chat.
  • Send and receive messages from your doctor using chat messaging, email, secure messaging, and secure file exchange.
  • Use remote patient monitoring so your doctor can check on you at home.

Find out how to stay healthy and at home with Telehealth Resources here. (English version)

Mandarin (Chinese version)

Portuguese version

Spanish version

Vietnamese version

According to the CDC, Flu Symptoms Influenza (flu) can cause mild to severe illness, and at times can lead to death. Flu is different from a cold. Flu usually comes on suddenly.

Understand flu symptoms and how to prevent the flu here. (English version)

Mandarin (Chinese version)

Portuguese version

Spanish version

Vietnamese version

 

 

 

 

Recent Drug Recalls 

 

 

DRUG NAME MANUFACTURER RECALL DATE FDA URL
Imperia Elita Vitaccino Coffee presence of undeclared Sibutramine and Fluoxetine

 

Dash Xclusive 05/28/2021 FDA Website
Hand Sanitizer

 

Global Sanitizers 05/25/2021 FDA Website
Hand Sanitizer

 

Dibar Nutricional S. de R.L. de C.V. 05/19/2021 FDA Website
Hand Sanitizer

 

Sanit Technologies LLC d/b/a Durisan 05/17/2021 FDA Website
Medically Minded Hand Sanitizer

 

Global Sanitizers 05/13/2021 FDA Website
Goose Creek, COCO, TKO Hand Sanitizer

 

 

 Scentsational Soaps & Candles, Inc. 05/13/2021 FDA Website
Dibar Labs Hand Sanitizer

 

Dibar Nutricional S. de R.L. de C.V. 05/12/2021 FDA Website
Poseidon Male Dietary Supplement

 

Yamtun7 05/11/2021 FDA Website
Levemir-Tresiba, Fiasp, Novolog and Xultophy  Product Samples

 

Novo Nordisk 05/10/2021 FDA Website
0.5% Bupivacaine Hydrochloride Injection, USP 30 mL and 1% Lidocaine HCl Injection, USP 30 mL

 

Hospira, Inc. 05/04/2021 FDA Website
Sterile Water for Injection, USP, 100 mL Single Dose Glass Fliptop Vial

 

Hospira, Inc. 05/04/2021 FDA Website