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: 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: 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 (last updated 2021)

Part D Formulary (last updated April 2021) 
SCO Formulary (last updated April 2021)
Prior Authorization Criteria  (last updated April 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
Hampden and Worcester counties
Middlesex and Essex counties
Norfolk and Suffolk counties

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

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
Hand Sanitizer Sanit Technologies LLC d/b/a Durisan

 

04/16/2021 FDA Website
Premium Orgazen 7000 and Ginseng Power 5000 capsules

 

NS NY Distributor Inc 04/09/2021 FDA Website
Dietary Supplement for male sexual enhancement

 

Yolo Studio 04/09/2021 FDA Website
Dietary Supplement for male sexual enhancement

 

QMART 04/05/2021 FDA Website
Acetaminophen Extra Strength 500 mg Tablets, 100 ct. bottles contained in Health Essentials Kits distributed by Humana

 

A-S Medication Solutions, LLC 04/02/2021 FDA Website
PremierZen Platinum 5000, Triple SupremeZen Gold 3500 Dietary Supplement for male sexual enhancement

 

NANA Collection LLC 04/01/2021 FDA Website
Dietary Supplement for male sexual enhancement

 

Nuri Trading LLC 03/31/2021 FDA Website
Dietary Supplement for male sexual enhancement

 

Ummzy LLC 03/31/2021 FDA Website
Guanfacine Extended-Release Tablets 2mg

 

Apotex Corp. 03/31/2021 FDA Website
Blue 69K Dietary Supplement for male sexual enhancement

 

Bit & Bet LLC 03/30/2021 FDA Website
Dietary Supplement for male sexual enhancement

 

Antoto-K 03/29/2021 FDA Website
Premier Zen Dietary Supplement for male sexual enhancement

 

Namoo Enterprise LLC 03/26/2021 FDA Website
Acyclovir Sodium Injection, 50 mg/mL, 10 mL and 20 mL vials

 

Zydus Pharmaceuticals 03/25/2021 FDA Website
Dietary Supplement for Male Enhancement

 

Imperial 03/25/2021 FDA Website
Telmisartan Tablets, USP, 20 mg

 

Alembic 03/24/2021 FDA Website
Antimicrobial Hand Sanitizer

 

Durisan 03/24/2021 FDA Website
ChloraPrep 3 mL Applicator

 

ChloraPrep; BD ChloraPrep 03/24/2021 FDA Website
Hand Sanitizer

 

Heal the World 03/17/2021 FDA Website