2021 Member Materials and Forms

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

 

2021 Annual Materials

Summary of Benefits (English)

Summary of Benefits (Spanish)

Explanation of Coverage (EOC) (English)

Explanation of Coverage (EOC) (Spanish)

Annual Notice of Changes (ANOC) (English)

Annual Notice of Changes (ANOC) (Spanish)

LIS Rider (English)

LIS Rider (Spanish)

LIS Premium Summary Chart  (English)

LIS Premium Summary Chart  (Spanish)

Formulary (List of Covered Drugs) (English) (Last updated September 2021)

Formulary (List of Covered Drugs) (Spanish) (Last updated September 2021)

 

2021 Provider & Pharmacy Directory (English)

Provider & Pharmacy Directory (Bronx)

Provider & Pharmacy Directory (Kings)

Provider & Pharmacy Directory (Nassau)

Provider & Pharmacy Directory (New York)

Provider & Pharmacy Directory (Queens)

Provider & Pharmacy Directory (Westchester)

 

2021 Provider & Pharmacy Directory (Spanish)

Provider & Pharmacy Directory (Bronx)

Provider & Pharmacy Directory (Kings)

Provider & Pharmacy Directory (Nassau)

Provider & Pharmacy Directory (New York)

Provider & Pharmacy Directory (Queens)

Provider & Pharmacy Directory (Westchester)

 

Pharmacy & Prescription Drug Materials

Formulary (List of Covered Drugs) (English) (Last updated September 2021)

Formulary (List of Covered Drugs) (Spanish) (Last updated September 2021)

Part D Formulary Change Chart (English) (Last updated September 2021)

Part D Formulary Change Chart (Spanish) (Last updated September 2021)

Guide to High Risk Medications

Prior Authorization Criteria  (Last updated September 2021)

List of Drugs Requiring Prior Authorization

Medication Therapy Management Program Overview (English)

Medication Therapy Management Program Overview (Spanish)

Request for Reconsideration of Medicare Prescription Drug Denial (English)

Request for Reconsideration of Medicare Prescription Drug Denial (Spanish)

Request for Medicare Prescription Drug Coverage Determination Form (English)

Request for Medicare Prescription Drug Coverage Determination Form (Spanish)

Online request for Medicare Part D Redetermination 

Online Request for Medicare Part D Prescription Drug Coverage 

Direct Reimbursement Claim Form (English)

Direct Reimbursement Claim Form (Spanish)

 

General Information

Behavioral Health Services Flyer

2021 Behavioral Health Providers

2021 Dental Services Providers

Notice of Privacy Practices (English)

Notice of Privacy Practices (Spanish)

2021 Star Ratings (English)

2021 Star Ratings (Spanish)

Non-Discrimination Notice (English)

Non-Discrimination Notice (Spanish)

 

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Member Forms

Appointment of Representative Form  (English)

Appointment of Representative Form (Spanish)

Authorization to Release Personal Health Information  (English)

Authorization to Release Personal Health Information  (Spanish)

Medicare Reconsideration Request Form (English)

New York State Health Care Proxy Form

Online Medicare Complaint Form

Personal Medication List (English)

Personal Medication List (Spanish)

 

Molina Healthcare Acquisition Frequently Asked Questions (FAQs)

 

Molina Healthcare Acquisition FAQs