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
Explanation of Coverage (EOC) (English)
Explanation of Coverage (EOC) (Spanish)
Annual Notice of Changes (ANOC) (English)
Annual Notice of Changes (ANOC) (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)
Non-Discrimination Notice (English)
Non-Discrimination Notice (Spanish)
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)