2022 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.

2022 Annual Materials

Annual Notice of Changes (ANOC): Describes changes to your SWH plan coverage, costs or service area.
English          Spanish

Summary of Benefits: a summary of what we cover and what you pay. For a complete list of covered services and exclusions, refer to your Evidence of Coverage.
English          Spanish 

Evidence of Coverage (EOC):  your Medicare health benefits and services and prescription drug coverage as a member of Molina Medicare Complete Care.
English          Spanish

 

2022 Provider & Pharmacy Directory

English-Spanish

 

Pharmacy & Prescription Drug Materials

LIS Premium Summary Chart: This chart explains your monthly plan premium if you get Extra Help paying for your prescription drugs.
English          Spanish

Formulary (List of Covered Drugs): a list of drugs covered by our plan.
English          Spanish 

Senior Whole Health Drug Transition Policy

Medicare Part D Coverage Determination Request Form (download and mail or fax form)
English          Spanish

Drugs Requiring Prior Authorization
English-Spanish

Search the formulary drug list here

Search for a pharmacy here

 

2022 Member Information

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.
English          Spanish

Notice of Privacy Practices: This document explains the steps Molina takes to protect your Personal Health Information (PHI).
English          Spanish

Notice of Nondiscrimination: This document explains our policies on nondiscrimination.
English          Spanish

Multi-Language Interpreter Services: This document explains how to get help if you speak languages other than English.