2020 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.

 

2020 Annual Materials

Summary of Benefits (English)

Summary of Benefits (Spanish)

Explanation of Coverage (EOC) (English)

Explanation of Coverage (EOC) (Spanish)

Member Handbook (English)

Member Handbook (Spanish)

LIS Premium Summary Chart

Formulary (List of Covered Drugs) (English)

Formulary (List of Covered Drugs) (Spanish)

 

2020 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)

 

2020 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)

Formulary (List of Covered Drugs) (Spanish)

Part D Formulary Change Chart (Nov. 2020)

Step Therapy Criteria (Nov. 2020)

Prior Authorization Criteria (Nov. 2020)

Non-Discrimination Notice (English)

Request for Reconsideration of Medicare Prescription Drug Denial (English)

Request for Reconsideration of Medicare Prescription Drug Denial (Spanish)

Drug Coverage Determination Form (English)

Online request for Medicare Part D Redetermination 

Online Request for Medicare Part D Prescription Drug Coverage 

 

General Information

Notice of Privacy Practices (English)

Notice of Privacy Practices (Spanish)

Star Ratings (English)

Star Ratings (Spanish)

Non-Discrimination Notice (English)

Non-Discrimination Notice (Spanish)

Part B Prior Authorization Drug List (English)

Part B Prior Authorization Drug List (Spanish)

 

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Member Forms

Appointment of Representative Form (English)

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