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)

 

General Information

Notice of Privacy Practices (English)

Notice of Privacy Practices (Spanish)

Star Ratings (English)

Star Ratings (Spanish)

Prior Authorization Criteria

Part D Formulary Change Chart

High Performance Step Therapy Groups

High Performance Prior Authorization Group Updates

Non-Discrimination Notice (English)

Non-Discrimination Notice (Spanish)

 

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Member Forms

Appointment of Representative Form (English)

Authorization to Release Personal Health Information

Drug Coverage Determination Form (English)

Online Request for Medicare Part D Prescription Drug Coverage 

Medicare Reconsideration Request Form (English)

Online request for Medicare Part D Redetermination 

New York State Health Care Proxy Form

Online Medicare Complaint Form

Personal Medication List (English)

Personal Medication List (Spanish)

Request for Reconsideration of Medicare Prescription Drug Denial (English)

Request for Reconsideration of Medicare Prescription Drug Denial (Spanish)