Pharmacy and Prescription Benefits

Senior Whole Health of New York NHC members get prescription drugs and other pharmacy benefits from the plan with no copays or deductibles. Your drugs are covered when you show your member ID card at a network pharmacy whenever you get your prescriptions filled.

We use Express Scripts to administer your pharmacy benefits. Visit the ESI portal* to:

  • Learn about potential drug-to-drug interactions
  • Understand your drugs common side effects or significant risks
  • Find out the availability of generic substitutions
  • Find the location of an in-network pharmacy based on a proximity search by zip code

What drugs does Senior Whole Health of New York NHC cover?

Senior Whole Health of New York NHC covers a comprehensive list of drugs chosen for their effectiveness by Senior Whole Health of New York NHC along with a team of doctors and pharmacists. This drug list, called a formulary, lists brand name and prescription drugs and lists any rules or restrictions that apply. Go to the Member Materials and Forms page to review the formulary.  We also cover many over-the-counter medications through your Healthy You Card benefit. Please visit the Extra Benefits and Services section for more information.

How much do I pay for my prescriptions?

There is no cost for prescriptions when you have them filled at a plan pharmacy. As a Senior Whole Health of New York NHC member, you have no copays, deductibles or premiums.

Where can I get my prescriptions filled?

To fill your prescription, use the Pharmacy Search Tool to find a network pharmacy near you. Our network includes many types of pharmacies and drugstores, including mail-order and specialty pharmacies.

To get your prescriptions delivered by mail, register here.

Once registered, use the link to order refills for existing and unexpired mail-order prescriptions.

How do I use the formulary?

There are two (2) ways to find your drug in the printed formulary (ENG) or formulary (SPN).

  1. Search by medical condition: Drugs are grouped by the medical conditions they are used to treat. If you know what the drug is used for, look for the category name, then the drug name. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Medications.
  2. Search by drug name: Use the index at the back of the book to search by drug name. Drugs in the Index are listed alphabetically. Then, go to the page number listed beside the drug name to get information about the drug.

When you find your drug, any rules or special requirements are listed under the column titled Requirements/Limits. There are generally three (3) types of requirements your drug may have:

  • Prior Authorization: indicated by PA in the Requirements/Limits column
  • Quantity Limits: indications by QL in the Requirements/Limits column
  • Step Therapy: indicated by ST in the Requirements/Limits column

You or your doctor can ask for an exception to these rules. Learn more here.

 

What is a prior authorization?

For certain drugs, you or your provider need to get preapproval (or prior authorization) from Senior Whole Health of New York NHC before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

These drugs will need prior authorization for our plan:

What are quantity limits?

Senior Whole Health of New York NHC limits the amount of certain medication you can receive within a certain time period. We do this to help ensure safe, cost-effective use of these drugs. For example, if it’s considered safe to take only one pill per day of a drug, we may limit the quantity you’re able to receive to 30 pills in a 30-day period.

What if I need a drug that's not on the formulary?

There may be times when you need a drug that’s not on our formulary or that is on our formulary but has restrictions. When this happens, you can:

  • Talk to your doctor to decide if you should switch to another drug on our formulary
  • Request a formulary exception
  • You may be able to get a temporary supply of the drug

Transition Supply (or temporary supply)

In certain situations, we can provide a temporary, or transition, supply of your drug. This applies to:

  • New Senior Whole Health of New York NHC members within the first 90 days of membership
  • Current members affected by an annual formulary change during the first 90 days of the new year

 

During the transition period, we will automatically process a 30-day supply refill of your drug. Quantity may be less if your prescription is written for less than a 30-day supply. Once we cover the temporary supply, we generally won’t cover the drug again under our transition policy. You’ll receive a written notice explaining the steps you can take to request an exception or to work with your doctor on finding another drug on our formulary.

Learn more about requesting a formulary exception.

For new members residing in long-term care facilities, we’ll cover more that one refill during the first 90 days of membership. If you’ve been enrolled for more than 90 days, we’ll cover a temporary 31-day emergency supply (unless the prescription is for fewer days) while you’re pursuing the formulary exception.

Can I get help managing my prescriptions?

Senior Whole Health of New York NHC offers a Medication Therapy Management (MTM) program for members with complex medical conditions. The program is free of charge and helps you safely manage all your medications.

The program is for individuals with three (3) or more chronic conditions who take at least eight (8) long-term drugs that cost more than $4,376 a year.

 

What is Medicare's best available evidence policy?

Individuals with Medicare who are also enrolled in Medicaid qualify for “Extra Help” paying for prescription drugs. This “Extra Help” is also called the Low-Income Subsidy (LIS). We use Medicare’s Best Available Evidence policy to determine the amount our dual-eligible members pay for prescription drugs. You may review the entire policy here.

If you believe you qualify for “Extra Help” or the LIS and are paying an incorrect copay amount for your prescriptions, please contact Member Services.

Contract Termination:
If your prescription drug coverage is provided under a contract with Medicare, your coverage is not guaranteed beyond the end of the current contract year. In the event that Medicare or Senior Whole Health of New York NHC terminates or chooses not to renew this contract, as is allowed by law, your coverage may end. If this occurs, you will be able to choose another plan without having to pay a late enrollment penalty, as long as you’re within the time period required by Medicare.

What is step therapy?

In some cases, Senior Whole Health of New York NHC requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called Step Therapy and it works to make sure you get the safest, most effective and reasonably-priced drug available.

For example, if drug A and drug B both treat your medical condition, Senior Whole Health of New York NHC may not cover drug B unless you try drug A first. If drug A does not work for you, Senior Whole Health of New York NHC will then cover drug B. The following document provides a list of drugs that require Step Therapy.

2020 Step Therapy Algorithm 

What is the Medication Therapy Management Program (MTM)?

Medication Therapy Management (MTM) is a program for members with complex medical conditions. The program helps you to safely manage your medications.

If you have at least three (3) chronic conditions and take at least eight (8) long-term drugs that cost more than $4,376 per year, you may be eligible. The program is not considered a benefit and is free to all members. You’re not required to participate, but we encourage you to.

If you qualify for the program, we’ll send you a letter with more information about the program. If you join, a pharmacist will meet with you to go over all your prescription drugs and give you a Comprehensive Medication Review (CMR). The pharmacist will look at how your medications work together and may suggest ways to make it easier for you to take them. You’ll get a Personal Medication List (PML) with instructions you can share with your doctors and caregivers. The appointment should last about 20 minutes.

As part of the CMR, the pharmacist may also help you with specific drug-related issues, called a Targeted Medication Review (TMR). The TMR will identify any drug therapy issues and may recommend alternatives to your provider. If you are unable to travel to a pharmacy, contact Member Services to schedule a telephone medication review with a pharmacist.

You can ask your pharmacist if they are an OutcomesMTM pharmacist. OutcomesMTM works with Senior Whole Health of New York NHC to provide this service. If your pharmacy doesn’t participate or you want to speak to another pharmacist, please call Member Services. If you choose another pharmacy for this service, you can still continue to fill your prescriptions at the pharmacy you currently use.

*Qualifying chronic conditions include: Rheumatoid arthritis, arthritis, chronic heart failure (CHF), diabetes, dyslipidemia, hypertension, chronic lung disorder, chronic obstructive pulmonary disease (COPD).

Information about Medication Therapy Management (English)

Personal Medication List form (English).

Personal Medication List form (Spanish)

How do I appeal a decision you made about my prescription drug?

Our members have the right to appeal any decision we make that terminates, suspends, delays, reduces or denies a prescription drug or service. Requesting an appeal means asking us to reconsider – and possibly change – the decision we made. This is called a Level 1 appeal.

A provider or family member may file an appeal on your behalf if they have the member’s written consent to do so. If you want someone other than your provider to act on your behalf, please complete this Appointment of Representative Form along with your appeal form.

Appointment of Representative Form (English)

Appointment of Representative Form (Spanish)

To appeal our decision to deny your Medicare Part D prescription drug(s) request:

  1. Phone: Call Member Services at 1-877-353-0185 (TTY 711)
  2. Write: Write to us or download and complete the Request for Redetermination Form

Request for Redetermination Form (English)

You can send it to:

SWH of NY NHC
Attn: Appeals
15 MetroTech Center, 11th Floor

Brooklyn, NY 11201

  1. Fax: You can fax your letter and/or the request form to us at 1-888-251-7823
  2. Online: You may complete this online form and submit it here:  Request for Redetermination Form
  • If you ask for a standard appeal, we must give you our answer within 7 calendar days after we receive it. You may appeal by phone or in writing.
  • If you request a “fast” appeal, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires it.

 

See Chapter 9 of the Evidence of Coverage for more details.


 

If the plan denies my appeal for a prescription drug, is there anything else I can do?

If your appeal is denied, you have the right to make additional appeals. If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process. Learn more about your rights by visiting the CMS web page on making appeals. You may also see Chapter 9 of the Evidence of Coverage for more details.

For a Level 2 Medicare Part D drug appeal,  you must use the Medicare Request for Reconsideration form– Second Level of Appeal. Your appeal will not be decided by SWH of NY NHC, It will be reviewed by a qualified independent contractor of CMS, called C2C Innovative Solutions. They decide whether the decision we made should be changed. You may send your Level 2 appeal request to:

Standard Mail:                                                                 Courier or Tracked Mail (e.g. FedEx or UPS):

C2C Innovative Solutions, Inc.                                    C2C Innovative Solutions, Inc.

Part D Drug Reconsiderations                                     Part D Drug Reconsiderations

P.O. Box 44166                                                            301 W. Bay St., Suite 600

Jacksonville, FL 32231-4166                                        Jacksonville, FL  32202

Or use their toll free fax: 1-833-710-0580

Learn more about C2C Innovative Solutions at https://www.c2cinc.com//Appellant-Signup.

 

You may request a standard or fast Level 2 appeal of your Medicare Part D prescription drug(s):

1. Standard Level 2 appeal:

  • For a drug you have not received yet, the independent contractor will answer your appeal within 7 calendar days after it receives your appeal.
  • For a drug you already bought and want to be repaid, the independent contractor must answer your appeal within 14 calendar days after it receives your request.

 

2. Fast Level 2 appeal:

  • Your health must require it.
  • If the independent contractor agrees to give you a “fast appeal,” they must answer your Level 2 Appeal within 72 hours after they receive it.
  • If they say yes to your request, we must provide the drug coverage that they approved within 24 hours after we receive their decision.

See Chapter 9 of the Evidence of Coverage for more details.

For information on how to appeal a denial of Medicare Medical Services, please visit our How Do I page. 

* Please note: By clicking on this link you will be leaving the Senior Whole Health of New York website.