Part D Formulary Exceptions
and Prior Authorizations
What is a Prior Authorization?
For certain prescription drugs, additional coverage or limit requirements may be
in place to ensure that our members use these drugs in a safe way, while also helping
to control costs for everyone.
We require you to get SilverScript Medicare Part D Formulary Prior Authorization (prior approval)
before certain drugs will be covered under the plan. To receive that approval, you and/or your doctor
must complete and submit a Prior Authorization (PA) form. (Download a PA form by
clicking on the Prior Authorization Form link below.)
Your prescribing doctor will need to tell us the medical reason why the plan should authorize coverage of your
prescription drug. Without the necessary information on the Prior Authorization form,
we may not approve coverage of the drug.
What is a Step Therapy requirement?
A Step Therapy requirement means you must first try one drug to treat your
medical condition before we will cover another drug for that same condition. For
example, if Drug A and Drug B both treat your medical condition, we may require
your doctor to prescribe Drug A first. If Drug A does not work for you, then we
will cover Drug B.
Prior Authorization and Step Therapy Criteria will be coming soon.
Look up your drugs and find out more
To find out if the prescription medications you take are subject to Prior Authorization
or Step Therapy restrictions, type the name of the drug in the “Look-Up” box below.
If your prescription does require Prior Authorization or Step Therapy, please download
and have your prescribing doctor complete a Coverage Determination Request Form. The completed form
may be faxed to us at 1-855-633-7673. You may also submit an electronic request
for a Prior Authorization or Appeal (Redetermination) using our
Drug Search Tool.
You may also find out if a drug you take is subject to additional requirements or
limits by reviewing your SilverScript 2014 formulary.
Or inquire by phone by calling SilverScript Customer Care toll-free at 1-866-362-6212,
24 hours a day, 7 days a week. TTY users call 1-866-552-6288.
Drug Search Tool
What is a Quantity Limit?
Certain covered drugs require a Quantity Limit restriction. That means we will only
cover the drug up to a designated quantity or amount. If your prescribing doctor
feels it is medically necessary to exceed the set limit, he or she must get prior
approval before the higher quantity can be covered. Quantity Limits are generally
used as a safety precaution to prevent certain prescription drugs from being used
What are Exceptions?
As a SilverScript member, you have the right to ask us to make an Exception
to our plan formulary. Examples of formulary Exception requests include asking us
- Cover your Part D drug even if it is not included on our formulary (Formulary Exception
- Waive a restriction (such as a Quantity Limit) on our coverage of a drug (Quantity
- Provide your drug at a lower copayment if there are drugs for your condition at
a lower copayment level. For example, if your drug is included in Tier 3, you can
ask us to cover it at the Tier 2 cost-sharing amount instead. Note: if we grant
your request to cover a drug that is not on our formulary, you may not also request
a higher level of coverage for the same drug. Also, you may not ask us to provide
a higher level of coverage for any Tier 4 (Specialty Tier) drugs (Tier Exception
How will I know if a Prior Authorization, Quantity Limit or Step
Therapy requirement applies to a drug I take?
There are two ways to find out if these restrictions apply to a drug you take:
- Search for the drug online using the Drug Search Tool. Search results will indicate
if any Prior Authorizations, Quantity Limits or Step Therapy requirements apply.
- If you cannot search online, call Customer Care toll-free at 1-866-235-5660, 24
hours a day, 7 days a week. TTY users call 1-866-236-1069.
How do I request an Exception?
The best way to request a drug formulary Exception is with the help of your prescribing
doctor. He or she must provide a written statement that explains the medical reasons
for requesting an Exception. Your doctor can submit a statement to us using a Prior
Authorization form or the coverage determination request form; however, no specific
form is required.
How long before I get an answer to my Exception request?
- For standard Exception requests, we will let you know of our decision within 72
hours after the Exception request form is submitted to us with your doctor’s supporting
- You also have the option to request an expedited Exception request
if your doctor believes your health could be seriously harmed by waiting up to 72
hours for a decision. If the Prior Authorization request form submitted to us with
your doctor’s supporting statement is considered urgent and we agree, we will let
you know of our decision no later than 24 hours.
How do I submit exceptions and prior authorization requests to
- To file a request by phone or to ask for help submitting your request, call Customer
Care toll-free at 1-866-235-5660, 24 hours a day, 7 days a week. TTY users
- To fax your written request, use our toll-free fax number: 1-855-633-7673.
- To submit a standard request in writing, mail to:
SilverScript Insurance Company
Appeals and Coverage Determination
MC109 P.O. Box 52000
Phoenix, AZ 85072-2000
- To submit your request electronically, use the Drug Search Tool.
If we approve your Exception request, our approval is typically valid until the
end of the plan year as long as your prescribing doctor continues to prescribe the
Part D drug for you and it continues to be safe and effective for treating your
condition. If we deny your Exception request, you may ask for a review of our decision
(called a Redetermination) by submitting an Appeal.