2019 SilverScript’s Medicare Part D Formulary Exceptions and Prior Authorizations
What is a Prior Authorization?
For certain prescription drugs, additional coverage 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 or other prescriber must complete and submit a Prior Authorization.
Your prescribing doctor or other prescriber will need to tell us the medical reason why the plan should authorize coverage of your prescription drug by answering a series of criteria questions. 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 or other prescriber to prescribe Drug B first. If Drug B does not work for you, or your doctor or other prescriber indicates why you cannot use Drug B, then we will cover Drug A.
Look up your drugs and find out more
Prescription medications subject to Prior Authorization or Step Therapy may differ between the SilverScript plans. To find out if the prescription medications you take are subject to Prior Authorization or Step Therapy you may review these documents, which explains our prior authorization and step therapy restrictions for SilverScript plans. You can also use our Drug Pricing Quote Tool to find eligibility criteria by clicking Coverage Details for each drug.
If your prescription does require Prior Authorization or Step Therapy, please download and have your prescribing doctor or other prescriber 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 Pricing Quote Tool.
You may also find out if a drug you take is subject to additional requirements or limits by reviewing your SilverScript formulary or by calling SilverScript Customer Care toll-free at 1-866-362-6212, 24 hours a day, 7 days a week. TTY users call 711.
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 or other prescriber 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 excessively.
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 to:
- Cover your Part D drug even if it is not included on our formulary (Non-Formulary Exception Request).
- Waive a restriction, such as a Quantity Limit, on our coverage of a drug (Quantity Exception Request).
- 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 4, and there are drugs to treat your condition in Tier 3, you can ask us to cover it at the Tier 3 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 5 (Specialty Tier) drugs (Tier Exception Request).
How will I know if a Prior Authorization, Quantity Limit or Step Therapy restriction applies to a drug I take?
To find out if these restrictions apply to a drug you take:
- Search for the drug online using the Drug Pricing Quote Tool or review your SilverScript Print Formulary. The search results and formulary drug list will indicate if any Prior Authorizations, Quantity Limits or Step Therapy requirements apply.
- Call Customer Care toll-free at 1-866-235-5660, 24 hours a day, 7 days a week. TTY users call 711.
How do I request an Exception?
The best way to request a drug formulary Exception is with the help of your prescribing doctor or other prescriber. He or she must provide a written statement that explains the medical reasons for requesting an Exception. Your doctor or other prescriber can submit a statement to us using an Exception Form or the coverage determination request form; however, no specific form is required.
How long will it be 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 upon receipt to us with your doctor or other prescriber’s supporting statement.
- You also have the option to request an expedited Exception request if your doctor or other prescriber believes your health could be seriously harmed by waiting up to 72 hours for a decision. If the Exception request form submitted to us with your doctor or other prescriber’s supporting statement is considered urgent, we will let you know of our decision within 24 hours upon receipt.
How do I submit an Exception or Prior Authorization request to SilverScript?
- 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 call 711.
- 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
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000
- To submit your request electronically, use the Drug Pricing Quote Tool.
- If we approve your Exception request, our approval is typically valid until at least the end of the plan year, as long as your prescribing doctor or other prescriber 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.