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The SilverScript Medicare Part D Appeals Process (Redetermination)

What is a SilverScript Medicare Part D Appeal?

If you disagree with a decision we make in response to your original request for a Coverage Determination, you have the right to ask us for a Redetermination by submitting an Appeal. An Appeal is the process of asking us to reconsider our initial Coverage Determination decision. There are additional levels of SilverScript Medicare Part D Appeals available to you if you disagree with a Redetermination.

To request a Redetermination by phone: Call toll-free, 1-866-235-5660, 24 hours a day, 7 days a week. TTY users should call 711.

To fax a written request for Redetermination: Fax toll-free: 1-855-633-7673.

To mail a written request for Redetermination: SilverScript Insurance Company
MC109 P.O. Box 52000
Phoenix, AZ 85072-2000

Standard and Expedited Redetermination Requests

Standard Redetermination Request

We will make our decision on a standard request within 7 days of receipt.

Expedited Redetermination Request

You have the option to make an expedited request (one that requires a faster response) if you or your doctor believe your health could be seriously harmed by waiting up to 7 days for a decision. If your request to expedite is granted, we will give you a decision no later than 72 hours after we receive your request and your doctor's written statement.

Note: If your doctor requests or supports your request for an expedited Redetermination and your doctor indicates that waiting for a standard decision could seriously harm your health or your ability to function, we will automatically give you a fast decision.

  • This chart provides an overview of the Coverage Determination and Appeals process
  • Your request
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  • What you can do
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  • What your plan will do
    • You believe your plan should:
      • Cover a Part D drug that's not covered by the plan formulary
      • Waive a coverage restriction
      • Pay a higher cost-sharing amount for a covered non-preferred drug
      • Pay for a prescription drug you've already purchased
      • Cover a service or item that is not covered by your plan, but you believe should be covered
    • Request a Coverage Determination from your plan. Your request can be made by phone or in writing.

      You may file a standard request or ask for an expedited request.
    • Respond with a Coverage Determination based on our interpretation of how your plan benefits apply to your specific situation.

      Standard requests are answered within 72 hours. Expedited requests (if granted) are answered within 24 hours.
    • Reconsider an unfavorable Coverage Determination
    • Submit an Appeal within 60 days from the date of the notice of the Coverage Determination asking us to reconsider our decision.
    • Respond with a Redetermination based on our interpretation of how your plan benefits apply to your specific situation.
    • Reconsider an unfavorable Coverage Redetermination
    • Request an Appeal conducted by an Independent Review Entity (IRE) not connected with your plan.
    • We will abide by the final outcome of your IRE Appeal.
    • Appeal a Redetermination Decision rendered by the Independent Review Entity (IRE)
    • Submit a request for Reconsideration within 60 days from the date you received the written Redetermination notice from the IRE.
    • We will abide by the final outcome of your Reconsideration by the IRE.

To file a Reconsideration Form by mail, send the form in writing to: Maximus Federal Services
C/O Part D Drug Appeals
3750 Monroe Ave, Suite 703
Pittsford, NY 14534-1302

To Fax a request for Reconsideration Form:
  • Fax number: 1-585-425-5390
  • Toll-Free Fax: 1-866-825-9507

SilverScript Medicare Part D Appeals Process and Plan Performance

As a SilverScript member, you have the right to receive additional plan information from us in a way that works best for you, including:

  • Your plan's financial condition
  • The number of Appeals made by plan members
  • Your plan's Star Performance ratings–including how the plan has been rated by plan members and how it compares to other Medicare prescription drug plans.

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