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
Medicare Part D Appeals available to you if you disagree with a Redetermination.
For doctors or other prescribers to request a Redetermination by electronic prior authorization (ePA) if your coverage determination
was previously requested by ePA: Your provider should visit their local electronic health record (EHR) platform or dedicated ePA
portal, such as covermymeds®, Surescripts®, or Novologix®.
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
To submit your request electronically, use the
Drug Search and Pricing Tool
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
or other prescriber 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
Note: If your doctor’s or other prescriber’s requests or supports your request for an expedited Redetermination
and your doctor or other prescriber indicates that waiting for a standard decision could seriously harm your
health or your ability to function, we will automatically give you an expedited request.
- This chart provides an overview of the Appeals process
- Your request
- What you or your prescriber can do
- What your plan will do
- 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 Reconsideration 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
To request a Reconsideration Form by phone:
To Fax a request for Reconsideration Form:
C/O Part D Drug Appeals
3750 Monroe Ave, Suite 703
Pittsford, NY 14534-1302
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.