Prescription Drug Coverage Determination
What is a Coverage Determination?
If your pharmacist tells you that a prescription drug is not covered by your plan and you believe it should be covered, you have the right to request a decision from us to cover that drug. The process by which we make this decision is called a Coverage Determination. You may also request a Coverage Determination if a prescription drug is covered, but at a higher cost than you think you are required to pay as a SilverScript member. Other common examples of when a Coverage Determination may be used are in instances of a Prior Authorization restriction or Quantity Limit.
The pharmacist cannot make a Coverage Determination at the pharmacy. The prescription drug Coverage Determination process requires you, your prescriber, or your authorized representative to call or write to your plan asking for a formal decision about your coverage.
Who may ask for a Coverage Determination?
You, your doctor or other prescriber or your authorized appointed representative can ask us for a Coverage Determination. If you authorize a representative to act on your behalf, a copy of the signed Appointed Representative form or Power of Attorney must be submitted.
Coverage Determination Forms
A Coverage Determination form is available for you, your doctor or other prescriber, or your appointed representative to complete. It is preferred, but not required, that your doctor or other prescriber submit requests on the request form provided. Have your doctor or other prescriber complete this form to ensure we have all the necessary information. This saves time and reduces the need to contact your doctor or other prescriber for additional information. We encourage you (and your prescriber) to use this form for the most efficient processing of your request.
For doctors or other prescribers to request a Coverage Determination by Electronic Prior Authorization (ePA): Your doctor or other prescriber should visit their local electronic health record (EHR) platform or dedicated ePA portal, such as covermymeds®, Surescripts®, or Novologix®.
To request a Coverage Determination 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 Coverage Determination: Fax toll-free: 1-855-633-7673.
To mail a written Coverage Determination: Mail your request to:
SilverScript Insurance Company
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000
To submit your request electronically, use the Drug Search and Pricing Tool.
Standard and Expedited Coverage Determination Requests
Standard Coverage Determination Request
If your request is a standard request, we will make our decision within 72 hours of receiving your request or your doctor's or other prescriber's written statement.
Expedited Coverage Determination Request
You have the option to make an expedited request (one that requires a faster response) if you, your doctor or other prescriber believes your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we will give you a decision no later than 24 hours after we receive your request or your doctor's or other prescriber's written statement.
Note: If your doctor or other prescriber requests or supports your request for an expedited Coverage Determination 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 a fast decision.
What if my request for a Coverage Determination is denied?
If we deny your request, we will send you a written explanation. We may deny your request altogether or in part. For example, if we deny your request for payment for a drug you have already received, we may pay nothing or only part of the amount you requested. If a coverage decision denies any part of your request, you have the right to appeal the decision (request a Redetermination).
This chart provides an overview of the Coverage Determination process
You believe your plan should:
- Cover a Part D drug that's not covered by the plan formulary
- Waive a coverage or quantity limit 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
What you or your prescriber can do
Request a Coverage Determination from your plan. Your request can be made by phone, fax, electronically or in writing.
You may file a standard request or ask for an expedited request.
What your plan will do
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 of receipt or within 72 hours of your doctor or other prescriber’s written statement. Expedited requests (if granted) are answered within 24 hours or receipt or within 24 hours of your doctor or prescriber’s written statement.
If you have questions regarding the prescription drug Coverage Determination process, please contact us today.