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 prescribing doctor 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 for each request and is valid for one year.

Coverage Determination Forms

A Coverage Determination form is available for you, your physician, or your appointed representative to complete. It is preferred, but not required that your doctor 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 for additional information. We encourage you (and your prescribing doctor) to use this form for the most efficient processing of your request.

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
MC109 P.O. Box 52000
Phoenix, AZ 85072-2000

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.

Expedited Coverage Determination 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 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 and your doctor's written statement.

Note: If your doctor requests or supports your request for an expedited Coverage Determination 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.

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

Helpful Links

If you have questions regarding the prescription drug Coverage Determination process, please contact us today.