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
To fax a written request for Coverage Determination: Fax toll-free:
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
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
- 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
- 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.
- Access the .
- Access the standard .
If you have questions regarding the prescription drug Coverage Determination process, please
contact us today.