Out-of-Network Coverage for SilverScript Medicare Part D
Out-of-Network Coverage Information
SilverScript has network pharmacies outside of our service area where you can fill your prescriptions using your plan benefit. However, if a network pharmacy is not available, you may need to go to an out-of-network pharmacy. Out-of-network pharmacies may include home infusion therapy, long-term care facility pharmacies, and retail pharmacies that are not in the plan's network. Generally, we cover prescription drugs filled at out-of-network pharmacies only for those circumstances when you are not able to use a network pharmacy, including:
- The prescription is for a medical emergency or urgent care.
- You are unable to get a covered drug in a time of need because there are no 24-hour network pharmacies within a reasonable driving distance.
- The prescription is for a drug that is out of stock at an accessible retail network pharmacy or through CVS Caremark Mail Service PharmacyTM (including high-cost and/or unique drugs).
If we do pay for the drugs you get at out-of-network pharmacies, you may still pay more than you would have paid if you had gone to an in-network pharmacy. Instances where you will receive benefit coverage for a prescribed covered drug include:
- When you are traveling outside of your plan’s service area.
- If you lose or run out of your covered drugs or you become ill and need a covered drug immediately and cannot access a network pharmacy.
- If you cannot obtain a covered drug within your service area in a timely manner due to lack of availability of a participating network pharmacy.
- If your covered drug is provided by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.
- If you are administered a vaccine covered by your plan in a doctor’s office.
- If you must fill a covered prescription that is not regularly stocked at an accessible network retail pharmacy or through CVS Caremark Mail Service Pharmacy.
How to submit a paper claim for a prescription for out-of-network coverage
When you fill a prescription for a covered drug at a network pharmacy, your plan's copay or coinsurance is all you pay, and your claim is automatically submitted to us by the pharmacy. If you use an out-of-network pharmacy for any of the reasons listed above, you will need to pay the full cost for your prescription, and then ask us to reimburse our portion of your cost. Out-of-network pharmacies will not submit a claim to us. We will send payment to you within 30 days after your request is received and approved.
To receive reimbursement for our portion of your cost, you can submit a SilverScript claim form. Submitting a claim creates a record of your purchase, which is applied toward your out-of-pocket costs. Mail the completed claim form along with the receipt for your covered prescription drug to:
SilverScript Insurance Company
Medicare Part D Claim Department
P.O. Box 52066
Phoenix, AZ 85072-2066
We will review the claim form and make an initial out-of-network coverage determination. Your claim will be processed according to your benefit coverage, and you will be notified of the outcome. For more information on initial coverage determinations, limits and financial responsibilities for drugs obtained from an out-of-network pharmacy, please refer to your Evidence of Coverage or call Customer Care toll-free at 1-866-235-5660, 24 hours a day, 7 days a week. TTY users call 711.