SilverScript Plan Support

SilverScript is committed to your peace of mind by supporting your health and protecting your Medicare Part D rights. Below is information on a variety of member support topics to help you resolve or seek assistance with benefits, coverage exceptions, service issues, grievances and membership changes, as well as programs that can help you pay your Part D costs.

Help Paying for Your Medications

Federal and state assistance is available to help pay for your medications if you qualify. Contact these programs to see if you are eligible:

Medicare’s Extra Help Program


Extra Help is offered by the Social Security Administration to help people with limited income and resources pay for their medications. To see if you qualify for Extra Help:


State Pharmaceutical Assistance Program (SPAP)


Many states offer SPAP assistance to help pay your plan premiums and/or medication copays. Assistance is based on your financial need as well as your medical condition or disabilities. To see if your state offers an SPAP program, see the appendix at the end of your Evidence of Coverage document or click here.

State Health Insurance Assistance Program (SHIP)


Every state offers SHIP assistance by counselors who will address your Medicare concerns and direct you to available resources. To contact your state’s SHIP, see the appendix in your Evidence of Coverage document or click here.

BenefitsCheckup.org

Additional information and assistance with Extra Help as well as a variety of senior-based assistance programs is available from the National Council on Aging. You may log on to their website by clicking here.

Drug Coverage Assistance from SilverScript

You may ask us to make an exception to your coverage in the form of a coverage determination based on your medical need. Types of coverage determinations you may request include:

  • Prior Authorization Exception: Waiving a coverage preapproval
  • Non-Formulary Exception: Covering a drug not on our list of covered drugs
  • Step Therapy Exception: Waving prior medication therapies or “steps”
  • Quantity Limit Exception: Removing a medication quantity restriction
  • Tiering Exception: Lowering your cost by moving your drug to a lower tier

In order for us to make a determination, your doctor or other prescriber will need to explain the medical reasons for the exception request by completing the specific Exception Forms found here. Your doctor or other prescriber may contact SilverScript one of fourways:

  • Electronic Prior Authorization (ePA): visit their local electronic health record (EHR) platform or dedicated ePA portal, such as covermymeds®, Surescripts®, or Novologix®
  • Phone: Call Phone Number1-855-344-0930 (TTY dialTeleType Number 711), 24 hours a day, 7 days a week
  • FAX: 1-855-633-7673, 24 hours a day
  • MAIL: Send all written exception requests to:
    SilverScript Insurance Company
    Prescription Drug Plans
    Coverage Decisions and Appeals Department
    P.O. Box 52000, MC109
    Phoenix, AZ 85072-2000

Returning a Mail Service Pharmacy Order

In certain instances, if you received a mail-ordered medication that you do not need, you may return it for a refund of your copay or coinsurance. Contact SilverScript Customer Care toll free at Phone Number1-866-235-5660, 24 hours a day, 7 days a week, TTY users dial TeleType Number 711, to request a return. If approved, you will be sent a prepaid package for returning your medication. Your refund check will be processed and mailed to you after the returned medication is received. Please keep in mind we cannot approve medication returns if:

  • You initiated the order either by:
    1. contacting Customer Care to place the order,
    2. through the Interactive Voice Response (IVR) system,
    3. online at Caremark.com
    4. through our text messaging system.
    5. sending us your prescription and order form through the mail
  • Your doctor or other prescriber sent in a prescription, and you gave authorization to process the order through your primary communication method.
  • Your doctor or other prescriber instructed you to discontinue taking the medication after the order had already been processed.
  • You are requesting to return an order more than 30 days after the date you received it.

Time Frames for Refilling Medications

For your safety, you may only refill your medication prescriptions when a certain amount of your current supply has been used, depending on the type of pharmacy you use.

  • If you use a retail pharmacy, you may request a refill of your medication when you have used 80% of your current month’s supply or 90% of your 90 day supply.
  • If you use our CVS Caremark Mail Service Pharmacy, you may request a mail order refill when 75% of your supply has been used to allow additional time for processing and shipping.
  • Note that if you are taking a controlled substance, you must wait until 80% of your medication has been used before requesting a refill.

Requesting an Early Refill

If you need to refill a medication earlier than expected, SilverScript may authorize an early refill in these situations:

  • You misplace your medication or it becomes damaged. This early refill exception applies one time per calendar year, per medication. For the misplaced or damaged supply, we will cover a replacement refill up to the quantity you initially received. The appropriate copay or coinsurance will apply.
  • You are travelling for an extended period with no access to a network pharmacy. We will cover an early refill for up to a maximum one month supply, per calendar year, per medication. The appropriate copay or coinsurance will apply.

Reimbursement for Drug Costs

To ensure your SilverScript copays and coinsurance costs are correct when filling a prescription—and to avoid paying full price for a covered medication—please be sure your pharmacy has your current SilverScript insurance information on record.

If you paid full price for a covered medication because the pharmacy was not able to submit a claim to us, you may request reimbursement for the amount we should have paid by submitting a paper reimbursement claim. If approved, you can expect to receive a reimbursement check in the mail within 30 days after submitting a paper claim.

Ending your SilverScript Membership

If circumstances require you to end your membership in a SilverScript Part D plan, you may do so during these enrollment periods:

  • Annual Enrollment Period (AEP): Each year Medicare’s AEP begins October 15 and ends December 7. During this time, Medicare allows you to end your membership with a Part D plan. Your request to leave a plan during the AEP takes effect January 1st of the following year.
  • Special Enrollment Period (SEP): In certain situations, such as moving out of your plan’s service area or taking residence in a long-term care facility, you may end your membership without waiting for the AEP. Click here to see the list of circumstances that qualify for an SEP or visit the Medicare website at www.medicare.gov.
  • Note that if you move out of state, you will lose your SilverScript membership, as it does not transfer from state to state. To resume coverage, you will need to re-enroll in the SilverScript plan that services your new state. To avoid coverage interruptions, we encourage you to contact SilverScript Customer Care toll free at Phone Number1-866-235-5660, 24 hours a day, 7 days a week, TTY users call TeleType Number 711, for enrollment guidance if you are planning to move out of state.

Coverage Determinations Process

SilverScript also supports you by providing you the opportunity to request and receive a written explanation (Coverage Determination) about your benefits. This includes your right to request decisions about exceptions to coverage, to waive a requirement or lower your cost for a certain drug—all based on medical need as explained by your doctor or other prescriber.

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Appeals Process

An Appeal is your right as a member and beneficiary to ask us to reconsider a decision (redetermination) should you disagree with a coverage or payment decision made by either Medicare or your Part D plan. In addition, the Appeals process offers you several levels of Appeals should you disagree with a redetermination.

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Fraud, Waste and Abuse

Healthcare fraud is often called a victimless crime, but fraud, in addition to waste and abuse, tarnishes the integrity of Medicare and increases costs for everyone. SilverScript is committed to targeting and fighting healthcare Fraud, Waste and Abuse with a dedicated program whose mission it is to protect you and everyone associated with the Medicare Trust Fund.

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Grievances

If you cannot resolve a service issue or complaint about your plan or a network pharmacy by contacting your Part D plan, you have the right to file a formal complaint called a Grievance.

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How to Disenroll

You usually disenroll from a Medicare plan so that you may enroll in another Medicare plan during one of Medicare’s enrollment periods. If you want to disenroll from a Medicare stand-alone prescription drug plan you may do so during the Annual Enrollment Period. If you choose to disenroll at any time and not elect a new plan, you would need to submit a written disenrollment request to your current Part D plan.

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Out-of-Network Coverage

Generally, you may use your SilverScript plan benefits only at pharmacies in your plan’s network. We may extend coverage for covered drugs purchased out of network if, for example, they were purchased for an illness while traveling in an area not served by a nearby in-network pharmacy. You will likely pay more for a covered drug at an out-of-network pharmacy; however, you may be reimbursed according to your plan benefit if we determine coverage should be extended.

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If you have questions about Medicare Part D plan support, please contact us today.