Which drugs are covered?

The formulary is the list of drugs covered by the Medicare Part D portion of your plan. The formulary does not include the drugs covered through the additional coverage provided by the GIC. For drugs not listed on the formulary, contact SilverScript Customer Care to find out if it is covered. TTY users should call 711.

The formulary may change throughout the year. Drugs may be added, removed or restrictions may be added or changed. These restrictions include:

  • Quantity Limits (QL) For certain drugs, SilverScript limits the amount of the drug that it will cover.
  • Prior Authorization (PA) - SilverScript requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before we fill your prescription. If you dont get approval, SilverScript will not cover the drug.
  • Step Therapy (ST) - In some cases, SilverScript requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, SilverScript will not cover Drug B unless you try Drug A first. If Drug A does not work for you, SilverScript will then cover Drug B.

How will I determine my drug costs?

SilverScript groups each medication into one of three tiers:

  • Generic drugs (Tier 1) – most cost effective drugs to buy. The active ingredients in generic drugs are exactly the same as the active ingredients in brand drugs whose patents have expired. They are required by the Food and Drug Administration (FDA) to be as safe and effective as the brand drug.
  • Preferred Brand drugs (Tier 2) – brand drugs that do not have a generic equivalent and are included on a preferred drug list. They are usually available at a lower cost than Non-Preferred Brand drugs.
  • Non-Preferred Brand drugs (Tier 3) – brand drugs that are not on a preferred drug list and usually are a high cost.

You will need to use your formulary to find out the tier for your drug or if there are any restrictions on your drug, as well as to determine your cost. The amount you pay depends on the drug's tier. If the actual cost of a drug is less than your normal copay for that drug, you will pay the actual cost, not the higher copay amount.

Additional drugs covered by the GIC

The GIC provides additional coverage to cover drugs that are not included on the SilverScript formulary, as well as certain drugs not covered under Medicare Part D, such as:

  • Prescription drugs for anorexia, weight loss or weight gain
  • Prescription drugs for the symptomatic relief of cough or cold
  • Prescription vitamins and mineral products not covered by Part D
  • Prescription drugs for treatment of sexual or erectile dysfunction
  • Certain diabetic drugs and supplies not covered by Part D
  • Prescription drugs for tobacco cessation
  • Part B products, such as oral chemotherapy agents.

These drugs are not subject to the SilverScript appeals and exceptions process and the cost of these drugs will not count towards your Medicare out-of-pocket costs or Medicare total drug costs. There may be other drugs covered by the additional coverage from the GIC. Contact SilverScript Customer Care for details.

Options for Filling Your Prescription 

The plan has a network of pharmacies, including retail, mail-order, long-term care and home infusion pharmacies. To find a network pharmacy near where you live or travel:

You must use a SilverScript network pharmacy, unless it is an emergency.

SilverScript has preferred network retail pharmacies where you can get up to a 90-day1 supply of your maintenance medications for the same copay as mail-order Current preferred network pharmacies include CVS Pharmacy®, Longs Drugs (operated by CVS Pharmacy) and Navarro. You will also be able to get up to a 90-day supply of your maintenance medication at non-preferred network retail pharmacies, but the copay will be three times the retail 30-day supply copay. Cost savings may be lower for those who receive Extra Help. If you qualify for Extra Help, you will get help paying any applicable monthly premium and prescription drug cost sharing (copayment and/or coinsurance information) if you qualify for Extra Help. Medicare or Social Security will periodically review your eligibility to make sure that you still qualify for Extra Help with your Medicare prescription drug plan costs. Your eligibility for Extra Help might change if there is a change in your income or resources, if you get married or become single, or you lose Medicaid.

With SilverScript, in addition to using CVS retail and network pharmacies, you have the convenient option of using CVS Caremark Mail Service Pharmacy™2. This option allows you to have your prescription drugs shipped directly to your home. See the Documents tab above for the mail order service form or call 1-877-876-7214 to have the form sent to you, TTY users should call 711.

You may use an out-of-network pharmacy only in an emergency. If you use an out-of-network pharmacy, you may be required to pay the full cost of the drug at the pharmacy. In this case, attach the detailed receipt to a completed paper claim form and send it for reimbursement processing to SilverScript for prescriptions filled in the United States and its territories and to the GIC for prescriptions filled outside the United States and its territories. You are responsible for your copay and will be reimbursed the plan’s share of the cost.

If you may need to get your prescription filled while you are traveling outside the country, contact SilverScript Customer Care before you leave the U.S. You can request a vacation override for up to a 90-day supply of your medication. If you are traveling outside of the country and have an emergency drug expense, submit your itemized receipt with the completed SilverScript claim form to the GIC at P.O. Box 8747, Boston, MA 02114.

Please note: Veterans Affairs (VA) pharmacies are not permitted to be included in Medicare Part D pharmacy networks. The federal government does not allow you to receive benefits from more than one government program at the same time.

If you are eligible for VA benefits, you may still use VA pharmacies under your VA benefits. However, the cost of those medications and what you pay out-of-pocket will not count toward your Medicare out-of-pocket costs or Medicare total drug costs. You may want to contact the VA Administration to find out the copay for the drugs you get filled at these facilities and also contact SilverScript for the same information so you can compare the two programs and determine the best option for you.

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1 CVS Caremark Mail Service Pharmacy will dispense 90-day supply except in the case of drug-specific exceptions.
The typical number of days after the mail order pharmacy receives an order to receive your shipment is up to 10 days. Enrollees have the option to sign up for automated mail order delivery. If your mail order drugs do not arrive within the estimated time frames please contact us toll-free, 24 hours a day, 7 days a week. Our contact information is listed under the “Contact Us” tab above.


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