SilverScript Pharmacy Benefits

HealthChoice Medicare Supplement Plans

Specialty drugs are usually high-cost drugs that require special handling and extensive monitoring. These types of drugs are available only in a 30-day supply. For copay or coinsurance information, refer to the HealthChoice Medicare Supplement Plans Handbook.

SilverScript Plans

You must purchase your specialty drugs from a HealthChoice SilverScript Network Pharmacy.

Without Part D Plans

You must purchase your specialty drugs from a HealthChoice SilverScript network pharmacy.

HealthChoice SilverScript Medicare Supplement (SilverScript Plans Only)

A transition supply of drugs is made available to provide time for you to change to a formulary drug or request a prior authorization. Up to a 90-day supply is available when:

• You enroll in a Medicare supplement plan.
• Your drug is no longer covered.
• You enter or leave a hospital or other setting such as a long-term care facility.

Other situations may qualify for a transition supply, and under some circumstances, this supply can be extended. In rare instances, such as when a drug is excluded or when a drug is covered under Part B, a transition supply is not available.

For more information on how to obtain a covered transition supply of drug, have your pharmacy contact the pharmacy helpline toll-free at 866-693-4620.

HealthChoice Medicare supplement plans

Usually, your claim is processed electronically at the pharmacy. If your pharmacy has questions, have them contact the HealthChoice SilverScript pharmacy helpline, 7:00 a.m. to 12:00 a.m., 7 days a week including holidays, at:

• SilverScript Plans toll-free 866-693-4620.
  
• Without Part D Plans toll-free 800-364-6331.
• TTY 711.

In some cases, you may need to pay the full cost of your drug and then ask HealthChoice to repay you for its share. You may need to ask for reimbursement when:

• You use a non-Network pharmacy.
  
• You pay the full cost for a drug because you did not have your plan ID card.
• Your drug has a restriction and you decide to purchase the drug immediately.

To ask for reimbursement, send your pharmacy receipt and the appropriate prescription claim form linked below to the pharmacy benefit manager at the address on the form.

SilverScript Plans –Medicare Part D Prescription Claim Form

Without Part D Plans –Prescription Reimbursement Claim Form

Some claims involve another insurance company. You may need to file a claim for benefits to get paid for drugs or other benefits. If your claim involves another insurance carrier or other benefit, you will need to send a copy of the receipt with your claim form.

If your claim is for a covered drug and you followed all plan guidelines, HealthChoice reimburses you for its share of the cost.

If your claim is for a non-covered drug or you did not follow plan guidelines, HealthChoice sends you a letter letting you know the reasons for not sending reimbursement and what your rights are to appeal the decision.

HealthChoice Medicare Supplement Plans – Non-Network Pharmacy Benefits

HealthChoice covers your prescriptions when they are filled at a non-network pharmacy subject to the following provisions.

SilverScript Plans

When you fill your prescriptions at a non-network pharmacy, a reduced benefit applies. In certain emergency situations, your prescriptions can be covered as if they were filled at a network pharmacy. An exception can be made if you cannot access a network pharmacy due to the following emergencies:

• You travel outside the HealthChoice service area and lose or run out of drug or become ill and need a Part D drug.
• You cannot fill a specialty drug timely because it is not in stock.
• There is no network pharmacy within reasonable driving distance with 24/7 service.
• You receive a Part D drug while in an emergency, observation or other outpatient setting.
• Evacuation or displacement from your residence due to a federal declared national disaster or other public health emergency.

You can replace drugs that were lost or damaged due to a declared national disaster or public health emergency. Your pharmacy must contact the pharmacy helpline toll-free at 866-693-4620. The helpline staff will work with your pharmacy to provide early refills or override the maximum supply per fill. You must still pay the applicable copay per fill.

If you must use a non-network pharmacy, you must pay the full cost for your drugs and then file a paper claim for HealthChoice to repay you for its share of the cost. Before you fill a prescription under these circumstances, check for a network pharmacy in your area by contacting the pharmacy benefit manager toll-free at 866-275-5253. TTY users call 711.

Without Part D Plans

When you fill your prescriptions at a non-network pharmacy, a reduced benefit applies. When you use a non-network pharmacy, you pay the full amount and submit your claim to the pharmacy benefit manager for reimbursement.

Before you fill your prescriptions at a non-network pharmacy, when possible, check to find out if there is a network Pharmacy in your area by contacting the pharmacy benefit manager toll-free at 877-720-9375. TTY users call 711.

HealthChoice SilverScript Medicare Supplement – Notice regarding formulary changes

Most formulary changes occur at the beginning of each plan year; however, sometimes formulary changes occur midyear. HealthChoice may:

• Add or remove a drug from the formulary
• Add or remove a coverage restriction
• Replace a brand-name drug with a generic
• Move a drug to a higher or lower tier

If a drug you take is affected by a change, HealthChoice SilverScript is required to notify you at least 60 days before the change, or at the time you request a refill. If you receive notice of a formulary change, work with your physician to switch your prescription to a covered drug. Depending on the type of change, you may be able to request a prior authorization and ask HealthChoice to continue to cover the drug for you.

If the Food and Drug Administration finds a drug is unsafe or a drug is removed from the market, HealthChoice SilverScript immediately removes the drug from our formulary and then notifies you of the change. Your doctor will also know about this change and can prescribe another drug for your condition.

For more information, please contact the pharmacy benefit manager, 7 days a week, 7 a.m. to 12 a.m., toll-free at 866-275-5253. TTY users call 711.

HealthChoice SilverScript Medicare Supplement Plans

Medication Therapy Management (MTM) is a free program for members who suffer from multiple, chronic health conditions and are being treated with multiple drugs. To be eligible for the program, the total costs of your drugs must meet or exceed the annual limit set by Medicare.

If you qualify, you are automatically enrolled in the program and are contacted by an MTM provider. The MTM provider is specially trained in patient counseling and can discuss topics such as:

• Drug use and compliance.
  
• Drug education.
• Health and safety.
• Cost saving measures.

While the program is voluntary, HealthChoice SilverScript encourages eligible members to participate. If you do not wish to participate in the program, you can call the pharmacy benefit manager toll-free at 866-275-5253. TTY users call 711.

Some drugs have restrictions

Some drugs have additional requirements or coverage limits. If there is a restriction on a drug you are taking, your provider must take extra steps in order for HealthChoice SilverScript to cover your drug. Refer to the HealthChoice SilverScript Medicare Formulary.

1. Prior authorization

Prior authorization (PA) is required before HealthChoice will cover certain drugs, even though they are listed in the formularies. Generally, prior authorization is required because the medication:

• Has a very high cost.
  
• Has specific prescribing guidelines.
• Might be covered under Medicare Part B.
• Is generally used for cosmetic purposes.

Requesting a pharmacy prior authorization

A request for prior authorization must be submitted by your physician. Your request must be approved before you fill your prescription. To apply:

1. Have your physician’s office contact the pharmacy benefit manager toll-free at:
   • SilverScript Plans 855-344-0930.
   • Without Part D Plans 800-294-5979.
2. The pharmacy benefit manager will assist your physician’s office with completing a prior authorization form.
3. If your prior authorization is approved, your physician’s office is notified of the approval within 24 to 48 hours. You are also notified in writing.
4. If your prior authorization is denied, your physician’s office is notified of the denial within 24 to 48 hours. You are also notified in writing.

Note: In most cases, a prior authorization is valid for one year from the date it is issued and must be renewed when it expires.

Tier exception (High Option plans only)

If you choose a non-Preferred drug when a Preferred drug is available, you must pay the non-Preferred copay, unless you get a tier exception for a lower copay. Specific medical guidelines must be met, and your physician must supply information to justify your request. Your physician can contact the pharmacy benefit manager toll-free at 855-344-0930.

Non-formulary or excluded drug prior authorization

If you are prescribed a drug that is non-formulary or excluded, you can:

1. Ask your physician for a prescription for a generic (Tier 1) or Preferred (Tier 2) drug that is listed on the formularies.
   
2. Continue your non-covered/non-formulary/excluded drug and pay the full cost.
3. Request a prior authorization to receive your drug at the non-Preferred copay.

For more information, contact the pharmacy benefit manager toll-free at:

• SilverScript Plans 855-344-0930.
  
• Without Part D Plans 800-294-5979.

2. Quantity limits

Due to approved therapy guidelines, certain drugs have quantity limits (QL). Quantity limits can apply to the number of refills you are allowed, or how much of the drug you can receive per fill. Quantity limits also apply if the drug is in a form other than a tablet or capsule. Refer to the HealthChoice SilverScript Medicare Formulary.

3. Limited availability

Certain drugs are subject to limited availability (LA) and can be purchased only at certain pharmacies. For more information, contact the pharmacy benefit manager toll-free at 866-275-5253. TTY users call 711.

4. Part B versus Part D drug

Part B versus Part D drugs (B/D) may be covered by Medicare Part B or Part D depending on the situation. Prior authorization is required to determine how the drug must be billed. Your physician must provide information about the drug's use and the place where the drug is administered.

5. Step therapy

Step therapy (ST) requires you to first try a less costly drug to treat your medical condition before HealthChoice SilverScript covers another drug for that same condition. For example, drug A and B both treat the same medical condition, but drug A is less costly. You must first try drug A, and if it does not work, HealthChoice SilverScript will cover drug B.

For a complete list of restricted drugs, refer to the HealthChoice SilverScript Medicare Formulary.

HealthChoice SilverScript Medicare supplement plans – Accessing Part D drugs during a declared disaster or other public health emergency

Members with Part D can replace lost or damaged drugs if the loss occurred as the result of a declared national disaster or public health emergency.

Your pharmacy must contact the pharmacy benefit manager helpline toll-free at 866-693-4620. This number is also located on the back of your HealthChoice pharmacy ID card. HealthChoice SilverScript will work with your pharmacy to authorize an early refill or override the maximum day's supply per fill. You are still responsible for the applicable copay per fill.

If you need more information, please contact the pharmacy benefit manager toll-free 866-275-5253 . TTY users call 711.

A formulary is a list of covered drugs selected by SilverScript in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. SilverScript will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SilverScript Network Pharmacy, and other plan rules are followed.

You must use network pharmacies to maximize your prescription drug benefit. Benefits, formulary, pharmacy network, and copayments/coinsurance may change on Jan. 1 and from time to time during the year. 

To view a complete list of your discounts and resources, log on to Caremark.com by following these steps below:

1. Go to Caremark.com.
   
2. Create a personal account or use your current log-in to view your prescription drug plan features and more.
   
3. Select the Health Resources tab on the home page.
   
4. Select Discount Programs.