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Medication Restrictions

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.

Refer to the HealthChoice SilverScript Medicare Formulary.

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 medication prior authorization

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

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

For more information, contact the pharmacy benefit managertoll-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 medication 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 pharmacybenefit 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 determinehow 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 medications, refer to the HealthChoice SilverScript Medicare Formulary.