Which drugs are covered?
The formulary is the list of drugs covered by the Medicare Part D portion of your plan. Additional coverage is provided by California’s Valued Trust (CVT) that covers drugs not on the formulary.
The formulary may change throughout the year. Drugs may be added or 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 don’t 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 four 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.
- High Cost/Specialty drugs (Tier 4) – high-cost biotech and other unique drugs and include both brand and generic drugs.
You will need to check the formulary to find out the tier for your drug or if there are any restrictions on your drug. The amount you pay depends on the drug's tier and whether you are in the Initial Coverage, Coverage Gap or Catastrophic Coverage stage. If the actual cost of a drug is less than your normal copayment for that drug, you will pay the actual cost, not the higher copayment.
Additional drugs covered by California’s Valued Trust (CVT)
California’s Valued Trust (CVT) 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 when used for anorexia, weight loss or weight gain
- Prescription drugs used to promote fertility
- Prescription drugs when used for the symptomatic relief of cough or cold
- Prescription vitamins and mineral products not covered by Part D
- Prescription drugs when used for treatment of sexual or erectile dysfunction
- Prescription drugs for tobacco cessation.
The cost of these drugs will not count towards your Medicare out-of-pocket costs or Medicare total drug costs. Please contact SilverScript Customer Care if you have any questions regarding your additional coverage from California’s Valued Trust (CVT).
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:
SilverScript has preferred network retail pharmacies where you can get up to a 90-day supply of your maintenance medications for the same copayment as mail-order, similar to Maintenance Choice through CVS Caremark. You will also be able to get up to a 90-day supply of your maintenance medication at standard network retail pharmacies, but the copayment will be three times the copayment for a 30-day supply.
Please note: After the mail order pharmacy receives an order, it takes up to 10 days for you to receive the shipment of your prescription drug. You have the option to sign up for automated mail-order delivery.
You may use an out-of-network pharmacy only in an emergency or non-routine circumstance. If you use a pharmacy that is not part of our network, you may be required to pay the full cost of the drug at the pharmacy. In this case, you must complete a paper claim form and send it to the plan to request reimbursement. You will be reimbursed:
- The amount you paid, less your copayment, if the drug is on the SilverScript formulary
- Only for the amount that California’s Valued Trust (CVT) would have paid at a network pharmacy, minus your copayment, if the drug is not on the SilverScript formulary and is paid through the additional coverage provided by California’s Valued Trust (CVT). If the drug costs more at an out-of-network pharmacy, you pay the difference in cost as well as your copayment.
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.
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. Each time you get a prescription filled, you can compare your California’s Valued Trust (CVT) benefit through SilverScript to your VA benefit to determine the best option for you.
SilverScript’s pharmacy network includes limited lower-cost, preferred pharmacies in Alaska; suburban and rural areas of Idaho, Puerto Rico, Washington, and Wyoming; and rural areas of Arkansas, Colorado, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Mexico, North Dakota, Oklahoma, Oregon, and Wisconsin. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call Customer Care (TTY: 711), 24 hours a day, 7 days a week, or consult the online pharmacy directory.
Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays.
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