Appeals Process

What is an appeal?
An appeal is a review of an unfavorable coverage determination. You would file an appeal if you wanted us to reconsider a decision on what Part D prescription drug benefits are covered for you or what we would pay for a prescription drug.

How to request an appeal
If you are unhappy with the coverage determination, you can ask for an appeal. The first level of appeal is called a re-determination. There are four additional levels of appeal that you may request.

Please call Customer Care to file a request for re-determination. You may ask us to reconsider even if only part of our decision is not what you requested. Your request for re-determination goes to people who were not involved in the original coverage determination. This helps ensure that we will give your request a fresh look.

How you submit your appeal depends on whether you are requesting reimbursement for a Part D drug you have already received and paid for, or for authorization of a Part D drug you have not yet received.

If your appeal concerns our decision on a Part D benefit that you have not yet received, then you and/or your doctor will first need to decide whether you need a fast appeal. The procedures for deciding on a standard or a fast appeal are the same as those described for a standard or fast coverage determination.

What kinds of decisions can be appealed?
You can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse you for a Part D drug, if you think your reimbursement should have been larger, or if you are asked to pay a different cost-sharing amount than you think is required.

Finally, if we deny your exception request, you can appeal. NOTE: If we approve your exception request for a non-formulary drug, you cannot request an exception to the co-payment we require you to pay for the drug.

Getting information to support your appeal
We will need to gather the information we need to make a decision about your appeal, and we may contact you for assistance. You also have the right to include additional information. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.
You can give us your additional information in any of the following ways:

In writing:
SilverScript Appeals Department
MC109, P.O. Box 52000
Phoenix, AZ 85072-2000

By fax, at: 866-884-9475.

By telephone – if it is a fast appeal – at: 866-235-5660.

You also have the right to ask us for a copy of information regarding your appeal. You can call us at 866-235-5660, or write us at the address listed above.

Who may file an appeal of the coverage determination?
For a standard request, you or your appointed representative may file the request. A fast appeal may be filed by you, your appointed representative, or your prescribing doctor.

Appointing a representative
If you want to name a relative, friend, advocate, doctor, or anyone else to act for you as your appointed representative, you and that person will need to complete and sign the SilverScript Appointment of Representative form. By completing this form you give that person legal permission to act as your appointed representative for your appeal. Please submit this form to our Appeals Department at the address provided in the previous paragraph. If you prefer you may fax the form to the fax number also provided in that section.

How soon must I file my appeal?
You need to file your appeal within 60 calendar days from the date on the notice of our coverage determination. We can give you more time if you have a good reason for missing the deadline. To file a standard appeal, you can send the appeal to us in writing to the SilverScript Appeals Department listed above.

What if I want a fast appeal?
You, your doctor, or your appointed representative may ask us to give a fast appeal (rather than a standard appeal) by calling our Appeal Department at 866-235-5660. Or you may deliver a written request to the address for standard appeals, above or fax it to 866-884-9475.

How does the appeals process work?
There are five levels to the appeals process. At each level, your request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in your favor (giving you some or all of what you have asked for), or it may be completely denied (turned down). If you are unhappy with the decision, there may be another step you can take to get further review of your request. Whether you are able to take the next step may depend on factors including the dollar value of the requested drug.

When you request coverage or payment of a Part D prescription drug from us, we review your request and make a coverage determination. If we deny your request, in whole or in part, you can go on to the first level of appeal by asking us to review our coverage determination. If you are still dissatisfied with the outcome, you can ask for further review. To help ensure a fair, impartial decision, all subsequent levels of appeal are decided by people connected to Medicare or the federal court system.

To become familiar with each level of the Appeals Process, please review your Evidence of Coverage.

How soon will my appeal be decided?
For a standard decision about a Part D drug, including reimbursement for a drug you have already paid for and received, we have up to 7 days after receiving your appeal to give you a decision. We will make it sooner if your health condition requires us to.
If we do not give you our decision within 7 days, your request will automatically go to the second level of appeal, where an independent organization will review your case.

For a fast decision about a Part D drug that you have not received, we have up to 72 hours after we receive your appeal to give you a decision. We will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to Appeal Level 2, where an independent organization will review your case.

Grievances and Appeal Policies
Coverage Determination Process
Grievances

To review this information in your plan Evidence of Coverage, click on Select A Plan of this site's sidebar. Enter a State, Select a Plan, scroll to the bottom of the page and download the Evidence of Coverage for your plan type and area. Grievance and Appeals policies are covered in Section 8.