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 drugs covered through the additional coverage provided by the World Bank Group.
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 obtain prior authorization for certain drugs. This means that you will need to get approval from us before we fill your prescription. If you do not obtain 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 the cost-sharing tiers for my drugs?
SilverScript groups each medication into one of four tiers:
- Generic drugs (Tier 1) – the 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 available at a high cost.
- High Cost/Specialty drugs (Tier 4) – high-cost biotech and other unique drugs; this includes both brand and generic drugs.
You will need to use your formulary to determine the tier for your drug or to find out whether there are any restrictions on your drug, as well as to determine your share of the cost. The amount you pay depends on the drug's tier and the payment stage you have reached.
Additional drugs covered by the World Bank Group
The World Bank Group has provided additional coverage to cover certain drugs that are not covered by Medicare Part D or that are not included on the SilverScript formulary, but are currently covered on the Retiree Medical Insurance Plan (RMIP) formulary.
These additional 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. However, the cost of these additional drugs will count toward your World Bank Group $1,200 annual out-of-pocket maximum. Please contact SilverScript Customer Care if you have any questions regarding your additional coverage from the World Bank Group.
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 retail pharmacy or the plan’s mail order pharmacy, CVS Caremark Mail Service Pharmacy™.
SilverScript has over 7,000 preferred pharmacies in its network. Similar to Maintenance Choice in your current CVS Caremark plan, you pay the same for a 90-day supply of maintenance medications at preferred network retail pharmacies as you would pay at the CVS Caremark Mail Service Pharmacy.
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 an out-of-network pharmacy, 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 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.
Whether you use a network pharmacy or an out-of-network pharmacy, your copayment or coinsurance will be applied toward your World Bank Group annual out-of-pocket maximum of $1,200.
Prescriptions filled outside the plan’s service area, the United States or U.S. territories, will continue to be covered under your medical plan. You will need to submit a paper claim to Aetna.
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 World Bank Group benefit through SilverScript to your VA benefit to determine the best option for you.
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