Manage your SilverScript Prescription Benefits

The formulary is the list of drugs covered by the Medicare Part D portion of your plan. Additional coverage is provided by Con Edison than 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, and Drug A is just as effective as Drug B, SilverScript may require you to try Drug A first. If Drug A does not work for you, then SilverScript will cover Drug B.

You will need to check the formulary to find out the tier for your drug or if there are any restrictions on your drug.

View formulary

SilverScript groups each medication into one of three 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.

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 Deductible, Initial Coverage, Catastrophic Coverage stage. The amount you pay depends on the drug's tier and whether you are in the Deductible, Initial Coverage, 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.

Through the additional coverage provided by Con Edison, you are covered for certain Part D drugs that are not covered on the SilverScript formulary. You also have coverage for drugs that Medicare will not cover, such as:

• Prescription drugs when used for anorexia, weight loss or weight gain
• 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 the treatment of sexual or erectile dysfunction
• Certain diabetic supplies not covered by Part D
• Prescription drugs for tobacco cessation
• Part B products, such as oral chemotherapy agents

Your deductible or copayments for these drugs will not count toward your Medicare Part D total drug costs or Medicare Part D out-of-pocket costs. Please contact SilverScript Customer Care for any questions regarding your additional coverage from Con Edison.

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:

• Use the Pharmacy Locator Tool
• Call SilverScript Customer Care

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 may also get up to a 90-day supply of your maintenance medications at standard network retail pharmacies, but the copayment will be three times the retail 30-day supply copay.

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 must use a network pharmacy to have your deductible and copayments count toward your Medicare Part D out-of-pocket costs and Medicare Part D total drug costs, unless it is an emergency or non-routine circumstance.

If you use an out-of-network pharmacy, you may have 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 deductible or copayment.

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 Part D out-of-pocket costs or Medicare Part D total drug costs. Each time you get a prescription filled, you can compare your Con Edison benefit through SilverScript to your VA benefit to determine the best option for you.