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Review of Controls at SilverScript Insurance Company to Ensure Adherence to Formularies

Our review of SilverScript Insurance Company (SSIC), a Medicare Part D sponsor, found that SSIC's claims for prescription drug event data generally complied with Federal requirements regarding drugs that are provided to beneficiaries but that are not included in a sponsor's Part D plan formulary (non-formulary drugs). Based on our review of 100 claims, 1 claim was unallowable because the prescription was filled outside the allowable transition fill period. Because this is below the threshold of six errors needed for a statistical projection, we have no findings.

The Part D program allows Part D plan sponsors to choose whether or not they will use a formulary to administer their Part D plans. Sponsors that use a formulary must comply with certain statutory and regulatory requirements governing formulary operation. In certain circumstances, sponsors that use a formulary can submit claims for non-formulary drugs for Part D coverage. If these circumstances are not met, the Part D program does not permit reimbursement for these non-formulary drugs.

This report has no recommendations.

Filed under: Center for Medicare and Medicaid Services