Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

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