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Welcome to SilverScript

(Cut Along Dotted Line) 1Internal SilverScript Insurance Company report dated June 2013. SilverScript is a Prescription Drug Plan with a Medicare contract offered by SilverScript Insurance Company. Enrollment in SilverScript depends on contract renewal. Y0080_WEB_71002_2014 CLT

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REQUEST FOR MEDICARE PRESCRIPTION DRUG …

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I request an exception to the plan’s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).* My drug plan charges a higher copayment for the drug my prescriber prescribed than it

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