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How Do I Request a Tiering Exception?

Dear Marci,

I recently started taking a new medication. It’s covered by my Part D plan, but when I went to the pharmacy, I was charged a high copay! What’s going on? How do I fix this?

-Maria (Sacramento, CA)

Dear Maria,

If your Part D plan covers your medication but your copayment is expensive, it could be that the medication is on a high tier. Part D plans use tiers to categorize prescription drugs. Higher tiers are more expensive and have higher cost-sharing amounts. Each plan sets its own tiers, and plans may change their tiers from year to year.

If you can’t afford your copay, you can ask for a tiering exception by using the Part D appeal process. A tiering exception is a way to request lower cost-sharing. To request a tiering exception, you or your doctor must show that the drugs for treatment of your condition that are on lower tiers of your plan’s formulary are ineffective or dangerous for you.

Here is some guidance on requesting a tiering exception:

If you are charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. If your copay is high because your prescription is on a higher tier than other drugs to treat your condition on the formulary, you can ask for a tiering exception.

Note that you can’t request a tiering exception if the drug you need is in a specialty tier. The specialty tier is limited to drugs above a certain dollar amount and plans may not require more than 33% coinsurance for drugs on this tier.

Ask your plan how to send your tiering exception request. It’s usually helpful to include a letter of support from your prescribing health care provider. This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful for you.

If your plan approves your tiering exception request, your drug will be covered at cost-sharing that applies to the lower tier. Normally, an approved exception will be in effect until the end of the current calendar year. If your plan denies your request, it should send you a letter titled Notice of Denial of Medicare Prescription Drug Coverage. You can appeal this decision.

You may wish to consider switching plans during the Fall Open Enrollment Period to a Part D plan that covers your drug with lower cost-sharing. I hope this helps. Best of luck!


Article Submitted by:

Stephanie Kirk, Owner & President, and Medicare Specialist

JC Madison Inc.


18887 Highway 305, Suite 300, Poulsbo

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