As you may know, Medicare Part D plans categorize prescription drugs in their formulary by tiers. To make sure we’re all on the same page, the “formulary” is a fancy word for the list of medicines covered by a plan. Usually, low-cost generic drugs are designated as Tier 1 and high-cost, branded rugs are placed in higher tiers that pass along greater costs to the enrollee. Often Tier 5 is the most expensive, but it varies by plan.
What If You Cannot Afford Your Copay?
If your Part D plan covers your prescription drug, but the drug is in a high tier and you feel that you cannot afford your copay, you can request a tiering exception as an avenue for lowering your cost-sharing amount.
How to Request a Tiering Exception
Follow these steps the request a tiering exception:
Talk to your pharmacist to find out exactly why your drug is so expensive. If your Part D provider has placed you drug on a higher tier than similar drugs that treat your condition, you can proceed with a tiering exception request. (However, please note that tiering exceptions are not provided for drugs in the specialty tier.)
Contact your Part D provider to find out their process for requesting a tier exception. Each insuror’s procedure will be a little different, so you will need to follow their instructions. As part of the Part D appeal process, you or your doctor must show that you need the drug prescribed and that lower tier drugs used for treatment of your condition are ineffective or dangerous for you.
Your Part D provider will approve or deny your request and notify you of their decision.
What if My Request is Denied?
If your request is denied, you should consider switching to a plan with lower cost-sharing during the next Annual Election Period, which runs from October 15th - December 7th.