No.  A Medicare Part D plan will not allow you to request a tiering exception (moving a drug to a lower-costing formulary tier) for a drug when your plan has just approved your formulary exception request to cover the non-formulary drug.

As background, your Medicare Part D prescription drug plan will allow you to request certain exceptions to the normal plan rules.  For example, you can ask your Medicare plan to waive a Usage Management requirement such as a Quantity Limit or Prior Authorization.  You can also ask your Medicare plan to cover a medication that is not on the plan's formulary or drug list.  Asking your plan to waive Usage Management restrictions or cover a non-formulary drug is called a "formulary exception" request.

As another example, you also have the right to ask your Medicare plan to move your drug to a lower-costing formulary tier.  Asking your Medicare plan to cover your formulary drug at a lower cost is a type of coverage determination known as a "tiering exception".

In some situations, a Medicare plan may allow you to ask for more than one formulary exception that is related to the same drug.  For example, your Medicare Part D drug plan may "agree to make an exception and waive a [usage management restriction] for you, [and also allow you to] ask for an exception to the copayment or coinsurance amount [the plan requires] you to pay for the drug."  In other words, you could ask to waive a drug's Prior Authorization (PA) requirement, and when granted, also ask your plan to cover the medication at a lower-costing formulary tier.

However, a Medicare Part D plan will not allow for a tiering exception (moving to a lower-costing tier) after the plan has just approved your formulary exception request to cover a non-formulary medication.

This means that you are you can either ask your Medicare Part D plan to cover a non-formulary drug - or ask your plan to move your formulary drug to a lower-costing formulary tier - but you cannot ask for both types of formulary exceptions (or coverage determinations) for the same drug.  In other words, when a plan approves the coverage of a non-formulary drug, you will not be permitted to then request a tiering exception (or cost-sharing reduction request) for that non-formulary drug.

Question:  Where can you learn more about your plan's coverage?

If you look in your Medicare plan’s Evidence of Coverage (EOC) document (the 200+ page document you received electronically or printed when first joining the Medicare plan), you will see language in the EOC section under "Formulary Exceptions" that states something such as:

“If we agree to make an exception and cover a drug that is not on the Drug List [or formulary], you will need to pay the cost-sharing amount that applies to drugs in Tier 4 [assuming a 5-tier formulary]. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the [coverage of a non-formulary] drug.”

Question:  What is the source of this rule?

In Section 40.5.2 "Formulary Exceptions" in the 2019 Medicare Manual (a merger of the former Chapter 18 of the Prescription Drug Benefit Manual and Chapter 13 of the Medicare Managed Care Manual) you can find:

"Note:  Under [federal regulation] 42 CFR §423.578(c)(4)(iii), an enrollee is prohibited from requesting a tiering exception for a non-formulary drug approved under the formulary exception process.  However, a drug that is subject to a UM [usage management] requirement is a formulary drug (i.e., a UM requirement placed on a formulary drug does not make that drug a non-formulary drug).  Therefore, an enrollee who requests a UM exception and receives an approval, may also request a tiering exception for the same formulary drug."  [emphasis added]

(Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (Effective January 2020) p.30)

Reminder about the Denial of Exception Requests and Appeals

Asking your Medicare plan for an exception to the coverage rules (like covering a non-formulary drug) is called a coverage determination and your Medicare plan is not required to grant your formulary exception request.  However, if your request is denied by your Medicare plan, you have the right to appeal the plan's negative decision.

Learn more about the multi-level appeal process available to Medicare plan members.

Learn more about formulary exceptions or coverage determinations.

Resources include: