Yes - depending on the drug.
Your Medicare Part D plan will have an established formulary or drug list with prescription organized by cost on 4, 5, or 6 different tiers - or cost-sharing levels (such as Tier 1 for low-cost generics). And in some situations, you will have the right to ask your Medicare Part D prescription drug plan (PDP or MAPD
) to have your more expensive or higher-costing drug moved to a lower-costing formulary tier
For example, you can ask that your Tier 4 "Preferred Brand" medication
(paying 46% of retail) is moved to the lower-costing Tier 3 (with a $30
copay) - and, if your plan grants your request, you will then pay less
for the formulary medication.
When you ask your Medicare plan to move your medication to a lower-costing drug
tier, you are asking for a type of "coverage determination" known as a
Question: Can I ask to move any formulary drug to a lower-costing drug tier?
You will find that your Medicare Part D plan will usually not grant
a "tiering exception" to lower the cost-sharing of "Specialty Drugs" (like cancer medications) that are usually organized on a high formulary tier (Tier 5). As noted in more detail below, you can read more about any formulary tiers excluded from a "tiering exception" in your Medicare plan's Evidence of Coverage document or by calling your plan's Member Services department (the telephone number is on your Member ID card).
Question: Will my Medicare plan always grant my tiering exception request?
Your Medicare plan can deny your request to move your medication to a lower-costing drug tier. However, if your Medicare Part D plan denies your tiering exception, you have the right to appeal
the plan's decision. But again, as noted above, if you ask your plan to cover your Tier 5 "Specialty Drug" is covered at a lower-costing tier, your plan will probably reject your request based on the plan documentation.
You can click on the following link to learn more about a formulary exception or coverage determination:
- Your cost-sharing does not impact when you enter the Coverage Gap (Donut Hole).
If your Tiering Exception is granted, it will not affect when you enter the Coverage Gap phase of your Medicare plan. What you ultimately pay (cost-sharing or copayment) for the medication (whether $30 or $300) does not affect when you enter the Donut Hole or Coverage Gap.
You enter the Donut Hole based on the plan’s negotiated retail drug price, not what you actually pay for the medication when using your Medicare Part D plan. So, even if you are granted a tiering exception for your formulary medication, the lowered coverage price will not affect when you enter the Donut Hole.
The good news is that when you enter the Donut Hole, your medication costs may be reduced by the75% Donut Hole discount.
- Your formulary exception request is only for the current plan year (January 1 to December 31).
If you received your Medicare Part D plan's approval for a
formulary or tiering exception request during the current plan year,
coverage for the drug approved under the exception will end on December
31 of the approval year. So you will need to submit a new formulary or
tiering exception request to continue coverage for the drug into the
next plan year (starting in January).
However, as noted below, you may
be able to ask for a formulary exception in December before the start of
your next year's plan coverage.
- You can ask for a formulary exception before the plan year begins.
If you join a Medicare Part D plan during the annual Open Enrollment Period (AEP running from October 15 through December 7), some Medicare Part D plans will allow you to ask for a formulary exception before the
start of the new plan year (for example, in December) - but this is only
after joining the Medicare plan.
- If your formulary exception request is denied, you can appeal the plan's denial.
As noted above, a formulary tiering request is not automatically granted and if your Medicare plan denies your
request, you can always appeal a negative decision through several appeal-levels, but this entire
process still may take a few weeks - even when you ask for an expedited decision. You can use the following link to read more about the multi-level appeal process available to Medicare plan members:
- Not sure you want to work through the formulary exception process or need some help?
Before enrolling in a Medicare Part D plan, speak with a Medicare
representative (1-800-633-4227) for an unbiased view of all of your
Medicare plan options to see if another Medicare plan in your area provides
more economical prescription and healthcare coverage - and you might be able to avoid the
formulary exception process. If you do not understand how to ask for a tiering exception after joining a Medicare plan, you can also ask the Medicare representative for assistance.
(no longer online as of 05/11/2021 - see: C2C Innovative Solutions,