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Can I ask my Part D plan to move my medication to a less expensive drug tier?

Category: Formulary Exceptions (Coverage Determinations)
Updated: Aug, 08 2023

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 "tiering exception".

Question:  Can I ask to move any formulary drug to a lower-costing drug tier?

No.  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?

No.  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: 

Other key points about tiering exceptions .  .  .
  • A "tiering exception" may not be available for Specialty Drug tiers.

    As noted in our FAQ "Can I ask my Medicare drug plan for a formulary exception lowering the coverage cost of my Tier 5 Specialty Drug," you cannot request a tiering exception if the prescription drug in question is in your Medicare Part D plan’s "Specialty tier" (usually a more expensive medication).

    In the section about "tiering exceptions" found within your Medicare plan's Evidence of Coverage (the 200+ page document you received when joining the plan - either printed or electronically), you should find a statement from your plan such as:

    "You cannot ask us [the Medicare plan] to change the cost-sharing tier for any drug in Tier 5 Specialty."

  • No formulary tiering exceptions granted after getting coverage of a non-formulary drug

    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.

    As noted in our FAQ "If my Medicare drug plan agrees to cover a non-formulary drug, can I also ask the plan to move the same drug to a lower-costing formulary tier?", 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.

    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 same non-formulary drug.

    If you look in your Medicare plan’s Evidence of Coverage document, you will see language in the 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, 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.”

  • Check your Medicare plan's documentation and definitions for more information about Formulary and Tiering Exceptions.

    Look for language in your Medicare plan's Evidence of Coverage document such as:

    "If your drug is in Tier 4: Non Preferred Brand Drugs you can ask us to cover it at the cost sharing amount that applies to drugs in Tier 3: Preferred Brand Drugs. This would lower your share of the cost for the drug.  If your drug is in Tier 2: Non-Preferred Generic Drugs you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 1: Preferred Generic Drugs. This would lower your share of the cost for the drug.  [But, as noted above] [y]ou cannot ask us to change the cost-sharing tier for any drug in Tier 5: Specialty Tier."

    Your Evidence of Coverage (EOC) document is a 100+ page guide to your Medicare plan and you may have received a printed copy when you enrolled into your Medicare plan - or you may have received a copy in late-September when you received your plan's Annual Notice of Change letter - or your Medicare plan may have provided you with a link where you can download the EOC document from the plan's website (you can call your plan's Member Services department for more information).

  • 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.
Sources include:

http://www.medicarepartdappeals.com/sites/default/files/PartDManualChapter18%2005%2012%2014v508.pdf (no longer online as of 05/11/2021 - see: C2C Innovative Solutions, Inc. (C2C)
https://partdappeals.c2cinc.com/Prescribers/Frequently-Asked-Questions, https://partdappeals.c2cinc.com/Part-D-Enrollees-Representatives/Frequently-Asked-Questions))

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