Probably not. In some situations, you have the right to ask your Medicare Part D prescription drug plan (
PDP or MAPD) to have a higher-costing drug moved to a lower-costing
formulary tier and this type of "coverage determination" is known as a
"tiering exception".
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
co-pay) - and, if your plan grants your request, you will then pay less
for the formulary medication.
However, you should find that your Medicare Part D plan will not grant a "tiering exception" to lower the cost-sharing of "Specialty Drugs" (like cancer medications).
Question: Where can I read about this exception to the tiering exception?
In your Evidence of Coverage (
EOC) document you will find that your plan coverage states:
“Drugs of our [insert name of specialty tier] are not eligible for this type of exception [a tiering exception]. We do not lower the cost-sharing amount for drugs in this tier”.
Remember, you will receive your 200+ page Evidence of Coverage
document
when you enroll into a new Medicare Part D prescription drug plan - or
you will be provided a link where you can download the EOC
electronically. Then each year you will receive an EOC for the upcoming
year along with your Medicare plan's Annual Notice of Change (ANOC)
letter mailed to you in late-September (or you will receive a link to where you can download the EOC).
Naturally, Medicare Part D plans with a only one formulary drug tier or Medicare drug plans that use the standard, fixed cost-sharing of (25%) across all tiers may exclude this Evidence of Coverage text - meaning there is need for the text in the EOC when there is no way to move your drug to a lower-costing formulary tier.
Suggestion to help lower coverage costs for expensive drugs . . .
Check the price of the drug using a
drug discount program.
You may also wish to consider contacting the drug manufacturer and ask
about any of the company's programs that can help Medicare beneficiaries
receive a discounted drug price (but, often a manufacturer's Patient
Assistance Program (PAP) is not available to anyone who is eligible for
Medicare due to the federal anti-kickback law).