"[i]f [the Medicare Part D plan agrees] to make [a formulary exception] and cover a drug that is not in the [plan's drug list], you will need to pay the cost-sharing amount that applies to drugs in Cost-Sharing Tier 4 - Non-Preferred drugs. You cannot ask for [another formulary] exception to [lower] the copayment or coinsurance amount we require you to pay for the drug." [emphasis added]This information should be found in the Section of your Evidence of Coverage entitled, "What is an exception?", and should be about 100+ pages into your plan's Evidence of Coverage document.
... or ...
"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 Cost-Sharing Tier 3: Non-Preferred Drug. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug." [emphasis added]
"Starting in 2015, a Part D sponsor must charge cost sharing for a temporary supply of drugs provided under its transition process such that the following conditions are met:In earlier guidance Medicare noted:
• For LIS [Low-Income Subsidy or Medicare Part D Extra Help] enrollees, a sponsor must not charge higher cost sharing for transition supplies than the statutory maximum copayment amounts.
• For non-LIS enrollees, a sponsor must charge
• The same cost sharing for non-formulary Part D drugs provided during the transition that would apply for non-formulary drugs approved through a formulary exception in accordance with §423.578(b); and
• The same cost sharing for formulary drugs subject to utilization management edits provided during the transition that would apply if the utilization management criteria are met."
For more information see FAQ:"A [Medicare Part D] plan may charge cost-sharing for a temporary supply of drugs provided under its transition process. Cost-sharing for transition supplies for low-income subsidy (LIS) eligibles can never exceed the statutory maximum copayment amounts ([such as] $3 or $5 copays, or 15% coinsurance, depending on the level of LIS for which a particular enrollee qualifies).
For non-LIS enrollees, a plan must charge cost-sharing based on one of its approved drug cost-sharing tiers (if the plan has a tiered benefit design), and this cost-sharing must be consistent with cost-sharing that the plan would charge for non-formulary drugs approved under a coverage exception."