Will my Medicare drug plan grant a formulary exception to lower the cost of my Tier 5 Specialty Drug?

Maybe.  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, your Medicare Part D plan will not grant a "tiering exception" to lower the cost-sharing of a Tier 5 "Specialty Drug" (like cancer medications) - unless - your Medicare Part D drug plan includes more than one Specialty drug tier with different cost-sharing.

For example, if your Medicare Part D plan formulary includes a Tier 5 for Specialty drugs and also a Tier 6 for Specialty drugs, you are allowed to ask that your higher-costing (Tier 6) Specialty drug be moved to a lower-costing (Tier 5) Specialty tier.

As reference, the Medicare Manual notes:

If a plan maintains one or two specialty tiers, as defined in 42 CFR § 423.104, the plan may design its exception process so that Part D drugs on the specialty tier(s) are not eligible for tiering exception(s) to non-specialty tiers. However, plans with two specialty tiers must permit tiering exception requests for drugs on the higher cost-sharing specialty tier to the lower cost-sharing specialty tier. [emphasis added]

Question:  Where can I read more about how my drug plan's handles a 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 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 no need for the text in the EOC when there is only one formulary tier so no lower-costing formulary tier is available.

Suggestion to help lower coverage costs for expensive drugs...

Check the price of your Specialty Tier 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, be aware that often a drug manufacturer's Patient Assistance Program (PAP) is not available to anyone who is eligible for Medicare due to the federal anti-kickback law).

Sources include: