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Paying more for 2023 Medicare Part D prescriptions? Ask your plan for a Tiering Exception.

Category: Your Medicare Plan Coverage
Published: Mar, 26 2023 10:03:23

Inflation aside, why does it seem as though I am already paying more for my 2023 Part D drugs?

Medicare Part D prescription drug plans change every year and, even if you stayed with your same plan from 2022, there are a number of possible reasons why you may be paying more for your 2023 prescriptions:

(1) your formulary medication was moved to a more expensive formulary tier in 2023 or
(2) the cost sharing for your drug’s formulary tier increased in 2023 or
(3) you are paying coinsurance (a percentage of retail) and the retail cost of your prescription has increased.  You can click here to read more about 2023 formulary changes.

What to do:  Request a tiering exception from your Medicare Part D plan.  A tiering exception is a type of Coverage Determination where you are formally requesting that your plan move your medication to a lower, more affordable drug tier.  A tiering exception is not automatically granted by a Medicare plan and, if your request is denied, you have the right to appeal the negative decision.

How to ask for a tiering exception:  To begin, telephone your Medicare drug plan’s Member Services department (using the toll-free telephone number found on your Member ID card) and ask the plan representative about the procedure to file the tiering exception and also ask that the plan send you any necessary forms.  If you are looking for average retail drug prices, you can use our Q1Rx Drug Finder see how average drug prices have changed over time for a particular drug.

Question:  If my Medicare plan has already agreed to cover a non-formulary drug, can I also ask for a tiering exception to lower the cost of the newly-covered drug?

No.  A Medicare Part D plan will not allow a tiering exception (moving a drug to a lower-costing formulary tier) after your plan has just approved your formulary exception request to cover the non-formulary drug.

Please note:  If your plan agrees to cover a non-formulary drug, your Medicare Part D plan will cover the non-formulary drug at a cost as noted in the plan documentation (for example, as a Tier 3 for brands or Tier 2 for generics).

Question:  Can I get a tiering exception to lower the cost of my expensive Specialty Drug.

No.  A tiering exception may not be allowed for all formulary drugs – especially for expensive drugs (such as Tier 5 Specialty Drugs).  You may find that your Medicare Part D plan’s Evidence of Coverage (EOC) document states something such as:
“Drugs of our [insert name of specialty tier] are not eligible for [a tiering exception]. We do not lower the cost-sharing amount for drugs in this tier”.

Suggestion:  Compare your coverage cost with the drug price you would pay using a drug discount program.  You can also contact the drug manufacturer and ask about any discount programs that may be available to Medicare beneficiaries.

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