If your Medicare Part D drug plan is covering your drug, but your copay is high, it may be because the drug is on a high cost tier.
Cost tiers are how drug plans price the drugs they cover, with the least expensive, generic drugs on Tier 1, and more expensive brand-name and specialty drugs in higher tiers. Each plan sets its own tiers, and plans often change their cost tiers from year to year.
If you’re charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. (There a number of reasons your copay could be high, for example, if the pharmacy isn’t one of your plan’s preferred network pharmacies, if there’s a problem with your secondary drug coverage, or if the plan changed its copays for the new year.)
If your copay is high because your prescription is in a higher cost tier than other similar drugs on the formulary, you can ask your Medicare drug plan to move it to a lower tier for you. This is called a request for a formulary tier exception.
You will need your doctor to fill out a Coverage Determination Request Form (click here) that says you’re requesting a formulary tier exception. All plans must accept this standard Coverage Determination Request Form, but some plans may have their own specific forms that they prefer you use.
The request should say:
- which similar drugs are on lower cost tiers on the plan’s formulary, and
- why those other drugs are ineffective or harmful for you, or are likely to be ineffective or harmful for you.
Note, however, that you can’t request that your plan move the drug to a lower tier if the drug you need is in a specialty tier (often the most expensive drugs), or if you want to get a brand-name drug placed on the same cost tier as a generic drug.
Call the plan to find out where to send the request. Keep proof, such as fax transmission reports or certified return receipts, of when you or your doctor sent the request.
Plans must also let you request an exception through a toll-free phone number or the plan website, but even when you do this, the plan can still require that your doctor submit a written statement of support. The plan won’t start processing your request until your doctor has provided the requested information.
Plans must respond within 72 hours of getting the doctor's written statement. If it’s an emergency, plans must respond to expedited requests within 24 hours. These are clock hours, not business hours. Your plan should send you a written coverage determination that says whether it will cover your drug at the lower cost tier. If you don’t hear from the plan in the proper timeframe, call and ask for the decision.
If the plan approves your request…
If your plan approves your request, that means the plan must cover your drug at the lower cost tier within 72 hours of getting the doctor’s written statement. Make sure the plan approves coverage at the lower tier for the rest of the year. Normally, plans will approve exceptions until the end of the calendar year (December 31).
If you aren’t sure for how long your plan has approved your medication, call and ask for that information in writing. It’s important to have this in case you have to ask for another exception.
If the plan denies the request…
If a plan denies your request, you can appeal the plan's decision. Your plan should respond to you in writing with a letter titled "Notice of Denial of Medicare Prescription Drug Coverage." You’ll need this written notice in order to appeal, and the notice will include instructions on how to appeal. Appealing is also called requesting a redetermination from your plan.
Note: The plan doesn’t consider your income when you request a formulary tier exception. However, if your income is low, you may qualify for programs that help pay your drug costs, such as Extra Help or your State Pharmaceutical Assistance Program.