If your Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. plan is covering your drug but your copayment A copayment, also known as a copay, is a set amount you are required to pay for each medical service you receive (like $35 for a doctor’s visit). is expensive, it could be that the medication is on a high tier. Part D plans use yiers to categorize prescription A prescription is an order for a health care service or drug written by a qualified health care professional. drugs. Higher tiers are more expensive and have higher cost-sharing Cost-sharing is the portion of medical care costs that you pay yourself, such as a copayment, coinsurance, or deductible, if you have health insurance coverage. See also: Out-of-Pocket Costs. amounts. Each plan sets its own tiers, and plans may change their tiers from year to year.
If you cannot afford your copay, you can ask for a tiering Exception by using the Part D appeal An appeal is a formal request for review if you disagree with an official health care coverage or payment decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare. Federal regulations and law specify appeals deadlines, processes for handling appeals, what information must be included in a decision, and the levels of review in the appeals process. process. A tiering exception request is a way to request lower cost-sharing. For tiering exception requests, you or your doctor must show that drugs for treatment of your condition that are on lower tiers are ineffective or dangerous for you.
Requesting a tiering exception
Follow the steps below when asking for a tiering exception:
- If you are charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. If your copay is high because your prescription is on a higher tier than other similar drugs on the
Formulary
The formulary is the list of prescription drugs covered by a Part D plan or Medicare Advantage Plan. If your drug is not on the formulary, you may have to request an exception, file an appeal, or pay out of pocket.
, you can ask for a tiering exception.
- You can’t make a tiering exception request if the drug you need is in a specialty tier (often the most expensive drugs).
- Ask your plan how to send your tiering exception request. It is usually helpful to include a letter of support from your prescribing physician. This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful for you. Your plan must give you a decision within 72 hours of receiving the request. You can request a fast (expedited) appeal if you or your doctor feel that your health could be seriously harmed by waiting the standard timeline for appeal decisions. If the plan grants your request to expedite the process, you will get a decision within 24 hours.
- You doctor may fill out a standard Coverage Determination Request Form to support your request. All plans must accept this form, but some plans may have their own forms that they prefer you use.
- You may be able to file your request over the phone, but the plan can still require that your doctor submit a written statement of support. Your plan may not process your request until your doctor has provided requested information. Keep records of the documents you and your doctor send and when they were sent.
- If your plan approves your tiering exception request, your drug will be covered at cost-sharing that applies in the lower tier. Normally, an approved exception will be good until the end of the current calendar year. Be sure to ask your plan if they will cover the drug after the year ends. If they will not, you can appeal again next year or consider switching during the Fall Open Enrollment Period to a Part D plan that does cover your drug. If your plan denies your request, it should send you a letter titled Notice of Denial of Medicare Prescription Drug Coverage—and you can appeal this decision. See step four of the Part D appeal process for information on appealing the plan’s denial of your tiering exception request.