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. The least expensive, generic drugs are on Tier 1. More expensive brand-name and specialty drugs are in higher tiers. Each plan sets its own tiers, and plans often change their cost tiers each year. Follow the steps below if you are appealing for a lower copayment:
- If you’re 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 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 can’t request your plan to move a drug to a lower tier if the drug you need is in a specialty tier (often the most expensive drugs).
- Call your plan to find out where to send the formulary tier exception request. You will need your doctor to fill out a form of support that says 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 for you. Your plan must respond within 72 hours of getting the doctor’s written statement. If it’s an emergency, your plan must respond to your expedited request 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 specific 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 won’t process your request until your doctor has provided the requested information. Keep copies of the documents you and your doctor send and when they were sent.
- If your plan approves your request, your drug will be covered at the lower cost tier. Normally, plans will approve exceptions until the end of the calendar year. If your 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. The appeal process is a little different for a tiering request, so go straight to step four.