At some point, some individuals with prescription coverage may find their prescription drug copay higher than expected. This could mean, the drugs are on a higher tier and therefore the copay is more. Higher tiered drugs are more expensive than lower tiered drugs. Although this can make out-of-pocket expenses significantly greater than expected, beneficiaries can request a tier exception. This may help lower the copay for the medication. In this post, we discuss how to request a tier exception.
What is a tier exception
A tier exception is a formal request individuals send to their insurance provider asking them to cover a drug at a lower cost tier. Typically, each insurance plan has a formulary (list of covered drugs) where they categorize medications into different tiers. Generic drugs are in the lowest-cost tiers and specialty or brand-name drugs in the highest-cost tiers. Individuals who have medication on a high-cost tier and cannot afford their copay can request an exception to lower their costs.
Review the formulary
Individuals should check their insurance provider’s formulary, which is the list of covered medications and their respective tiers. This cost for drugs on each tier is available in the plan’s evidence of coverage. Enrollees can also request a plan formulary from the plan provider or review it on the plan’s website. If the drug is on a high-cost tier, check and see if there are lower-tier alternatives that might work. If that is not an option, a tier exception may provide a way to afford the necessary medication.
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Obtain a supporting statement from the doctor
The enrollee’s insurance company will require a supporting statement from the prescribing doctor explaining why lower-tier alternatives are not suitable for the individual. The doctor must specify that:
- The lower-tier medications have been ineffective or would cause adverse effects.
- The requested drug is necessary to treat the specific condition.
Submit a formal request to the insurance carrier
Contact the insurance company to obtain the tier exception request form. The doctor’s office may be able to do this for the patient. Complete the form, attach the supporting statement, and submit it through the insurance company’s designated method (fax, email, mail, or online portal).
Wait for a decision
In the majority of cases, insurance carriers have 72 hours to make a decision on a standard request. If the situation is urgent and the medication is needed immediately, request an expedited review, which requires a response within 24 hours.
If the request is approved
The drug will be covered at a lower cost sharing amount that applies to the new drug tier. In most cases, the approval will last until the end of the calendar year. Beneficiaries may request the drug tier be honored the following year. In the event the carrier does not allow the exception the following year, the plan enrollee can start the process over again or use the Medicare AEP to find a plan that covers the drug at a lower rate.
If the request is denied
If the tier exception request is denied, beneficiaries have the right to appeal the decision. Each plan will provide instructions on how to appeal, which often includes submitting additional medical documentation. If the appeal is still denied, the beneficiary can escalate it to an independent review entity.
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Requesting a tier exception can help make prescription medications more affordable, but it may require careful documentation and persistence. Those facing high medication costs must work closely with their doctors and insurance carrier to improve their chances of approval.
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