A tiering exception can help make medication more affordable for patients who may not be eligible to participate in savings programs but need assistance covering costs. They can help a patient gain access by outlining the reasons why a treatment is necessary to meet your medical needs.
A tiering request is a way to request lower cost sharing for medications. If your Part D plan is covering your drug but your copayment is expensive, it could be that the medication is on a high tier. Tiers 3, 4, and 5 are more expensive.
You can request a Tiering Exception for your medication if you cannot afford your copay. The request, to your insurance company, allows you to get the same medicine at a lower copay. Your doctor must show that medicine on lower tiers were ineffective or even dangerous to you. Once received, the insurance company must make a decision within 72 hours from the time they received you and your doctor’s request.
If your plan approves your Tiering Exception request, your drug will be covered at copays that apply in the lower tier, and 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 Open Enrollment to a Medicare Part D plan that does cover your drug.