There are many parts to a Medicare prescription drug (Part D) plan. There are your copays, the drug tiers, the drug copays, the annual deductible, the restrictions put on the type of drug you are taking (step therapy, quantity limits, and prior authorizations).
So what exactly are the drug tiers and what do they mean?:
- Tier 1: Preferred Generic: Least expensive drug options, often generic drugs.
- Tier 2: Generic: Higher price generic and lower-price brand-name drugs.
- Tier 3: Preferred Brand: Mainly higher price brand-name drugs.
- Tier 4: Non-Preferred: Highest cost prescription drugs.
- Tier 5: Specialty drugs: new medications in the marketplace and clinical trial drugs
Each Medicare insurance company or plan may change the medications on those tiers from year to year.
If your medication falls on a higher tier, like a Tier 3, 4, or 5 and can’t afford to pay the copay for that tier you can ask for an exception by using the Part D appeal process.
The following is TAKEN FROM A MEDICARE RIGHTS CENTER article:
A tiering exception is a way to request lower cost-sharing. To request a tiering exception, you or your doctor must show that the drugs for treatment of your condition that are on lower tiers of your plan’s formulary are ineffective or dangerous for you. Here is some guidance on requesting 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 drugs to treat your condition on the formulary, you can ask for a tiering exception.
- Note that you can’t request a tiering exception if the drug you need is in a specialty tier. The specialty tier is limited to drugs above a certain dollar amount and plans may not require more than 33% coinsurance for drugs on this tier.
- Ask your plan how to send your tiering exception request. It’s usually helpful to include a letter of support from your prescribing health care provider. This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful for you.
- If your plan approves your tiering exception request, your drug will be covered at cost-sharing that applies to the lower tier. Normally, an approved exception will be in effect until the end of the current calendar year. If your plan denies your request, it should send you a letter titled Notice of Denial of Medicare Prescription Drug Coverage. You can appeal this decision.
* This article is for information purposes only. I don’t recommend, support, or diagnose any featured writer or article. I am not a doctor. Your health is one of a kind. What works for one person may not for another, so the information in these articles should not take the place of an expert opinion. Before making significant lifestyle or diet changes, please consult your primary care physician or nutritionist. You and your doctor will know your own health best.