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Understanding Tier Exemptions

09.11.19 07:46 PM Comment(s)

What to do when your Rx drugs cost too much

If you are on a Medicare Advantage Plan or a stand alone Part D Plan, you are probably familiar with tiers and formularies.   The formulary is the official list of drugs covered by the plan, and the tier is the pricing level for those drugs.  Most plans have five tiers, and contrary to popular believe, there are generic and brand name drugs on ALL of the tiers.  Each year the insurance companies make changes to their formularies.  You may find that your drug is covered on tier one when you first sign up for your plan.  Then it might be dropped by the plan or moved to a more expensive tier in following years.  This is why it is always good to check your drugs in a plan finder, like the one we provide, every Medicare Annual Election Period (October 15th to December 7th).  Although these are estimates, they do give you an idea as to whether or not you are looking at a major change for the coming year.  

But what happens if your doctor puts you on an expensive drug during the year when you can't change plans?

Medicare provide a way for you to get drugs covered that are not on a plan's formulary and a way to get drugs moved to cheaper tiers.  

To get a drug covered if it is not on a plan's formulary at all, you need to request a "formulary exemption".   This is a form that you get from your agent that you take to your doctor.  The doctor fills out the form explaining that the drug he/she prescribed is "medically necessary".  The doctor's office then faxes the form to the plan.  Decisions by the plan on formualry exemptions are made very quickly.  

If the drug is on the formulary, but covered at a tier three, four, or five, it might be too expensive for you.  In this case you need to request a "tier exemption" form from your agent.  The process is the same.  You take the form to your doctor who fills it out and faxes it to the plan.  Decisions are normally made very quickly.

What are my chances of getting the exemption approved?

Although I have never seen any hard data on the ratio of approved tier and formulary exemption request, my personal experience is that they are approved more often than not.  In any case, it if worth the few minutes it takes to ask your agent to email you the form and for you to ask your doctor to fill it out.