A Tiering Exception is a request made by a Medicare beneficiary to ask their plan to lower the cost-sharing amount for a specific drug. This process is available when a medication is placed on a higher, more expensive tier of a Medicare Part D formulary, and the individual believes it should be placed on a lower, more affordable tier. If approved, a tiering exception allows the beneficiary to pay a reduced copay or coinsurance, typically aligned with a lower-cost alternative on the plan’s formulary.
Tier 1 -> None
Tier 2 -> Down to Tier 1
Tier 3 -> Brand - none, Generic - T1
Tier 4 -> Brand - T3, Generic - T1
Tier 5 -> None per CMS Guidelines