Lowering Prescription Costs: Formulary and Tier Exceptions

Medicare prescription plans are required to maintain a formulary that includes a list of prescriptions they’ll cover. Although each company is required to cover at least 2 prescriptions in each therapeutic class, sometimes what works for some folks is simply not covered. Especially for brand-name medications such as inhalers, oftentimes we find ourselves in situations where certain medications are not covered by any stand-alone drug plan or Advantage plans. In other scenarios, the co-pays are simply too high and there is no assistance available.  

In these situations, all hope is not necessarily lost. There are 2 additional ways to request additional coverage from your current plan.

1) Formulary exception

A formulary exception is when a prescription drug plan agrees to cover a medication not on the formulary for typically the rest of the calendar year. The request must be made from your prescribing provider to the drug plan directly. Although the request is not guaranteed, we’ve seen that a good number of clients have had great success. 

2) Tier exception

In cases where a medication may be a tier 3 or 4 (brand name) and the co-pays are unaffordable, you may be able to request a tier exception. A tier exception is when a prescription drug plan lowers the tier of your medications to a lower co-pay tier. To request a tier exception, please contact the number on the back of your insurance card. In certain cases, the drug plan may require a provider to certify that this particular drug is more effective than a lower-cost alternative.