How to Use Tier Exceptions to Lower Your Medication Copays

Imagine paying $150 a month for your arthritis medication-then finding out you could pay just $45 with a simple request. That’s not a fantasy. It’s what happens when you use a tier exception to move your drug to a lower cost tier on your Medicare Part D plan. Most people never hear about this option, but for those who do, it can mean hundreds of dollars saved every year. You don’t need a lawyer or a financial advisor. You just need to know how to ask-and what to say.

What Is a Tier Exception?

A tier exception is a formal request to your drug plan to let you pay less for a medication that’s already on the formulary but stuck in a high-cost tier. It’s not about getting a drug that’s not covered. It’s about getting the drug you need at the price of a cheaper one.

Medicare Part D plans group medications into tiers. The lower the tier, the less you pay. Tier 1 usually covers generic drugs-sometimes even $0. Tier 2 is for preferred brand-name drugs. Tier 3 is for non-preferred brands, often $50-$100. Tier 4 and 5 are for specialty drugs, where you might pay 30-40% of the full price-sometimes over $1,000 a month.

A tier exception lets you bypass that high cost if your doctor says the lower-tier alternatives won’t work for you. Maybe you had side effects. Maybe the cheaper drug didn’t control your condition. Maybe your body just doesn’t respond to it. That’s enough to qualify.

Why Most People Miss Out

Only 18% of eligible Medicare beneficiaries even try to get a tier exception, according to Kaiser Family Foundation data. That’s shocking when you consider the savings. Moving a drug from Tier 4 to Tier 2 could cut your monthly cost from $100 to $20. Going from Tier 3 to Tier 1? That’s often $0.

The problem isn’t lack of need. It’s confusion. People think if their drug is on the formulary, they’re stuck with the price. Or they assume their doctor will handle it. But doctors don’t always know about tier exceptions unless you bring it up.

One patient on Reddit shared: “My Humira was $150/month. My doctor submitted the request. Got approved in 10 days. Now it’s $45. I cried.”

Another wasn’t so lucky: “I asked for Xarelto to move to Tier 1. Got denied. Asked again. Got approved to Tier 2-still $40. I was hoping for $10.”

The difference? Documentation. The first person’s doctor gave clear, specific reasons. The second didn’t.

How to Start the Process

Step one: Know your current copay. Check your plan’s formulary online or call customer service. Ask: “What tier is my medication on? What’s the copay?”

Step two: Talk to your doctor. Don’t say, “Can you make this cheaper?” Say: “I need to request a tier exception for this drug. Can you help me prove it’s medically necessary?”

Your doctor doesn’t need to write a novel. But they do need to explain why lower-tier alternatives won’t work. Here’s what works:

• “Patient experienced severe GI bleeding on Warfarin, requiring hospitalization. Switch to Apixaban is medically necessary.”
• “Patient developed rash and swelling on Lisinopril. Alternative ACE inhibitors caused same reaction. Losartan is the only tolerated option.”
• “Patient has relapsing-remitting MS. Previous therapies failed to prevent relapses. Ocrelizumab is the only effective option.”

Avoid vague statements like “I don’t like the other drug” or “It’s too expensive.” Those get denied.

What Your Doctor Needs to Submit

Your doctor will fill out a tier exception form from your plan. Most plans have an online portal now. UnitedHealthcare, for example, launched an automated pre-check tool in April 2023 that lets doctors see approval likelihood before submitting. That cuts approval time from 9 days to under 4.

The form requires:

• Your name, date of birth, and member ID
• The name of the drug you want moved
• The name of the preferred drug(s) on a lower tier
• A clinical justification-why the lower-tier drug won’t work for you
• The doctor’s signature and contact info

Some plans let you submit the request yourself, but without the doctor’s note, it won’t be approved. The documentation is non-negotiable.

Timing Matters

Don’t wait until you’ve filled your prescription and got the bill. That’s too late. Request the exception before you fill it.

Why? Because if you fill the prescription at the high tier, you’ve already paid the full cost. Even if you get approved later, you won’t get refunded.

The best time? Right after your doctor writes the prescription. Ask them to submit the request the same day. Proactive requests-submitted with the initial prescription-have an 89% same-day approval rate, according to the Medicare Rights Center. Reactive requests (after you’ve paid) only get approved 67% of the time.

What Happens After You Submit?

Your plan has 72 hours to respond if your doctor says your health is at risk if you wait. That’s an expedited request. For example, if you’re on a drug that prevents seizures or heart failure, and switching could be dangerous, that qualifies.

Otherwise, they have up to 14 days. You’ll get a letter or email. If approved, your copay drops immediately. If denied, you get a reason why.

Don’t give up if you’re denied. About 37% of initial requests get turned down-but 78% of those are approved on appeal with better documentation.

If your first request was too vague, ask your doctor to rewrite it with more clinical detail. Add lab results, hospital records, or past treatment failures. That’s what gets approvals.

Who Benefits Most?

Tier exceptions aren’t for everyone. They’re most useful for people taking specialty drugs for chronic conditions:

• Rheumatoid arthritis (biologics like Humira, Enbrel)
• Multiple sclerosis (Ocrevus, Tysabri)
• Chronic kidney disease (SGLT2 inhibitors)
• Complex heart failure (Entresto)
• High-risk diabetes (GLP-1 agonists like Ozempic)

These drugs are often in Tier 4 or 5. They’re expensive. But they’re also medically necessary. That’s exactly what tier exceptions were made for.

What’s Changing in 2025?

Starting January 1, 2025, the Inflation Reduction Act caps out-of-pocket drug costs for Medicare beneficiaries at $2,000 per year. That sounds like it might make tier exceptions less important.

But it doesn’t. The cap applies to your total spending across the year. If you’re on a $1,000/month drug, you’ll hit that cap quickly. But until then, you’re still paying full tier prices. Lowering your copay now means you spend less before hitting the cap-and you have more money left for other meds.

Plus, the cap doesn’t apply to people under 65 on Medicare due to disability. Or to those on Medicaid-Medicare dual eligibility. Tier exceptions still matter.

What If It’s Denied?

If your request is denied, you have rights:

• You can appeal. The plan must give you instructions.
• You can ask for an external review by an independent third party.
• You can file a complaint with Medicare at 1-800-MEDICARE.

The Patient Advocate Foundation says 58% of people who appeal get approved. But you need to act fast. You have 60 days from the denial date to file an appeal.

And don’t do it alone. Call the Medicare Rights Center at 1-800-333-4114. They offer free counseling and help with appeal letters.

Real Savings, Real Stories

One 72-year-old in Ohio was paying $87 a month for her blood thinner. Her doctor submitted a tier exception, showing she had a history of falls and bleeding on the cheaper alternative. Approved. Now she pays $15.

A veteran in Texas was paying $1,200 a month for his MS drug. After a tier exception, he dropped to $300. That’s $10,800 saved a year.

These aren’t outliers. They’re what happens when people know how to ask.

Final Checklist

Before you let your prescription go to the pharmacy, check this:

• Is your drug on a high tier (Tier 3 or above)?
• Have you checked your plan’s formulary for lower-tier alternatives?
• Have you talked to your doctor about a tier exception?
• Is your doctor willing to write a clear clinical reason?
• Have you asked them to submit the request before you fill the script?

If you answered yes to all five, you’re set. If not, you’re leaving money on the table.