Case Flash: Tiering Exceptions in a Part D Plan

Ms. B is enrolled in Original Medicare Parts A and B and has prescription coverage through a stand-alone Medicare Part D prescription drug plan (PDP). Ms. B takes several medications, including one to control her blood pressure. She had tried a number of different blood pressure medications in the past, but only this particular drug stabilized her condition without serious side effects. Two months ago, Ms. B got a written notice from her plan telling her that next year this effective medication would no longer be a “Tier 2” drug (a less expensive or “preferred” brand-name drug). It would be moved to “Tier 3” of her plan’s formulary (list of covered drugs) and would be considered a “non-preferred” brand-name drug that would cost twice as much. The notice informed Ms. B that a different, preferred brand-name drug would be available at the Tier 2 cost.

Since Ms. B could neither take the plan’s suggested alternative, nor afford to pay twice as much for her medication, she began looking at options that would help her get assistance. She quickly discovered her income was too high for Medicaid, Extra Help and her State Pharmaceutical Assistance Program (SPAP).

Ms. B called the Medicare Rights Center and explained her situation. The hotline counselor told Ms. B that she had another option besides assistance programs. While plans are allowed to change prescription drug costs and restrictions from one year to the next, plan members have the right to ask their plan for an “exception” to certain rules. When you ask for a “tiering exception,” you write a formal request to your plan, asking the plan to move your medication to a lower-cost tier for you. As long as your medication is not in a “specialty tier” (generally the most expensive medications), you can request a tiering exception. The counselor advised Ms. B to ask her doctor to write a letter of support explaining why she needs to take this particular medication rather than the other brand-name medication that the plan would cover in Tier 2. Ms. B sent her tiering exception request to the plan along with the letter from her doctor. A few days later, she got a letter back from the plan, denying her request.

Ms. B called the Medicare Rights Center hotline again, and the hotline counselor told her about her right to continue to fight the plan’s decision. Ms. B could ask the plan to reconsider their denial by asking for a “redetermination”; she would just need to resubmit her written request and the letter from her doctor. If the plan turned her down again, she could appeal at a higher level. Ms. B ultimately sent in her request for redetermination and the plan again refused to grant the tiering exception. She then followed the counselor’s advice and appealed to the “Independent Review Entity” (IRE), a review body unaffiliated with the plan. The IRE eventually decided to grant Ms. B the tiering exception, so that Ms. B would be able to continue to get her medication at the lower cost next year.

-From: MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center, Vol. 11 , No. 20 : September 30, 2008.

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