Tier Exception Letter Sample With Insurance
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FAQ
A tiering exception is a type of exception request through the Part D appeal process. You can request lower cost-sharing for a prescription on a higher tier if you show that similar drugs on the formulary at lower tiers are ineffective or harmful for you.
Ask your plan how to send your tiering exception request. It is usually helpful to include a letter of support from your prescribing physician. This letter should explain why similar drugs on the plan's formulary at lower tiers are ineffective or harmful for you.
For tiering exceptions, the prescriber's supporting statement must indicate that the preferred drug(s) would not be as effective as the requested drug for treating the enrollee's condition, the preferred drug(s) would have adverse effects for the enrollee, or both.
An exception request is a type of coverage determination. An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception.
Health plans have the option to change the formulary at any time, even in the middle of a plan year. If you need a medication that is not on your plan list, you can formally ask your insurer to cover the medication for you by submitting a ?formulary exception.?