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 if your insurance moved it to a lower tier. That’s not a fantasy. It’s a tier exception, and it’s one of the most powerful but underused tools to cut your out-of-pocket drug costs. Most people don’t know it exists, and even fewer know how to ask for it. But if you’re paying high copays for a medication that’s already covered by your plan, a tier exception could save you hundreds-maybe even thousands-each year.

What Exactly Is a Tier Exception?

Your prescription drug plan puts medications into tiers, like levels on a price ladder. Tier 1 is cheapest-usually generics. Tier 2 is preferred brand-name drugs. Tier 3 is non-preferred brands. Tier 4 and 5 are specialty drugs, often costing $100 to $1,000 a month. The higher the tier, the more you pay at the pharmacy.

A tier exception is a formal request to move a drug you’re already taking from a higher tier to a lower one-so your copay drops. It’s not about getting a drug your plan doesn’t cover. That’s a formulary exception. A tier exception means the drug is on the list, but you’re stuck paying more than you should.

For example: If your medication is on Tier 3 with a $50 copay, and you get it moved to Tier 1, your copay could drop to $0 or $10. That’s a 100% savings on that drug. According to Medicare.gov, nearly 92% of Medicare Part D plans use this tier system, affecting 48 million people. But only about 18% of eligible patients even try to get a tier exception, according to Kaiser Family Foundation data.

When Does a Tier Exception Make Sense?

You should consider a tier exception if:

• You’re paying $30 or more per month for a brand-name drug that has cheaper alternatives on lower tiers
• Your doctor says the cheaper alternatives don’t work for you-or cause bad side effects
• You’re taking a specialty drug (like Humira, Xarelto, or Copaxone) and your copay is over $100
• You’ve been denied a lower copay because your plan says another drug is “preferred,” but it didn’t work for you

Common conditions where tier exceptions succeed include rheumatoid arthritis, multiple sclerosis, heart failure, and chronic kidney disease. These often require specific medications that can’t be swapped out without risking health. For example, one patient switched from warfarin to apixaban after a dangerous bleeding episode. The plan wanted to keep them on warfarin because it was cheaper. A tier exception got apixaban moved to Tier 2, cutting their copay from $85 to $25.

How to Request a Tier Exception: The Step-by-Step Process

You can’t request this yourself without your doctor’s help. The system requires clinical proof. Here’s how it actually works:

1. Check your current copay. Look at your pharmacy receipt or log into your plan’s portal. Note the tier your drug is on and your copay amount.
2. Talk to your doctor. Ask: “Can we request a tier exception for this medication?” Don’t wait until you’re at the pharmacy. Do this before your next refill.
3. Your doctor fills out the form. Most plans have a standard form. Some let you download it online. Others require the office to submit it electronically. The form asks why the lower-tier alternatives won’t work.
4. Your doctor writes a medical justification. This is the key. Generic statements like “I prefer this drug” won’t cut it. You need specifics: “Patient developed GI bleeding on generic Xarelto alternative; switched to brand-name Xarelto with no recurrence in 6 months,” or “Patient experienced severe dizziness and falls on preferred beta-blocker; this medication is the only one tolerated.”
5. Submit the request. Your doctor’s office usually submits it. But you can also submit it yourself through your plan’s website or phone line if you have the completed paperwork.
6. Wait for a decision. If your doctor says your health is at risk without the drug, the plan must respond in 72 hours. Otherwise, you’ll wait up to 14 days.

Why Most Requests Get Denied-and How to Fix It

The biggest reason tier exceptions get denied? Weak documentation. According to CMS data, 37% of initial requests are rejected because the medical reason isn’t clear enough. But here’s the good news: 78% of those get approved on appeal.

Here’s what makes a denial turn into an approval:

• Use real medical language. Don’t say “I don’t like the side effects.” Say “Patient developed angioedema after one dose of lisinopril, requiring emergency care.”
• Include lab results or hospital records. If you’ve been hospitalized because of a reaction to a preferred drug, attach the discharge summary.
• Prove the alternative failed. If you tried the cheaper drug and it didn’t work, say so. “Patient was switched to metformin ER but HbA1c rose from 6.8% to 8.1% in 8 weeks.”
• Appeal immediately. If denied, don’t wait. File an appeal within 60 days. Add more evidence: previous prescriptions, lab values, or even a letter from a specialist.

One Reddit user tried twice for Xarelto. First time: denied because the doctor wrote “patient prefers this.” Second time: doctor wrote “Patient developed deep vein thrombosis while on rivaroxaban; switched to Xarelto with no recurrence. Rivaroxaban caused elevated liver enzymes.” Approved to Tier 2. Copay dropped from $60 to $40.

Real Savings: What You Can Expect

The Medicare Rights Center surveyed 1,200 beneficiaries who tried tier exceptions. Here’s what they found:

• 58% were successful in lowering their copay
• Average monthly savings: $37.50 per prescription
• Some saved $100+ per month on specialty drugs
• Annual savings: $300-$600 per medication, on average

For a drug like Humira (used for autoimmune diseases), moving from Tier 4 ($150/month) to Tier 3 ($45/month) saves $1,260 a year. Move it to Tier 2 ($20/month)? That’s $1,560 saved. And if you’re in the coverage gap (donut hole), lowering the tier can mean you stop paying 25% coinsurance entirely.

Timing Matters: Don’t Wait to Fill Your Prescription

The best time to request a tier exception? Before you fill your first prescription. If you wait until you’ve paid $150 and then ask for a refund, you’re too late. Most plans won’t retroactively adjust copays.

A new trend called “proactive tier exceptions” is catching on. Doctors now submit the request at the same time they write the prescription. According to the Medicare Rights Center, this leads to 89% same-day approval-compared to 67% when requested after the fact.

What’s Changing in 2025?

Starting in 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 here’s the catch: That cap applies only after you’ve spent $2,000. If you’re on multiple high-cost drugs, you could hit that cap fast. And even after you hit it, you still pay lower copays on tier 1 and 2 drugs. Lowering your tier now means you’ll spend less money before you reach the cap-and you’ll keep paying less after.

Also, specialty drugs (tiers 4-5) now make up 53% of total Medicare drug spending, even though they’re only 2% of prescriptions. That means insurers are still pushing hard to control costs-and tier exceptions remain your best countermove.

What to Do If Your Request Is Denied

Don’t give up. Here’s what to do next:

• Request a written denial letter. It must explain why your request was denied.
• File an appeal within 60 days. Use the form on your plan’s website or call their member services.
• Ask your doctor to write a stronger letter. Add new data: lab results, specialist notes, or prior treatment failures.
• If you’re still denied, you can ask for an external review by an independent third party.

The Patient Advocate Foundation says 80% of appeals with solid documentation are approved. You have rights. Use them.

Final Tips to Maximize Your Success

• Keep a copy of every form, letter, and email. Document everything.
• Call your plan’s pharmacy help line. Ask: “What’s the exact clinical criteria for a tier exception on [drug name]?”
• Use your plan’s online portal. Many now let you check the status of your request in real time.
• If you’re on Medicaid or private insurance, the same rules apply-just check your plan’s formulary and exception process.
• Ask your pharmacist. They often know which drugs are easiest to get moved to lower tiers.

Frequently Asked Questions