How to Use Tier Exceptions to Reduce Medication Copays

Getting hit with a $150 monthly copay for your medication isn’t just annoying-it can make you skip doses or skip filling the prescription altogether. But what if you could cut that cost to $45-or even $0-without switching drugs? The answer lies in something most people don’t know about: a tier exception.

Here’s the reality: your Medicare Part D or private insurance plan puts your medications into tiers. Tier 1 is usually generic drugs with a $0-$10 copay. Tier 2 is preferred brand-name drugs at $10-$20. Tier 3? That’s where non-preferred brands live, often $30-$100. And then there’s Tier 4 or 5-the specialty tier-for drugs like Humira, Xarelto, or Orencia, where you might pay 30-40% of the list price, which can be $1,000+ per month.

But here’s the key: if your drug is on the formulary (meaning it’s covered), but stuck in a high tier, you can ask for a tier exception. This isn’t about getting a drug added to the list. It’s about moving an already-covered drug down to a lower, cheaper tier. And it works more often than you think.

How Tier Exceptions Actually Work

Think of your drug plan like a store with price tags. Some drugs are on sale (Tier 1). Others cost more because the insurer didn’t negotiate a good deal on them. A tier exception is your way of saying: "This drug isn’t just expensive-it’s medically necessary for me, and the cheaper alternatives won’t work."

According to CMS (Centers for Medicare & Medicaid Services), a tier exception is a formal request to lower your cost-sharing for a drug that’s already covered. It’s not a loophole. It’s a built-in part of the Medicare Part D rules, created back in 2006. And it’s used by millions-just not nearly enough.

Take Humira. A typical copay on Tier 4 might be $150. But if you get a tier exception approved and move it to Tier 3, that drops to $45. Move it to Tier 2? You’re looking at $20. And if you’re lucky and your doctor makes a strong case? It could drop to Tier 1-$0.

The difference isn’t small. One patient in San Diego saved $1,380 last year just by getting her rheumatoid arthritis drug moved from Tier 4 to Tier 2. That’s over $100 a month. That’s groceries. That’s gas. That’s not choosing between meds and rent.

Who Can Request a Tier Exception?

You can request one yourself. So can your doctor. Or someone helping you manage your care. But here’s the catch: the request must come with a statement from your prescriber. No doctor note? No exception.

Your doctor doesn’t just say, "I think this is better." They have to explain why the lower-tier alternatives won’t work for you. For example:

• "Patient developed severe GI bleeding on warfarin, requiring a switch to apixaban. Warfarin is not safe for this patient."
• "Patient has severe allergy to sulfa-based diuretics, making hydrochlorothiazide contraindicated. The prescribed alternative, chlorthalidone, is not on a lower tier."
• "Patient tried two preferred alternatives for multiple sclerosis but experienced debilitating nausea and dizziness. This medication is the only one they can tolerate."

Generic statements like "My patient prefers this drug" or "They’ve been on it for years" won’t cut it. You need clinical facts. Real outcomes. Specific side effects. Hospitalizations. Lab results. That’s what approval hinges on.

How to Get a Tier Exception Approved

The process is simple, but it takes action. Here’s how to do it right:

1. Check your copay-When you get your prescription filled and see a high cost, don’t just pay it. Ask your pharmacist: "Is this drug on a higher tier? Can we request a tier exception?"
2. Call your insurance-Ask for the tier exception request form. Most plans have one. Some even have downloadable PDFs on their website. If they can’t find it, ask for the name of the form: "I need the Medicare Part D tier exception form for non-preferred drugs."
3. Get your doctor involved-Give them the form. Ask them to complete it and attach a short letter (1-2 pages) explaining medical necessity. Use the exact language CMS requires: efficacy, tolerability, or safety concerns with alternatives.
4. Submit it ASAP-Don’t wait. Submit the request before you fill the prescription. If you’ve already paid full price, you can still request it-but you might not get a refund for what you already paid.
5. Track it-Plans must respond within 72 hours if it’s urgent (your health is at risk) or 14 days for standard requests. Call the number on your card if you haven’t heard back in 10 days.

Pro tip: Many doctors now submit tier exceptions at the same time as the original prescription. That’s called a "proactive tier exception." One study showed 89% of those get approved the same day. Reactive requests? Only 67%.

What Gets Approved? Real Examples

Not every drug gets moved. But certain conditions have high success rates:

• Rheumatoid arthritis - Biologics like Humira, Enbrel, Orencia are frequently moved from Tier 4 to Tier 2 or 3.
• Multiple sclerosis - Drugs like Tysabri, Lemtrada, and Gilenya often qualify because side effects make alternatives unusable.
• Heart failure or blood clots - Xarelto, Eliquis, Pradaxa are commonly moved if patients had bleeding events or kidney issues with older drugs.
• Diabetes - Newer GLP-1s like Ozempic or Trulicity sometimes qualify if insulin caused hypoglycemia or weight gain.

According to the Medicare Rights Center, 58% of tier exception requests succeed. And when they do, the average savings per fill is $37.50. Multiply that by 12 fills a year? That’s $450 saved. For specialty drugs? You could save $300-$600 per month.

Why Most Requests Fail (And How to Fix It)

Dr. Robert Johnson of UnitedHealthcare says 37% of initial requests get denied-not because they’re invalid, but because the documentation is weak. Common mistakes:

• "My patient has been on this drug for 5 years." → Too vague. Why does that matter? What happened when they tried alternatives?
• "They don’t like the side effects." → Not enough. What side effects? How bad? Did they go to the ER?
• No lab results, no hospital records, no specific diagnosis codes.

Here’s how to fix it: Your doctor should include:

• Specific diagnosis (e.g., "Rheumatoid arthritis, active, with joint erosion on X-ray")
• Previous drugs tried and why they failed (e.g., "Leflunomide caused liver enzyme elevation >3x ULN")
• Current drug’s benefits (e.g., "Humira reduced CRP from 12 to 2.1 in 8 weeks")
• Any adverse events (e.g., "Patient required hospitalization for GI bleed on aspirin")

If you get denied, don’t give up. The appeal rate is 78%. Submit the same request with more documentation. Add a copy of your medical records. Include a note from your pharmacist if they’ve seen side effects firsthand.

What’s Changing in 2026?

The Inflation Reduction Act caps out-of-pocket drug costs at $2,000 per year starting in 2025. That sounds like good news-but it doesn’t eliminate tier exceptions. Why? Because that cap only kicks in after you hit the threshold. If you’re paying $150/month for a drug now, you’ll hit that cap fast. But if you move that drug to a lower tier? You’ll never reach it. You’ll pay less all year.

Also, new tools are helping. UnitedHealthcare’s automated pre-check system lets doctors see if a tier exception is likely to be approved before they even submit it. Other insurers are rolling out similar tools. That means faster decisions, fewer denials.

And usage is rising. Analysts predict a 22% annual increase in tier exception requests through 2026. More people are learning about it. More doctors are doing it. And the savings are real.

Bottom Line: Don’t Pay More Than You Have To

If you’re paying more than $20-$30 a month for a drug that’s already covered, you’re leaving money on the table. A tier exception isn’t a complicated legal maneuver. It’s a simple, legal, and widely available tool built into your plan.

You don’t need to be a Medicare expert. You don’t need to call a hotline. You just need to ask two questions:

1. "Is this drug on a high tier?"
2. "Can we request a tier exception?"

If your doctor says yes, they’ll handle the paperwork. If they say no, ask why. If they’re unsure, ask them to call the plan. Most doctors are happy to help-they’ve seen patients skip doses because of cost. And if you’re managing your own care? Download the form. Fill it out. Submit it. It takes 15 minutes. The payoff could be hundreds-or thousands-of dollars a year.

Don’t assume your copay is fixed. It’s not. And you have more power than you think.