How to Use Tier Exceptions to Lower Your 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 drop that same drug from tier 4 to tier 2 and pay only $40 instead? That’s where a tier exception comes in. It’s not a secret loophole. It’s a formal right built into Medicare Part D and most private insurance plans. And yet, most people never ask for it.

What Exactly Is a Tier Exception?

Your insurance plan puts your medications into tiers. Tier 1 is usually generic drugs with the lowest copay-sometimes even $0. Tier 2 is preferred brand-name drugs. Tier 3 is non-preferred brands. Tier 4 and 5? Those are specialty drugs-often biologics, cancer meds, or treatments for autoimmune diseases-and they can cost $100 to over $1,000 per month. You pay a percentage of the price, not a flat fee.

A tier exception lets you move a drug from a higher tier to a lower one-even if it’s not the plan’s first choice-because your doctor says you need it. It’s not about the drug being better. It’s about your body reacting differently. Maybe the cheaper alternative gave you nausea, or caused a dangerous drop in blood pressure, or didn’t control your symptoms at all. That’s enough.

The Centers for Medicare & Medicaid Services (CMS) defines it clearly: a tier exception is a request to get a drug on the formulary at a lower cost-sharing level. It’s different from a formulary exception, which is for drugs your plan doesn’t cover at all. This one? You’re asking to pay less for a drug they already cover-but too expensively.

Why Most People Don’t Ask (And Why You Should)

A 2023 survey by the Medicare Rights Center found that only 18% of patients who could benefit from a tier exception actually request one. Why? Because they don’t know it’s an option. Or they assume their doctor already handled it. Or they got scared off by the paperwork.

Here’s the reality: if your drug is on your plan’s formulary but you’re paying $80 a month, and there’s a cheaper version of the same drug class that your doctor says won’t work for you, you’re leaving money on the table. The average savings? $37.50 per fill. That’s over $450 a year for one drug. For specialty meds, moving from tier 4 to tier 2 can cut costs from $1,200 to $80 a month. That’s not a small win-it’s life-changing.

And here’s the kicker: 62% of tier exception requests are approved when submitted with proper documentation. That’s better than flipping a coin. But if the paperwork is sloppy? Approval drops to 31%.

How to Get a Tier Exception: Step by Step

It’s not complicated. But it does require two people: you and your doctor.

1. Check your copay before filling the prescription. When your pharmacy tells you the price, ask: “Is this the lowest tier this drug is on?” If it’s not, and it’s higher than you expected, don’t fill it yet.
2. Ask your doctor to submit a tier exception request. Tell them: “I can’t afford this copay. Can you request a tier exception to move this drug to a lower tier?” They’ll need to fill out a form from your insurer. Most have online portals now. Some still use paper.
3. Make sure the doctor’s note is specific. Generic statements like “This drug works better for me” won’t cut it. They need to say: “Patient experienced severe dizziness and syncope on Lisinopril. Switching to Losartan is medically necessary due to intolerance.” Or: “Patient developed GI bleeding on Warfarin. Apixaban is required to avoid recurrence.” Specifics = approval.
4. Submit the request. Your doctor’s office can submit it for you. Or you can log into your insurer’s portal and upload the form yourself. Either way, keep a copy.
5. Wait for a decision. For non-emergencies, you’ll hear back in 14 days. If your doctor says your health is at risk without the drug, request an expedited review-you’ll get a decision in 72 hours.

What If They Say No?

Denials happen. But they’re not final.

About 37% of initial requests get denied because the clinical documentation is too vague. That’s fixable. You can appeal. And 78% of appeals with better documentation get approved.

Here’s how to appeal:

• Get a second note from your doctor. Add more detail: lab results, hospitalizations, prior medication failures.
• Include a letter from your pharmacist if they’ve seen you struggle with side effects.
• Call your insurer’s member services. Ask for the appeals process. Write down the name of the rep you speak to.

Real story: One patient tried twice for Xarelto. First denial said “insufficient clinical detail.” Second time, the doctor added: “Patient had two episodes of epistaxis on Rivaroxaban. Xarelto is the only anticoagulant tolerated.” Approved-moved to tier 2. Copay dropped from $60 to $40. Not perfect, but better.

Which Drugs Are Most Likely to Qualify?

Tier exceptions are most common-and most valuable-for drugs treating chronic, complex conditions:

• Rheumatoid arthritis: Biologics like Humira, Enbrel, or Orencia often sit in tier 4. Moving to tier 3 can cut costs by 70%.
• Multiple sclerosis: Drugs like Tysabri or Lemtrada are specialty tier. A tier exception can drop coinsurance from 35% to $50 flat.
• Heart failure or atrial fibrillation: Switching from a generic blood thinner to a preferred brand due to bleeding risk.
• Diabetes: Insulin analogs like Humalog or Lantus sometimes get stuck in tier 3. If you’re on Medicare, you’re now capped at $35/month for insulin-but tier exceptions still help with other meds like GLP-1 agonists.

Timing Matters

Don’t wait until you’ve paid $150 for your first fill. The best time to request a tier exception is right after your doctor writes the script-before you go to the pharmacy.

New trend: “Proactive tier exceptions.” Doctors submit the request at the same time they write the prescription. In 2023, UnitedHealthcare reported 89% approval rates for proactive requests versus 67% for reactive ones. Why? Because the insurer gets the full picture before the patient even tries the drug.

What’s Changing in 2025?

Starting in 2025, the Inflation Reduction Act caps out-of-pocket drug costs for Medicare Part D beneficiaries at $2,000 per year. That’s huge. But here’s the catch: that cap only kicks in after you’ve spent $2,000. So if you’re paying $100 a month for a drug, you’ll hit that cap in 20 months. But if you lower your copay to $40? You’ll hit it in 50 months.

Tier exceptions still matter. They keep you under the cap longer. They reduce financial stress. They prevent gaps in care.

And even if you’re not on Medicare-most private insurers use the same tier system. The rules are similar. The process is the same.

Final Tip: Know Your Plan

Every plan is different. Some have 4 tiers. Some have 5. Some include specialty drugs in tier 4. Others have a separate tier 5. Your plan’s formulary list is online. Look it up. Find your drug. See what tier it’s on. Then compare it to alternatives. If you see a drug in a lower tier that’s in the same class, ask your doctor: “Could I use this? If not, why?” That’s your opening to request an exception.

You don’t need to be a medical expert. You just need to know your rights. And if you’re paying too much for a drug your doctor says you need, you’re not being unreasonable. You’re being smart.