Tip for Tiering Exception

A tiering exception moves your drug to a lower copay tier — it does not make it free

Tip for Tiering Exception

Your prescriber must certify that the lower-tier drugs are not as effective or would cause adverse effects

Tip for Tiering Exception

Tiering exceptions are specific to Part D and some commercial plans — check your plan's rules

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Tiering Exception Request

Tiering Exception · Part D Plans / Commercial Insurers

Request to obtain a non-preferred drug at the lower cost-sharing tier. Prescriber must provide a supporting statement documenting why the lower-tier alternatives are not appropriate.

Form Details

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Where to Submit This Form

📠

Fax to your insurer or Part D plan's exceptions department

Fax number is on the formulary or plan documents.

🌐

Through the plan's provider portal or CoverMyMeds

📬

Mail to the plan's coverage determination department

Required Attachments

📎 Completed tiering exception request form
📎 Prescriber's supporting statement explaining why the lower-tier alternatives are not appropriate
📎 Medical records documenting prior treatment attempts with lower-tier drugs
📎 Clinical rationale for the higher-tier medication

Processing Time

Standard: 72 hours (Part D). Commercial plans: varies, typically 15-30 days.

What Happens Next

If approved, the drug moves to a lower cost-sharing tier. If denied, you have the right to appeal. The plan must provide written notice of the decision with appeal rights.

Tips for This Form

✓ A tiering exception moves your drug to a lower copay tier — it does not make it free
✓ Your prescriber must certify that the lower-tier drugs are not as effective or would cause adverse effects
✓ Tiering exceptions are specific to Part D and some commercial plans — check your plan's rules
✓ If denied, follow the standard appeals process (redetermination, then IRE review for Part D)

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Part D Plans / Commercial Insurers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.