Medicare offers various exceptions to beneficiaries, including tiering, formulary, and continuing employment.

Generally, Medicare has set rules and regulations. However, there are certain times and circumstances when Medicare makes exceptions for beneficiaries.

An exception request is a type of coverage determination. These requests can be made by an enrollee, a prescriber, or a representative of the enrollee.

Medicare Part D plans generally place covered prescription drugs into tiers. Prescriptions in higher tiers typically cost more. Each Medicare-approved private insurance company that offers Part D plans can set its own tiers.

Part D tier examples

  • Tier 1 (lowest copayment): most generic prescription medications
  • Tier 2 (medium copayment): preferred, brand-name prescription medications
  • Tier 3 (higher copayment): nonpreferred, brand-name prescription medications
  • Specialty tier (highest copayment): very high cost prescription medications

A tiering exception can be requested to receive a nonpreferred drug at a lower cost-sharing term typically reserved for lower-tier drugs.

Generally, this request is used when a person can’t afford the copayment on a drug that they need. To request a tiering exception, follow these steps:

You cannot request a tiering exception if your prescription is in a specialty drug tier.

  • Speak with your pharmacist or Part D plan provider about why your prescription costs more. If the copayment is higher because the prescription is on a higher tier than other similar drugs, you can request a tiering exception.
  • Ask your plan how to request a tiering exception. You may need a letter of support from your healthcare professional that explains why similar medications in a lower tier are ineffective.
  • If your plan approves the request, you will be able to receive your prescription at the cost-sharing amount that applies to the lower tier. Usually, this agreement is good for the rest of the calendar year. It is important to speak with your plan to see if they will continue to cover the prescription at the lower cost after the end of the year.

Your plan must give you a decision within 72 hours of receiving your request. However, you can request an expedited decision if your healthcare professional feels your health could be harmed by waiting the standard time. If the plan grants the expedited request, they will generally give you a decision within 24 hours.

Each Medicare Part D plan has a formulary. This is a list of all the prescription drugs the plan covers. Formularies can include both brand-name and generic drugs, and may also include original biological products and biosimilars. Part D plans can set their own formularies.

A note on formularies

Each formulary includes at least two drugs in the most common prescribed categories and classes. All plans must include most drugs in certain protected classes on their formularies.

These protected classes include:

It is possible that your plan’s formulary may not include a specific medication. However, there is generally a similar drug available. If your healthcare professional believes none of the medications on the formulary will be effective for your needs, you can request an exception.

Your request must include a statement from your healthcare professional indicating that the nonformulary drug is necessary because any of the covered drugs wouldn’t be as effective or would have more adverse effects.

Your plan should give you a decision within 24 hours for expedited requests or 72 hours for regular requests.

Generally, Medicare does not provide coverage outside of the United States and its territories like Puerto Rico and Guam.

There are limited situations when you may be able to get Medicare Part A and Part B coverage outside the United States. These exceptions are:

  • You’re in the United States when an emergency occurs, and a foreign hospital is closer than the nearest U.S. hospital.
  • You’re traveling through Canada without unreasonable delay between another state and Alaska when a medical emergency occurs, and the Canadian hospital is closer than a U.S. hospital.
  • You live in the United States, and a foreign hospital is closer to your home to treat you, regardless of whether you have a medical emergency.

There are certain times when you can request exceptions to some of Medicare regulations. This includes requesting a medication to be on a lower tier or getting coverage for a prescription that is not on your drug plan’s formulary.

There are also specific exemptions to Medicare coverage outside the United States.

You can speak with Medicare or with your plan provider if you have questions about exemptions.