How to Get a Tier Exception Approved by Insurance

A tier exception allows health insurance to cover a prescription medication at a different, often lower, cost-sharing tier than initially assigned. Health plans organize drugs into tiers, each with a different out-of-pocket cost. This process seeks coverage for a medically necessary drug that would otherwise be more expensive due to its placement on a higher cost tier within the plan’s formulary, the list of covered drugs.

Understanding Exception Eligibility

A tier exception is considered when a patient cannot use a formulary alternative due to medical necessity. Insurance providers grant these exceptions when specific clinical criteria are met, demonstrating why the higher-tiered drug is the most suitable option. Eligibility requires proving the requested drug is medically appropriate and necessary for the individual’s condition.

Reasons for an exception include when a formulary alternative drug has been tried and found ineffective. Another situation involves formulary alternatives that have caused or are expected to cause adverse reactions, or are otherwise contraindicated. An exception may also be granted if no comparable formulary alternative drug is available to effectively treat the patient’s condition. The prescribing physician’s statement must clearly indicate why preferred drugs would not be effective or would have negative effects.

Gathering Request Information

Preparing a tier exception request involves compiling specific details and supporting documentation, often requiring collaboration between the patient and their prescribing physician. Accurate patient information, including full name, date of birth, and insurance identification number, is foundational. Complete prescriber information, such as the doctor’s full name, contact details, and National Provider Identifier (NPI), is also necessary for identification and communication.

Detailed medication specifics are crucial, including the full drug name, dosage, frequency, quantity, and a clear reason for its prescription. The most substantive part of the request is the medical rationale, requiring in-depth notes from the prescribing physician. This rationale must explain why the non-formulary drug is medically necessary and why lower-tiered formulary alternatives are unsuitable due to ineffectiveness, adverse side effects, or contraindications. Include any relevant diagnostic test results or medical history that support the need for the specific drug.

Insurance companies provide specific forms for tier exception requests, found on their website or through their pharmacy benefits manager. These forms guide the submission process by outlining required fields for patient, prescriber, and medication details. Completing these forms accurately with all gathered information is an important step in preparing a strong and compliant request.

Submitting the Request

Once all necessary information and documentation are gathered, submit the tier exception request to the insurance provider. Common submission methods include online portals, fax, or mail; some plans also accept requests via phone. Ascertain the preferred submission method for the specific insurance plan to avoid delays.

While patients provide personal details, the prescribing physician’s office handles the actual submission, given the clinical detail required. The physician’s office is best equipped to provide the supporting medical statements and documentation central to the request. Before submission, double-check that all required fields on forms are completed and all supporting documentation is attached.

After submitting the request, obtain confirmation of its receipt. This can involve noting confirmation numbers for online submissions, securing fax confirmations, or tracking mailed documents. Keeping a record of the submission date and method is helpful for future reference and tracking the request’s progress.

Navigating the Decision Process

After submission, the insurance company’s medical review team evaluates the tier exception request based on medical necessity and established plan criteria. This review assesses whether the provided medical rationale sufficiently justifies the need for the requested drug over available formulary alternatives. The review team includes medical professionals who examine the clinical details and supporting statements.

Insurance companies are required to provide a decision within specific timelines. For standard requests, a decision is communicated within 72 hours of receiving the complete request and supporting statement from the prescriber. If the patient’s health could be seriously harmed by waiting, an expedited review can be requested, yielding a decision within 24 hours. These timelines are set by federal regulations for plans like Medicare Part D, and similar standards apply to many commercial plans.

Decisions are communicated through a written notice, sent via mail, or through an online portal or phone notification. If approved, the notice details coverage terms, including the new cost-sharing tier. If denied, the communication outlines the reasons, allowing the patient and prescriber to understand the basis. Should a request be denied, immediate next steps include seeking clarification from the insurer and potentially providing additional supporting documentation. An internal appeal process can then be initiated to formally dispute the denial, allowing reconsideration by the insurance plan.