The Centers for Medicare & Medicaid Services (CMS) do not allow tier lowering in certain scenarios for Medicare Advantage Part D prescription drug coverage.
However, a review of appeals for drug coverage shows that many providers continue to request tiering exceptions for medications that are ineligible for tier lowering. Appeal requests in these scenarios will be denied, which is consistent with CMS rules.
To help avoid future denied appeals, we are offering a flyer with a list of scenarios related to Medicare Advantage Part D prescription drug coverage which are not eligible for tier-lowering.
For reference, please download and print the flyer to keep on hand as a reminder of these sample scenarios.
Note: Also, an approval for a tier exception will not reduce the copay/coinsurance when the member is in the coverage gap.
We recommend you review this list before prescribing drugs in the excluded drug categories. Providers with questions can contact Customer Service at 1-800-ASK-BLUE (1-800-275-2583).