Tier Exception Criteria - Medicare Part D

Tier Exception Criteria for Approval

1. The member must have tried at least three alternative formulary drugs that are on a lower tier and approved to treat the same condition as the requested drug AND the member either did not respond to or did not tolerate the formulary alternative drugs. (NOTE: If the drug requested for tier exception is a multi-source brand and the generic equivalent is covered on the formulary, the member must have tried and failed the generic drug equivalent as one of the three required formulary alternatives.) OR
2. The prescriber provides an explanation of why formulary drugs on a lower tier than the requested drug would not be as effective in treating the member’s condition and/or would cause the member to have adverse effects.

NOTES:

• Drugs on the Specialty Tier are not eligible for a Tier Exception.
• Tier Exceptions for brand name drugs will be approved to the lowest tier which contains brand name alternatives.
• Tier Exceptions for biological products will be approved to the lowest tier which contains biological alternatives.
• Tier Exceptions for generic drugs will be approved to the lowest tier which contains generic alternatives.
• Tier Exception requests cannot be considered for drugs that do not have an alternative available on a lower tier (e.g., levothyroxine tablets).
• Tier Exception requests cannot be considered for drugs that have been approved as a Formulary Exception.

Length of Approval: 12 months