Medicare drug plan exception request
Ask your Medicare drug plan to cover a drug that is not on its list, or to charge a lower cost-sharing tier. Your prescriber must support the request.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. When your Medicare Part D drug plan will not cover a drug you need because it is not on the plan's list of covered drugs (the formulary), or it sits on a tier that costs too much. This is a request for an exception to a coverage determination, the plan's first decision. Your prescriber must give a supporting statement, and the plan's clock starts when it receives it.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of your Medicare drug plan, from your denial notice]
Re: Medicare drug plan exception request Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am asking my Medicare drug plan, [Name of the health plan], for a coverage determination with an exception. My member identification (ID) number is [Member ID].
Drug: [The drug, strength and amount] Prescriber: [Your prescriber's name] Type of exception: [Type of exception]
My prescriber says I need this drug because: [Why you need this drug, as your prescriber explained it]
My prescriber is providing, or has provided, a supporting statement. I understand your deadline to decide an exception request starts when you receive that statement: 72 hours for a standard request, or 24 hours for an expedited request. If the statement does not reach you within 14 calendar days, I ask that you decide within 72 hours after that period ends.
A formulary exception asks the plan to cover a drug that is not on its list. A tiering exception asks the plan to charge a lower cost-sharing amount for a drug that is on its list. If I have chosen the wrong kind, please tell me which applies. If you need anything more from me or my prescriber, please tell us right away.
Please send me your decision in writing, with the reason and my right to appeal. You may reach my prescriber at [Your prescriber's phone number].
Enclosures: 1. Copy of the plan's notice or the pharmacy's rejection, if you have one 2. Your prescriber's supporting statement, if you have it 3. Receipts, if you already paid
Sincerely, [Your name]
Before you send it
Send it to the coverage determination address or fax number on your plan's notice or your plan's website, or call the member services number on your card and ask how to submit it. Ask your prescriber to send the supporting statement to the same place. Keep proof of the date.
What to enclose
- Copy of the plan's notice or the pharmacy's rejection, if you have one
- Your prescriber's supporting statement, if you have it
- Receipts, if you already paid
What happens next
- Ask your prescriber to send the supporting statement right away. For a tiering exception it must say the preferred drug would not be as effective or would have adverse effects. For a formulary exception it must say the requested drug is medically necessary for a reason the rules list.
- If the plan says no, ask for a redetermination within 60 calendar days after you receive the written denial. The Centers for Medicare & Medicaid Services (CMS) describes this as 65 calendar days from the date on the notice. Check the date on your notice, which controls. The plan must decide in 7 calendar days, or 72 hours if expedited.
- The next level is not automatic. If the plan upholds its denial, you, your representative or your prescriber must ask the Independent Review Entity in writing within 60 calendar days after receiving the redetermination (CMS: 65 calendar days).
- If the plan misses its deadline, that counts as a denial, and the plan must forward your request to the Independent Review Entity within 24 hours.
- Plans may exclude specialty-tier drugs from tiering exceptions, and need not move a brand-name drug to a tier that holds only generics.
- If you are new to the plan, ask about a one-time temporary supply. In the first 90 days of coverage, the plan must give a temporary supply of a drug that is not on its list or that needs prior approval, and must send you written notice within 3 business days.
- State Health Insurance Assistance Programs give free, one-on-one Medicare counseling and are not connected to any insurance company. Find yours at shiphelp.org or call 877-839-2675. You can also call 1-800-MEDICARE (1-800-633-4227).
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".