Prescription drugs

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A formulary exception is a request to cover a drug the plan does not normally cover. Your prescriber has to explain, in a statement, why the drug is medically necessary for you.
In a Medicare drug plan (Part D), the plan must answer within 72 hours, or 24 hours if urgent, once it has the prescriber's statement.
A rejection at the pharmacy counter is not yet a written denial. Ask the plan for the denial in writing so you have something to appeal.

More guides, tools, letters 13

Drug not covered: formulary exceptions
How to ask your plan to cover a drug that is not on its formulary. See who supplies the medical reasons and the Medicare drug plan deadlines.
Quantity limits, tier exceptions and forced switches
What to do when your plan limits how much of a drug you can get, charges a high tier price, or tells you to switch drugs. Also what Medicare drug plans must do.
Step therapy exceptions
How to ask your plan to skip the "try this drug first" rule. See what a step therapy exception request must show, and where state rules and Medicare drug plan deadlines fit.

Tool

Drug exception planner

Find the right request for a drug denial: formulary exception, step therapy exception, tier or quantity exception.

Letter or script

Appeal: formulary exception

Asks your plan to cover a drug that is not on its drug list, or to lift a quantity limit, using your prescriber's reasons why the covered alternatives do not fit.
Letter or script

Appeal: step therapy exception

Asks your plan to excuse you from trying other drugs first, using the drugs you have already tried and your prescriber's reasons, and to send its step therapy rules.
Letter or script

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.
Letter or script

Phone script: pharmacy rejection

What to ask at the pharmacy counter and then your plan when a prescription is rejected, so you learn why and what to send.
Letter or script

Step therapy exception letter (for your clinician)

A letter in your clinician's voice asking the plan to skip a required first-try drug because it has failed, is unsafe or is otherwise not right for you. Every clinical statement is a blank for the clinician to complete.

Denial reason

Drug not on the formulary

The drug your doctor prescribed is not on the plan's list of covered drugs. You can ask for an exception. Your prescriber will need to state why this drug, and not the covered ones, is right for you.
Denial reason

Quantity or dose limit

The plan covers your drug but only up to a set amount or on a set schedule. If your prescriber ordered more, you can ask the plan whether it has an exception process for this limit. It turns on your dose, your history and what happens at lower amounts.
Denial reason

Step therapy required

The plan wants you to try cheaper drugs first. You can ask for an exception. Holding a denial letter? File the appeal by your deadline, and ask your doctor to send the exception request at the same time.

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Questions to keep handy

Your notice or plan document controls if it differs from a general rule. Keep a copy of everything and the date and way you sent it.