How fast must the plan decide a formulary exception?

For plans subject to the federal essential-health-benefit drug exception rule, the initial decision is due no later than 72 hours after a standard request or 24 hours after a qualifying expedited request. Other plans may use different timeframes, so check the plan documents.

What if the exception is denied?

Plans subject to the federal essential-health-benefit exception rule must provide an independent external exception-review process. Other coverage may use a different internal or external appeal route; follow the denial notice.

"Drug not covered": how to get a formulary exception

Q: What is a formulary exception?

A formal request asking a plan to cover a clinically appropriate drug that is not on its covered-drug list. Marketplace and other non-grandfathered individual and small-group plans subject to federal essential-health-benefit drug rules must provide this process; other employer and public-program coverage follows its own plan and program rules.

UPDATED JULY 2026 · U.S. PLANS · NOT LEGAL OR MEDICAL ADVICE

A formulary is the plan's covered-drug list — and "not on the formulary" may not be the end of the conversation. Marketplace and other non-grandfathered individual and small-group plans subject to federal essential-health-benefit drug rules must offer a formulary exception process, with decisions due within 72 hours for standard requests and 24 hours for qualifying expedited requests. Other employer and public-program plans can use different rules.

What a well-supported exception addresses

The formulary alternatives were tried and failed, or caused adverse effects; or
The alternatives are contraindicated for your conditions/medications; or
The alternatives are expected to be ineffective for your specific case; and
Your prescriber says so in writing — their statement is the engine of the request.

Step 1 — Check the formulary and its tiers

Get the plan's current formulary (insurer website or member portal). Confirm your drug is truly excluded — sometimes it's covered on a high tier or behind prior authorization or step therapy instead, which changes the play. Note which alternatives the plan lists for your condition; your request must address why each is inappropriate.

Step 2 — Arm your prescriber

Prescriber support is central to many exception requests. Bring them: your medication history (drug, dates, outcomes — pharmacy dispensing records help), and the plan's listed alternatives. Ask them to file the exception request stating the specific clinical grounds per alternative and using the plan's required form or channel.

Step 3 — Follow up in writing

Free template — formulary exception request

[Your name] · Member ID: [ID] Reference #: [if any] · [Date] [Insurer / PBM name] — Coverage Determinations / Appeals [Address from denial letter or plan documents] RE: Formulary exception request — [medication, strength], prescribed by Dr. [name] To whom it may concern: I request a formulary exception for [medication], prescribed for my diagnosis of [diagnosis]. The formulary alternatives are inappropriate in my case: 1. [Alternative drug A]: tried [dates]; result: [failure/adverse effects]. Records enclosed. 2. [Alternative drug B]: [contraindicated because … / expected ineffective because …], per Dr. [name]'s enclosed statement. My prescriber's supporting statement is enclosed. [IF YOUR PLAN IS SUBJECT TO THE FEDERAL ESSENTIAL-HEALTH-BENEFIT EXCEPTION RULE: "Please issue the standard decision no later than 72 hours after receiving this request."] [IF EXPEDITED: "I request expedited review under the applicable plan standard; my prescriber's statement explains the exigent circumstances. Please apply the deadline stated in my plan and applicable rules."] If this request is denied, please provide the clinical rationale in writing; I intend to appeal and, if necessary, pursue independent external review. Enclosed: prescriber's supporting statement; pharmacy/medical records [list]. Sincerely, [Signature] · [Name] · [Phone]

If the exception is denied

Follow the denial notice. Plans subject to the federal essential-health-benefit exception rule must offer an independent external exception review after a denial; other coverage may use a different internal appeal or external review route. Keep the denial letter and the plan's exception instructions.

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Frequently asked questions

Is this the same as step therapy?

Related but different: step therapy means the drug is covered *after* you try others first; formulary exclusion means it isn't on the list at all. Exclusions use the exception process; step therapy uses exception grounds tied to the required drugs. If your denial mentions "fail first," see the step-therapy guide.

Can I just pay cash for the drug?

You can ask about cash pricing and assistance programs, but a purchase made outside the plan may not count toward your deductible or out-of-pocket maximum. Confirm with the plan before assuming that it will.

If granted, how long does the exception last?

Under the federal essential-health-benefit rule, a standard exception covers the duration of the prescription, including refills; an expedited exception covers the duration of the exigency. Other plans may use different periods, so read the written approval.