Questions & answers · Health insurance
My health plan dropped my medication from its formulary. How do I get an exception?
Health insuranceAppealChecked Nov 5, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: eCFR · 45 CFR 156.122 · § 156.122(c), (c)(1)(ii)-(iii), (c)(2)(ii)-(iii), (c)(3)(i)-(ii) View original ↗
In short
- You or your doctor can ask the plan to cover a drug not on its list.
- The plan must answer in 72 hours, or 24 hours if it is urgent.
- If it says no, you can ask for an outside review.
What this means
Plans that must cover "essential health benefits" (this includes marketplace plans) must have a way for you, someone you name, or your prescriber to ask for a drug that is not on the plan's list. This is called an exception request [1].
Standard request: the plan must decide and tell you and your prescriber no later than 72 hours after it gets the request. If it says yes, it must cover the drug for the length of the prescription, including refills [1]. Urgent ("exigent") request: this applies when your health is in serious danger or you are in the middle of treatment with the drug. The plan must decide within 24 hours [1].
If the plan says no, you can ask an independent review organization to look at it. The reviewer must decide within 72 hours for a standard request, or 24 hours for an urgent one [1].
Your next step
Ask your prescriber to send the plan an exception request with a note on why you need this drug. Ask for an expedited request if you are mid-treatment or your health is at risk.
Deadline: the plan must answer within 72 hours (24 hours if urgent).
Check it yourself
Your plan's drug list and member papers explain how to ask. This rule covers plans that must provide essential health benefits; for large employer plans and Medicare Part D, other rules apply — "Don't know yet" here.
Where this comes from (1)
[1] eCFR · 45 CFR 156.122 · § 156.122(c), (c)(1)(ii)-(iii), (c)(2)(ii)-(iii), (c)(3)(i)-(ii) · checked 2026-11-05
A health plan providing essential health benefits must have the following processes in place that allow an enrollee, the enrollee's designee, or the enrollee's prescribing physician (or other prescriber, as appropriate) to request and gain access to clinically appropriate drugs not otherwise covered by the health plan (a request for exception). … A health plan must make its determination on a standard exception and n…
How we found this
We matched your question to 1 official source, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.
What we don’t know yet
Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.
Every answer is checked against the official rule it quotes.
Information only — not legal advice. Your plan, insurer or agency decides.
This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.
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