My health plan dropped my medication from the formulary. How do I get an exception?

Health insuranceAppealChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 45 CFR 156.122(c) Prescription drug benefits · § 156.122(c)(1)–(3) View original ↗

In short

If your plan has essential health benefits, it must have a drug exception process.
Your prescriber can ask. A standard answer is due in 72 hours, urgent in 24.
If the plan says no, you can ask for an independent review.

What this means

Some plans must have a drug exception process. These are plans that provide essential health benefits. A health plan must have a process for you, your designee or your prescriber to ask for a review of a decision that a drug is not covered by the plan [1].

The plan must answer a standard request in 72 hours. It must answer an urgent request in 24 hours [1]. A request is urgent if your health could be seriously harmed, or if you are on a current course of treatment with that drug [1]. If the plan says no, you can ask an independent review organization to look at it [1].

A Medicare drug plan works differently. Medicare.gov calls its appeals Coverage Determination Requests [2].

Your next step

Ask the plan how to request an exception for a drug it does not cover. You, your designee or your prescriber can ask [1]. The deadlines these sources give are 72 hours for a standard request and 24 hours for an urgent one [1]. They give no deadline in days or weeks for you to ask.

Check it yourself

Your plan's formulary list and exception form tell you how to ask. Plans that do not provide essential health benefits may follow other rules — "Don't know yet".

Where this comes from (2)

[1] GovInfo · 45 CFR 156.122(c) Prescription drug benefits · § 156.122(c)(1)–(3) · checked 2026-11-06
A health plan must make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request … Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or abi…
[2] Medicare.gov · Appeals in a Medicare drug plan · Level 1 · checked 2026-11-06
Appeals of coverage decisions in a Medicare drug plan are called Coverage Determination Requests. When you're in a plan, you have the right to a coverage determination, either orally or written, to see if a drug is covered

How we found this

We matched your question to 2 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

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.

Ask a question Get help with my claim