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My Medicare Part D plan won't cover my drug. How do I ask for an exception and how fast must they decide?
Health insuranceAppealChecked Nov 6, 2026
From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: CMS · Exceptions (Part D) · page text View original ↗
In short
- Ask your plan for an exception. Your prescriber sends a statement.
- The plan decides in 72 hours, or 24 if urgent, after the statement.
- If it says no, you can appeal.
What this means
A Part D plan has two kinds of exceptions. A tiering exception asks for a lower price on a drug in a higher tier. A formulary exception asks for a drug that is not on the plan's list, or asks to waive a rule like step therapy [1]. You, your prescriber or your representative can ask [1].
Your prescriber has to send a statement that supports the request [1]. After the plan gets it, it must give written notice of its decision within 24 hours for a fast request. A standard request is 72 hours [1]. To be paid back for a drug, the plan has 14 days [1]. If the answer is no, the notice tells you how to ask for a redetermination. That is the first appeal [1].
Your next step
Call your plan this week and ask for its exception form. Ask your prescriber to send the supporting statement. Write down the date the plan got it. The deadline these sources give is 24 hours for the plan to decide a fast request [1].
Check it yourself
Your plan's formulary list and exception form show how to ask. The exact steps for the appeal levels are in Medicare.gov's drug plan appeals page.
Where this comes from (1)
[1] CMS · Exceptions (Part D) · page text · checked 2026-11-06
An enrollee, an enrollee's prescriber, or an enrollee's representative may request a tiering exception or a formulary exception … A formulary exception should be requested to obtain a Part D drug that is not included on a plan sponsor's formulary, or to request to have a utilization management requirement waived (e.g., step therapy, prior authorization, quantity limit) for a formulary drug … Therefore, an enrollee's …
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 2026-11-06.
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.
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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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