Procedure
If your Part D plan does not list the drug, or lists it behind a requirement you cannot meet, the route is a formulary exception. It is a specific request with a specific name; asking generally for coverage will not start it.
Only Medicare Part D works this way. If you have commercial or employer coverage, use the internal appeal route instead.
The request does not proceed without it. Your prescriber must state why the formulary alternatives are not appropriate for you.
Say whether you want a drug added that is not on the formulary, or a utilization requirement waived, such as step therapy, prior authorization or a quantity limit.
The clock starts when the plan receives your prescriber's supporting statement, not when you first called.
Sixty calendar days from receiving the written coverage determination. Receipt is presumed five days after the date on the notice.
If the plan misses its own deadline, the case moves to the independent reviewer automatically within 24 hours.
What to say on the phone
I am requesting a formulary exception for [drug name] under my Part D plan. My prescriber is submitting a supporting statement. Please confirm the fax number or portal for that statement, and tell me the date the 72-hour clock starts.
Ask for the reference number for the coverage determination request and keep it. Every later deadline is measured from that decision.
Every number above comes from one of these. If a deadline here decides something for you, read the source, not our summary of it.
A formulary exception is used to obtain a Part D drug that is not on the plan's formulary, or to have a utilization management requirement such as step therapy, prior authorization or a quantity limit waived.
Centers for Medicare & Medicaid Services · source · read August 2026
Your prescriber must submit a supporting statement to the plan for the request to proceed.
Centers for Medicare & Medicaid Services · source · read August 2026
A request for redetermination must be filed within 60 calendar days after receiving the written coverage determination notice.
42 CFR §423.582(b) · source · read August 2026
A request for reconsideration must be filed with the independent review entity within 60 calendar days after receiving the redetermination.
42 CFR §423.600(a) · source · read August 2026
If the appeal fails, or you cannot wait
Cash-pay telehealth is the fallback, not the bargain: you pay the whole cost yourself, and a covered prescription is almost always cheaper than any of these. Use this route when coverage has actually been exhausted, or when you need to start while an appeal runs.
These companies pay us a commission if you start care through the links below. That is how this site is funded, and it does not change what is written above. How we pay for this.
Prices in those notes were read from each company's own site in August 2026 and change often. Check the current number before you buy.
Other procedures are listed on the procedures page, and the coverage matrix shows where your state stands.