Exception Requests for Prescription Drugs

An exception request is a type of appeal that you can file with your health insurance company when a medication is not covered on the list of drugs covered by your plan, also known as a formulary.
If your health care team can show that taking the specific drug is medically necessary for you, your health insurance company may make an exception to their process.
There are different types of exception requests:
- Non-formulary drug exception: a request to cover a non-formulary drug
- Tier exception: a request to treat a drug as if it were in a lower tier, reducing your out-of-pocket costs
- Brand exception: a request to cover a brand-name drug, if your policy only covers the generic form of the drug

When Exception Requests Might Be Helpful

Medications available on the formulary are not appropriate for your medical condition
Alternative medications on the formulary result in an allergic reaction
The use of a formulary medication might escalate symptoms of an underlying medical condition

Exception Request Tips

Work With Your Health Care Team

Your health care team can help you file exception requests, and they may do it for you.
They will send evidence and supporting paperwork to your health insurance company explaining why you need to take the medication they prescribed

Pay Attention to Due Dates

Once the request is filed, the plan should make a decision within 72 hours.
If your doctor feels that you not having the medication could put you in serious harm, an “urgent” or “expedited” request can be filed, and a decision should be made by your health plan within 24 hours.

Plan Next Steps

Your health insurance company will look at the evidence provided by your health care team and decide whether to cover the medication.
If your exception request is denied, you can speak with your health care team about appealing the decision or looking for alternative medications.

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Disclaimer: The information on this site is intended for U.S. residents only and is provided purely for educational purposes. Health, legal, regulatory, insurance, or financial related-information provided here is not comprehensive and is not intended to provide individual guidance or replace discussions with a healthcare provider, attorney, or other experts. All decisions must be made with your advisers considering your unique situation. © Triage Cancer & Pfizer Inc. 2024