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Exception Requests for Prescription Drugs

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What is an Exception Request?
  • 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 

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Copyright © 2024 Triage Cancer.
All rights reserved.