The pharmacist says the plan will not cover it. Or it is covered, but on a tier where your share is several hundred dollars. Neither answer is necessarily final. Part D includes a formal process for asking your plan to cover a drug it excludes, to charge you a lower tier's cost sharing, or to waive a restriction like prior authorization — and the plan has to answer within a set number of hours. The process is not complicated, but it has one requirement that determines everything: your prescriber has to supply a supporting statement, and the clock does not start until the plan receives it. Here is how to work through it in 2026.
Coverage Determinations and Exceptions
A coverage determination is your plan's initial decision about whether a drug is covered and what you pay for it. An exception is a specific type of coverage determination — a request to depart from the plan's standard rules. Three kinds come up most often:
- Formulary exception — asking the plan to cover a drug that is not on its formulary at all
- Tiering exception — asking the plan to charge you the cost sharing that applies to a lower tier
- Utilization management exception — asking the plan to waive prior authorization, step therapy, or a quantity limit
A request may be filed by you, your appointed representative, or your prescriber. Filing does not require a lawyer or a formal hearing, and it costs nothing.
Before You File: Two Faster Options
Sometimes there is a simpler answer than an exception request.
Ask about a therapeutic alternative. If a covered drug in the same class would work, your prescriber can switch the prescription and the problem is solved that afternoon. This is worth asking about first, because a formulary exception generally requires demonstrating that alternatives would not be as effective or would cause harm.
Check whether a transition supply applies. If you are new to a plan, or your plan dropped a drug you were already taking, Part D transition rules generally require the plan to provide a temporary supply — typically at least a month's supply during the first 90 days of the plan year or your enrollment. That supply is meant to buy time to file an exception or switch drugs, not to solve the problem permanently. Our guide to formulary tiers and coverage rules explains how drug lists are structured.
The Prescriber's Supporting Statement
This is the heart of the request. Your prescriber must provide a statement explaining, in medical terms, why the plan's standard rule should not apply — for example, that formulary alternatives have been tried and were not effective, or would be expected to cause an adverse reaction given your history.
Two practical points:
- For exception requests, the plan's decision clock does not begin until it receives the prescriber's supporting statement. A request filed without it can sit unanswered
- If the statement never arrives, there is a backstop: after 14 calendar days from the request, the plan must issue its decision within 72 hours of the end of that period — which usually means a denial
The most effective thing you can do after filing is to confirm with the prescriber's office that the statement has been sent, and then confirm with the plan that it has been received.
The Deadlines
| Request type | Plan's deadline | |---|---| | Standard exception request | 72 hours after receiving the prescriber's supporting statement | | Expedited (fast) exception request | 24 hours after receiving the supporting statement | | Standard coverage determination (no exception) | 72 hours after receiving the request | | Expedited coverage determination | 24 hours after receiving the request | | Request for reimbursement of a drug you already paid for | 14 calendar days |
Expedited review is available when waiting the standard time could seriously jeopardize your life, health, or ability to regain maximum function. If your prescriber states that this applies, the plan must expedite the request. Without prescriber support, the plan decides whether the situation qualifies. Expedited review is not available for requests to be paid back for a drug you have already purchased.
Tiering Exceptions: What They Can and Cannot Do
A tiering exception asks the plan to apply a lower tier's cost sharing to your drug. Plans have discretion here, and there are structural limits worth knowing before you file:
- Plans may exclude drugs on a specialty tier from tiering exceptions entirely
- A tiering exception generally moves a drug to the tier used for alternatives in the same category — it does not let you pick any tier
- Brand drugs generally cannot be moved to a generic tier unless the plan's rules allow it
A supporting statement for a tiering exception usually needs to explain why the lower-tier alternatives in that drug class would not be as effective for you, or would cause an adverse reaction.
If the Request Is Denied
A denial is the beginning of the appeals process, not the end of it. The written denial notice must explain the reason and the next step.
- Level 1 — Redetermination by the plan: you generally have 60 days from the denial notice to request it. The plan must respond within 7 calendar days for a standard request or 72 hours for an expedited one
- Level 2 — Independent Review Entity: an outside organization reviews the case, with the same 7-day and 72-hour deadlines
- Levels 3 through 5 — an Administrative Law Judge hearing (subject to a minimum dollar amount in dispute, which is adjusted annually), the Medicare Appeals Council, and federal district court
Our guide to appealing a Medicare decision walks through the levels in more detail, including deadlines and how to submit additional evidence.
What Happens If the Request Is Approved
An approved formulary exception generally remains in effect for the rest of the plan year, as long as your prescriber continues prescribing the drug and it remains safe for your condition. Two follow-ups matter:
- The approval does not automatically carry into the next plan year. Formularies reset each January, so check your Annual Notice of Change and re-file if needed
- Costs still count normally. Amounts you pay for an approved drug count toward the $2,100 out-of-pocket cap in 2026 — see our guide to the Part D out-of-pocket cap
If affording the drug is the underlying problem rather than coverage, two programs may help: Extra Help, which lowers premiums, deductibles, and copays for people with limited income and resources, and the Medicare Prescription Payment Plan, which spreads out-of-pocket drug costs into monthly installments.
How to Get Help and Learn More
- Your plan — Coverage determination request forms are on every plan's website, and CMS publishes a model form plans generally accept.
- Medicare.gov — See medicare.gov/claims-appeals for the drug appeals process.
- 1-800-MEDICARE (1-800-633-4227) — For general questions about drug coverage decisions. TTY users can call 1-877-486-2048.
- State Health Insurance Assistance Program (SHIP) — SHIP counselors help with exception requests and appeals at no cost, at shiphelp.org.
Summary and Next Steps
- An exception is a type of coverage determination — for a non-formulary drug, a lower tier, or waiving prior authorization, step therapy, or quantity limits
- The prescriber's supporting statement is required, and for exception requests the decision clock starts when the plan receives it
- Plans must decide within 72 hours (standard) or 24 hours (expedited); reimbursement requests take up to 14 calendar days
- Specialty-tier drugs may be excluded from tiering exceptions
- If denied, you generally have 60 days to request a redetermination, decided in 7 days or 72 hours if expedited
- Approvals generally last through the plan year, but formularies reset each January
Two phone calls move most requests along: one to the prescriber's office to confirm the supporting statement was sent, and one to the plan to confirm it was received. Until that statement lands, the clock is not running.
