Formulary and Step Therapy Exceptions: How to Request One

Which exception to ask for

A formulary is your plan’s list of covered drugs. The reason your plan gives tells you which request fits, so start with the denial letter or the pharmacy’s rejection message.

Prior authorization is different. The drug is on the plan’s list, and the plan checks that you meet its criteria before it pays. With an exception, you are asking the plan to go beyond its list or its rules. If you do not meet the prior authorization criteria, your prescriber can ask for an exception to them.

How to ask

1. Find the exact reason. Read the letter or ask the pharmacist what the rejection said. "Non-formulary", "step therapy required" and "quantity limit" can all lead to an exception. "Excluded" or "not a covered benefit" usually cannot, as explained below.
2. Ask your prescriber’s office to file it. On Medicare, you or your prescriber can ask by letter, on a model form or by phone, but your prescriber has to give the medical reason. Private plans set their own process, so call the number on your card and ask for the plan’s drug exception process.
3. Send the evidence. Name each drug you tried, when, and what happened, and explain why the plan’s alternatives are unsafe or unlikely to work for you. If you are stable on the drug, say for how long.
4. Ask for an expedited decision if you cannot wait. Medicare allows one if waiting may seriously jeopardize your life, health or ability to regain maximum function. Marketplace plans also allow one if you are already being treated with a non-formulary drug.
5. Keep the paperwork. Write down when the request went in and keep the decision letter. Some maker programs ask for it.

How fast your plan must decide

If a Medicare plan misses its deadline, the rules treat that as a denial, and the plan must send your case to an independent reviewer within 24 hours.

Medicaid works differently. State programs must answer a prior authorization request within 24 hours and, in an emergency, supply at least 72 hours of the drug. Ask your state program or Medicaid plan how to request a drug it does not list.

What happens if it is approved

• How long it lasts. On Medicare, refills should not need a new approval during the plan year, as long as your prescriber keeps prescribing the drug and it stays safe for you. The plan may continue the approval into the next year but does not have to, so check at open enrollment. On Marketplace plans, a standard approval lasts for the prescription, including refills, and an expedited one lasts as long as the urgent need.
• What you pay. On Medicare, an approved tier exception gets you the lower tier’s cost, and a plan cannot create a special tier just for drugs approved by exception. HealthCare.gov says Marketplace plans generally charge the copay for their most expensive covered drugs, such as a non-preferred brand.
• Whether it counts. What you pay for a drug approved this way counts toward your yearly out-of-pocket limit, on Medicare and on Marketplace plans.

What an exception cannot fix

• Drugs your plan excludes. Some plans keep excluded drugs apart from non-formulary ones. One administrator’s list says excluded products are "NOT eligible for formulary exception review." With job-based coverage, ask your benefits office whether the exclusion is part of your plan’s design and whether any review exists.
• Weight-loss drugs on regular Medicare Part D. The law that created Part D excluded drugs used for weight loss, and the exceptions process cannot be used to cover a drug that is not a Part D drug. The Medicare GLP-1 Bridge is a separate, temporary program that covers some of these drugs at $50 a month.
• Some tier requests. A Part D plan can refuse to move a brand-name drug to a tier that holds only generics, or a biologic to a tier with no biologics. It can also keep specialty-tier drugs out of lower, non-specialty tiers. The federal rule for Marketplace plans covers drugs a plan does not otherwise cover and does not mention tiers, so ask your plan whether it takes tier requests.

Step therapy and state law

Step therapy, also called "fail first", means trying a lower-cost drug before the plan covers the one your prescriber chose. An American Bar Association survey found that, as of early 2026, 38 states and D.C. had some form of step therapy law. Most set limits rather than ban it. Roughly 33 states require an exception if the drug already failed for you, 32 if it is unsafe for you, and 31 if it is expected not to work. Illinois banned step therapy outright from January 1, 2026.

These laws generally do not reach self-funded employer plans, which federal law keeps out of state insurance rules, and about 67% of workers with job-based coverage were in such plans in 2025. Ask your benefits office whether your plan is self-funded or fully insured. A federal bill, the Safe Step Act (S. 2903 and H.R. 5509), would require an exception process in those plans too, but as of that September 2026 survey it had not become law.

While you wait

• Medicare. In your first 90 days in a new plan, you can get a one-time temporary supply of at least a month of a non-formulary drug. Plans also have to offer a transition if a formulary change affects you.
• Marketplace plans. HealthCare.gov says some insurers offer a one-time refill after you first enroll, and your plan may let you use the drug until it decides.
• Private insurance. Some makers supply the drug while you pursue coverage. We track 10 bridge programs, none of which accepts Medicare or Medicaid.

If the plan still says no

Check your copay card first, because a denial can end it. The terms of the cards for 31 drugs we track say your plan must cover the drug, including Humira, Ozempic, Wegovy and Zepbound. The cards for Ajovy, Brilinta and Symbicort also say the plan cannot have a step therapy or prior authorization restriction in place. A few cards name a price for when the plan does not cover the drug:

Some free-drug programs also take you when your plan will not pay. These are the ones whose terms say so:

If none of these fits, ask your prescriber about a covered alternative, and compare cash prices: a discount card can help with lower-cost drugs. How patient assistance programs work explains who qualifies for free-drug help.