What if my drug isn't on my plan's formulary?
Last updated Jul 19, 2026
Reviewed by Jason Burns, Editorial Steward
Published by Senior Direct Answers · Licensed under Citation License 1.0
You have three main protections. First, you (or your prescriber) can request a formulary exception - if your doctor provides a supporting statement that the formulary drugs would be less effective or harmful for you, the plan must cover the drug; plans must decide standard requests within 72 hours and expedited requests within 24 hours. Second, if the plan says no, you can appeal through several levels (redetermination, independent review, and beyond). Third, if you are new to a plan or your plan changed its formulary, transition rules generally entitle you to a temporary fill (at least a one-month supply within your first 90 days) while you pursue an exception or switch drugs. Formularies change every plan year, so recheck coverage during each Open Enrollment.
What the government has said, on the record
“We developed specific procedures for timely exceptions and appeals. In using this procedures, a Medicare beneficiary can get coverage for a drug not on a plan's established formulary”
— Mark B. McClellan, M.D., Ph.D., Administrator of the Centers for Medicare & Medicaid Services (2004-2006); previously Commissioner of the U.S. Food and Drug Administration (2002-2004), Hearing, "Meeting the Challenges of Medicare Drug Benefit Implementation," U.S. Senate Special Committee on Aging (S. Hrg. 109-380), 2006-02-02 (source)
Editor's note: Historical source (2006, first year of Part D) - the exceptions/appeals framework it describes still exists, but surrounding transition-period details from 2006 do not; the phrase "In using this procedures" is a verbatim typo in the official GPO transcript (sic); current specifics (72/24-hour decision deadlines, transition fill amounts) come from current CMS rules, not this quote.
Who said this
Mark B. McClellan, M.D., Ph.D. — Administrator of the Centers for Medicare & Medicaid Services (2004-2006); previously Commissioner of the U.S. Food and Drug Administration (2002-2004) (current).
Also asked as
- What if my drug isn't on my plan's formulary — plain answer
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Last verified: 2026-07-18