Non-formulary drug
A drug not included on your plan's covered drug list. Requires a formulary exception request for coverage.
When a drug isn't on your plan's formulary, the plan won't cover it without a formulary exception. Federal law requires all ACA-compliant plans, Medicare Part D plans, and most commercial plans to maintain an exception process. The prescriber documents why formulary alternatives are clinically inappropriate (allergy, intolerance, contraindication, prior failure). Decisions: 24-72 hours for urgent, 7-14 days for standard.
Frequently asked questions
What is non-formulary drug?
When a drug isn't on your plan's formulary, the plan won't cover it without a formulary exception. Federal law requires all ACA-compliant plans, Medicare Part D plans, and most commercial plans to maintain an exception process. The prescriber documents why formulary alternatives are clinically inappropriate (allergy, intolerance, contraindication, prior failure). Decisions: 24-72 hours for urgent, 7-14 days for standard.
Is this relevant to a denial appeal?
If the formulary exception is denied, internal appeal and external review apply.
Related terms
- FormularyThe list of prescription drugs your plan covers, organized into tiers with different cost-sharing.
- Formulary exceptionA request for coverage of a non-formulary drug, supported by a prescriber statement of medical neces
- Step therapyA plan requirement to try and fail a cheaper drug before the plan covers the requested drug.
Appeal a denial
If the formulary exception is denied, internal appeal and external review apply.
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