Part D Exception Request Letter
Builds a Part D exception request with the prescriber statement the rule requires.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Kind of exception
- Tiering (a lower cost-sharing tier)
- Basis the prescriber states
- The alternatives would have adverse effects
- The prescriber provides the supporting statement
- Yes
- Drug, strength and quantity
- drug 10 mg, 30 tablets
- Enrollee name
- Pat Doe
- Member ID
- X123
- Plan name
- Example PDP
- Prescriber name and NPI
- Dr. Lee, NPI 1234567890
- Name of enrollee or prescriber signing
- Dr. Lee
- Request date
- 2026-09-20
Result: The plan decides within 72 hours of receiving the supporting statement. 1 blank left to fill before sending.
The tool opens with these values already filled in. Replace them with your own.
What you enter
- Kind of exception
- Basis the prescriber states (not needed for a dose restriction)
- The prescriber provides the supporting statement
- Drug, strength and quantity
- Enrollee name
- Member ID
- Plan name
- Prescriber name and NPI
- Name of enrollee or prescriber signing
- Ask for an expedited decision
- Request date (YYYY-MM-DD; blank for today)
How this is calculated
Citation
42 CFR 423.578: the prescriber's supporting statement for a tiering exception ((a)(4)), a non-formulary drug, step therapy or dose restriction ((b)(5)); decisions 72 hours (24 expedited) after the statement arrives (423.568(b), 423.572(a)). Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.