Find answers to commonly asked questions about therapeutic use exemptions and the application process.
A Therapeutic Use Exemption (TUE) is special permission to use a prohibited substance for medical reasons based on substantial medical documentation. The USADA TUE process is consistent with the World Anti-Doping Agency International Standard for Therapeutic Use Exemptions and designed to protect the rights of clean athletes
Start here. In general, a TUE is required for all prohibited substances and methods (see WADA’s Prohibited List), however the requirements vary depending on your competition status. For athletes who are a part of the USADA or IF National or International Registered Testing Pool, a TUE is required for all prohibited substances or methods. For recreational or masters level athletes also referred to as ‘non-national level athletes,’ USADA has special arrangements in place that require a TUE in advance for some medications but not others. For a thorough review of this policy, please see USADA’s TUE Policy. If you are competing at an International Event (an event sanctioned by the International Federation of your sport), you must obtain a TUE in advance of using any prohibited substance, regardless of your competition level. Failure to do so may results in an anti-doping rule violation.
All US athletes are encouraged to submit their application directly to USADA, even though in some instances the International Federation is the granting body for the TUE. USADA has special arrangements with the International Federations such that we receive all TUE applications. USADA will interact with the National and International Sporting Bodies on behalf of the athlete.
To obtain a TUE, you should visit the Apply for a TUE page on the USADA Website. There you will find two documents to download: 1) an application form and 2) medical information required to justify the use of the prohibited substance. Read both documents so that you understand the requirements, and bring them with you to your doctor’s appointment. Your doctor should review the medical requirements for the TUE so that he or she can supply all of the relevant information. After completing the application, submit it to USADA by fax, mail, or email according to the instructions on the application form. We will notify you when we receive your application. If you don’t hear from us within three days, let us know – we may not have received your application.
The most important aspect of a TUE application is the medical file. The Therapeutic Use Exemption Committee will need to review any and all relevant medical details related to the application, including patient history, test results, how the disease/disorder/injury has been managed over time, and any and all attempts to use non-prohibited medications and methods. Read the application form and the medical information requirements closely and urge your doctor to do the same. The medical file should be as complete as possible.
The TUEC is the group of doctors and medical experts that review your TUE application with a focus on your medical file, and provides the recommendation for approving or denying your TUE application. The TUEC takes into account your entire medical file, the anti-doping rules established by the World Anti-Doping Agency and USADA, and the current opinion for best medical practice. Each anti-doping agency and International Federation has its own TUEC. Your identity is never revealed to the TUEC.
Your doctor plays a crucial role in supplying the medical information necessary for the approval of a TUE. The Therapeutic Use Exemption Committee relies on the information supplied by your doctor to determine if your file meets the medical criteria set by the World Anti-Doping Agency.
USADA and the International Federations have authority to grant TUEs. The granting body for your TUE will be determined by your membership in a testing pool; whether you compete locally, nationally, or internationally; and the prohibited substance being applied for. USADA has mutual recognition agreements with several International Federations. When you submit your application to USADA we will notify you as to who is the granting authority for your TUE. Regardless of the granting authority, all applications from U.S. athletes should be submitted to USADA.
Competition status refers to whether you compete in local, State, National, or International events, and whether you are a member of a testing pool (USADA National Testing Pool or International Federation International Testing Pool). Your competition status is used to determine the granting authority for your TUE. USADA grants TUEs for all athletes competing at or below the National Level. For athletes in an International Testing Pool, or for athletes competing in International Events, the granting authority is the International Federation. Regardless of the granting authority, all U.S. athletes should submit their TUE application to USADA.
A testing pool is a pool of athletes identified as National or International caliber athletes by USADA or an International Federation. USADA refers to athletes in a testing pool as NTP – National Level athletes. Athletes who are not in a testing pool are generally referred to as ‘non-national level’ athletes. You will be made aware if you are in a testing pool. Otherwise you are a non-national level athlete.
Athletes are informed if they are part of a testing pool. USADA and/or the International Federation for your sport will be able to tell you if you belong to a testing pool.
A non-national level athlete is an athlete who does not belong to the USADA national testing pool. Sometimes this is also referred to as “non-national level” athletes in USADA documentation.
In some instances, a TUE application is returned to the athlete without being reviewed by the TUEC. Applications are often returned because they are not complete, or because a TUE is not required. A returned application should not be interpreted as a denial of your TUE. If your application is formally denied by the TUEC you will receive specific notification of this. If your application has been returned to you because it is incomplete, you are encouraged to resubmit it with new information.
I'm a recreational or masters level athlete, but I like to compete in events and races. Do I need a TUE?
Start here and consult USADA’s policy on TUEs. You may need a TUE depending on the level at which you compete. If you compete at events sanctioned by an International Sporting Federation, then you need to obtain TUEs for prohibited substances along the same lines as an athlete in a testing pool of the International Federation. If you compete at a National level or below, then the requirements for TUEs vary based upon the medication. Please note, sometimes “international events” are held in the United States, and not all events occurring in another country are considered “International Events” for the purposes of TUEs.
My TUE was approved by USADA- why do I need to submit another TUE application to my International Federation?
Generally, athletes who compete at the National Level or below need only obtain a TUE from USADA. When such an athlete wishes to compete at an event sanctioned by the International Federation (whether in the US or abroad), a new TUE application may need to be submitted to the International Federation. USADA has mutual recognition agreements in place with many International Federations, and thus some IF’s recognize the TUE issued by USADA. However, in order to protect the athlete in the event of testing, it is important to ensure that the International Federation will recognize the TUE that USADA has issued. You should check with your International Federation to determine their TUE requirements, and you should notify USADA immediately if you intend to compete at an International Event. We can help you if a new TUE process needs to be initiated.
Not all International Federations will recognize a TUE issued by USADA for an International Event. For this reason, it is very important that you notify USADA if you intend to compete Internationally. Please note, sometimes “International Events” are held in the United States, and not all events occurring in another country are considered “International Events” for the purposes of TUEs.
I'm not sure if the event I plan on competing in is local, National, or International- how do I find out?
Your National and International Governing Bodies for your sport can help you determine if an event is considered to be National or International Level. Please note, sometimes “International Events” are held in the United States, and not all events occurring in another country are considered “International Events” for the purposes of TUEs.
If you are prescribed a prohibited substance for an emergency, you should file an emergency TUE. The process is essentially the same – you should download the relevant forms from the TUE application page and submit them as a matter of urgency. Make sure to write EMERGENCY TUE at the top of the form so that we know to expedite processing. It is understood that in some instances not all medical information can be obtained quickly. You should make your best effort to submit a medical file that is as complete as possible, and submit the TUE application as soon as practicable.
In the first instance, you should contact USADA to determine exactly why the TUE was denied if it is not made clear in the denial letter. Sometimes, there may be a critical piece of information that was overlooked or not provided, or new relevant information or test results may be available that would allow the TUE to be approved. You should investigate whether there is scope for resubmission of your application. Failing this, you may appeal the decision to the World Anti-Doping Agency. Information regarding the appeal process is available on the WADA website.
Predicting the time it takes for a medication to clear completely from your system is complicated, can vary greatly, and is unique between individuals and to each medication. For this reason, USADA cannot predict urine and/or blood clearance times for athletes. You will need to talk with your physician and/or pharmacist about the average time it takes the body to clear a particular medication, and whether there are any known factors that might affect how your body might process that medication. Once you have that information, you will need to decide for yourself whether the “clearance time” estimated by your physician or pharmacist is sufficient for you to compete. If you are not certain that the medication will have cleared by the time you compete, you are encouraged to apply for a TUE.
If you are planning a surgery, your first step is to look up all medications that you will be given (or that will be administered) during or after your surgery on www.GlobalDRO.com. For general anesthesia, it is common for more than one medication to be used. There may be cases when it is not possible to find out in advance of what medications you will receive (such as in an emergency) and sometimes the anesthesiologist will change his or her mind during the surgery about the most appropriate medication to use. In all cases, request a copy of the surgical notes in order to find out which medications were administered and submit an emergency TUE if necessary. Please review the USADA surgery checklist before a planned visit or emergency visit to the hospital.
The NCAA has different rules and regulations regarding medical exemptions compared to USADA, thus please contact the appropriate person at your education institution or NCAA to discuss your medication and if the medication is on the NCAA Banned Drug List. You may need to obtain a Medical Exception for Banned Substances with NCAA for this medication. Please note, if you are competing in NCAA events AND competitions sanctioned by the governing body for your sport, you may need a TUE from USADA for the competitions sanctioned by your national governing body as well as a Medical Exception for Banned Substances with your education institution or NCAA. The application and review processes are completely separate.
The beta-2-agonist inhaler I am prescribed for asthma has a threshold listed for the inhaler dose, but not my nebulizer dose. What is the maximum amount of the nebulizer I can use?
The beta-2-agonists used for the treatment of asthma that have a limited dose or threshold set by WADA include inhaled salbutamol (maximum 1600 micrograms over 24 hours), inhaled formoterol (maximum delivered dose 54 micrograms over 24 hours) and salmeterol when taken by inhalation in accordance with the manufacturers’ recommended therapeutic regimen. These include the isomers when available, such as levalbuterol (Xopenex®) and arformoterol (Brovana®). The threshold for the presence in urine of salbutamol is 1000 ng/mL and formoterol is 40 ng/mL. When used as a nebulized treatment, the dose used is more than that listed for the inhalers. This is because a nebulizer device does not deliver that full amount into your lungs. Instead, only a fraction of that dose is inhaled. The amount you take per treatment is dependent on both the nebulizer device you use and the way in which that medical device nebulizes the specific drug. USADA does not maintain a list of all nebulizer devices or the percentage of drug each administers. As the athlete, you should contact the manufacturer of the nebulizer device and ask what percentage of the drug you are using is administered with each dose. If the amount inhaled is higher than the dose allowed by WADA, submit a Therapeutic Use Exemption for the use of your nebulizer and related inhalers.