Therapeutic Use Exemption (TUE)

  1. What is a Therapeutic Use Exemption (TUE)?
  2. What is the Prohibited List?
  3. When to apply for a TUE?
  4. Where should a national or lower-level athlete submit a TUE application?
  5. Where should an international level athlete submit a TUE application?
  6. What is the process for applying for a TUE?
  7. What happens after a TUE is granted?
  8. What are the conditions to obtain a TUE?
  9. What is a retroactive TUE?
  10. What is the role of WADA in the review of TUEs?
  11. What is a recognition of a TUE?
  12. What is an automatic recognition?
  13. What happens if the International Federation or Major Event Organizer refuses to recognize the NADO TUE?
  14. Can a Major Event Organizer (MEO) grant a TUE?
  15. What can an athlete do if their TUE is denied or not recognized by an IF?
  16. Where can an athlete appeal a decision made by WADA?
  17. Is the TUE granted by a NADO valid for an event or period of competition where the athletes falls under the jurisdiction of another NADO?
  18. Should athletes declare medications on the Doping Control Form (DCF)?
  19. Will the information in the athlete's TUE application remain confidential?
  20. What other resources on TUEs are available and where to find them?

1. What is a Therapeutic Use Exemption (TUE)? Up

Athletes may have an illness or medical condition that require them to take a medication or undergo procedures. If this medication or method is prohibited as per the World Anti-Doping Agency’s (WADA) Prohibited List, a TUE may give that athlete an exemption to take the medication or use the method, while competing in sport without invoking an anti-doping rule violation (ADRV) and applicable sanction.

2. What is the Prohibited List? Up

The Prohibited List (PL) is published by WADA and comes into effect on the 1st of January every year.   Many common medications that one may not associate with doping are on the PL such as insulin for diabetes treatment and some high blood pressure medications as well as prohibited methods such as intravenous (IV) use. If an athlete takes any medications at all, it is important to know where to always check the List on the WADA website or with a trusted National Anti-Doping database.  If one needs the treatment for legitimate medical reasons, then one must apply for a TUE.

3. When to apply for a TUE? Up

For substances prohibited in-competition only:

  • Athletes should apply for a TUE at least 30 days before their next competition, unless it is an emergency or exceptional situation.
  • If athletes know they will be taking a prohibited substance on a longterm basis, even if it is only prohibited in-competition, they should still apply as soon as possible to the appropriate Anti-Doping Organization (ADO).

For substances prohibited at all times:

  • The TUE application must be submitted as soon as the medical condition requiring the use of a prohibited substance or prohibited method is diagnosed, or as soon as the athlete reaches a competitive level requiring advance application for a TUE.

See ISTUE Guidelines - Chapter 3: When to apply for a TUE

4. Where should a national or lower-level athlete submit a TUE application? Up

National-level athletes must apply to their National Anti-Doping Organization (NADO) for a TUE. However, since criteria may differ from one NADO to another, athletes are advised to contact their NADO if there is a need for clarification.

See the ISTUE Guidelines – Chapter 4: Where to Apply, Flowchart ‘WHERE SHOULD NLAs APPLY’

Note that some athletes may not be considered as National-level athletes and/or may be a low priority athlete for that particular NADO. They may not need to apply in advance for a TUE. Athletes should consult the NADO rules or contact the NADO for clarification.

5. Where should an international level athlete submit a TUE application? Up

International-level athletes must apply for a TUE directly to their International Federation (IF). IFs decide which athletes are considered international level within their sport and are required to publish this information on their website.

If the athlete is still uncertain where to apply, they should contact their IF directly.

See ISTUE Guidelines – Chapter 4: Where to Apply?

6. What is the process for applying for a TUE? Up

First, the athlete should get a TUE application form from the relevant Anti-Doping Organization (ADO):

  • Nationallevel athletes: National Anti-Doping Organization (NADO)
  • Internationallevel athletes: International Federation (IF)
  • At a Major Games: The Major Event Organizer (MEO)

Then, the athlete’s physician should fill out their sections in the TUE application form (Medical information, Medical Details and Medical Practitioner’s declaration) and the athlete should send it, along with the relevant medical information, to their ADO.

Remember! It is the athlete’s responsibility to provide a complete TUE application containing adequate medical information to confirm the diagnosis to the ADO and the ADO’s TUEC. It is important to note that supporting medical evidence must clearly establish the diagnosis. The athlete is strongly recommended to bring the TUE application form and the relevant TUE Checklists with them to their physician or have an electronic version readily accessible. The TUE Checklists are documents specifically designed for athletes and their treating physicians to help them gather required medical evidence to submit a complete TUE application.   

See ISTUE Guidelines - Chapter 5: What are the responsibilities of an athlete in submitting a TUE application?

7. What happens after a TUE is granted? Up

All approved TUEs are only valid for a specific duration. The athlete’s exemption will have an expiry date. This means that after this date the TUE certificate is no longer valid, and if the athlete wishes to continue using the prohibited substance, they will need to reapply for a new TUE.

See ISTUE Guidelines - Chapter 7: What happens after a TUE is granted?

8. What are the conditions to obtain a TUE? Up

Four criteria need to be met:

- The prohibited substance or prohibited method in question is needed to treat a diagnosed medical condition supported by relevant clinical evidence;

- The therapeutic use of the prohibited substance or prohibited method will not, on the balance of probabilities, produce any additional enhancement of performance beyond what might be anticipated by a return to the athlete’s normal state of health following the treatment of the medical condition;

- The prohibited substance or prohibited method is an indicated treatment for the medical condition, and there is no reasonable permitted therapeutic alternative;

- The necessity for the use of the prohibited substance or prohibited method is not a consequence, wholly or in part, of the prior use (without a TUE) of a substance or method which was prohibited at the time of such use.

9. What is a retroactive TUE? Up

For some levels of athletes, and in specific circumstances, a TUE may be applied for after an athlete has started the treatment or after they were tested.

Athletes can apply for a retroactive TUE if:

  • They needed emergency or urgent treatment for a medical condition, and they needed to take a medication that was a prohibited substance;
  • There was insufficient time, opportunity or an exceptional circumstance that prevented them from applying for a TUE before being tested;
  • The antidoping rules of the athlete’s NADO or IF, or their sport prioritization process, allows them to apply for a TUE retroactively because of their sport or the level they are competing at;
  • They tested positive incompetition for a medication that was taken out of competition.  

In exceptional circumstances, athletes may apply for and be granted a retroactive TUE if, considering the purpose of the Code, it would be manifestly unfair not to do so.

10. What is the role of WADA in the review of TUEs? Up

WADA’s role in the TUE process is two-fold:

  1. WADA, through its TUEC, has the right to monitor and review any TUE granted by an anti-doping organization (ADO) and, following such review, may uphold or reverse the decision.
  2. The athlete who submits a TUE Application to an IF and is denied a TUE, can ask WADA to review the decision. WADA is not obliged to review all cases and athletes may appeal their denial to national review boards or to CAS.  There are certain cases, such as a discrepancy between an IF and NADO, where WADA must review TUE decisions.

Note that WADA does not accept TUE applications from athletes. All applications must be made to the appropriate ADO.

11. What is a recognition of a TUE? Up

When an athlete already has a TUE granted by a NADO but then becomes a subject to the requirements of an International Federation (IF) or Major Event Organizer (MEO) (example: Athlete becomes an international level athlete), their TUE must be recognized at the higher level. The IF or MEO will recognize or not recognize the athlete’s TUE.

12. What is an automatic recognition? Up

If an athlete moves up a level, they need not immediately apply for a new TUE to the IF or MEO but should first consult their websites to check whose TUE decisions they will automatically recognize. If the athlete’s TUE falls into a category of TUEs that are automatically recognized, athletes need not take further action.

In the absence of such recognition, they should submit a request for recognition of the TUE to the IF or MEO either via ADAMS or as otherwise specified by that IF or MEO.

See ISTUE Guidelines - Section 6: TUE recognition process

13. What happens if the International Federation or Major Event Organizer refuses to recognize the NADO TUE? Up

The athlete or their NADO has 21 days from the notification of the decision of non-recognition by the IF to refer the matter to WADA for review. During WADA’s review, the NADO TUE is valid for national level competition and out-of-competition testing only.

If the athlete and/or NADO decide not to refer the matter to WADA, the NADO must determine whether the original TUE that it granted should remain valid for national level competition and out-of-competition testing. Pending the NADO’s decision, the TUE remains valid only for national level competition and all out-of-competition testing (Code Article 4.4.3.1).

A decision by a Major Event Organization not to recognize or not to grant a TUE may be appealed by the Athlete exclusively to an independent body established or appointed by the Major Event Organization for that purpose. If the Athlete does not appeal (or the appeal is unsuccessful), the Athlete may not Use the substance or method in question in connection with the Event, but any TUE granted by the Athlete’s National Anti-Doping Organization or International Federation for that substance or method remains valid outside of that Event (Code Article 4.4.4.3).

See ISTUE Guidelines - Section 6: TUE recognition process

14. Can a Major Event Organizer (MEO) grant a TUE? Up

Yes, but these TUEs are valid only for the duration of their event. A TUE granted by a NADO or an IF is not valid for the event unless it is recognized by the MEO.  MEOs may automatically recognize TUEs from other organizations but the athlete should verify this on the MEO’s website. Note that if the TUE is denied by the MEO, it remains valid outside of that event.

See ISTUE Guidelines - Chapter 15: ADOs involved in the TUE process – 3.0 MEOs

15. What can an athlete do if their TUE is denied or not recognized by an IF? Up

If the TUE is rejected:

  • If a nationallevel athlete wishes to appeal a NADO TUEC decision, they would do so before the relevant national appeal body in their country. If no such body is in place and available at the time of the appeal, the athlete has a right to appeal to CAS. The NADO should guide the athlete through this process.
  • An internationallevel athlete may request that WADA review their refused TUE application. WADA is not obliged to review all TUE decisions but may do so at their discretion (ISTUE 8.3; Code Article 4.4.6).

There are two situations where WADA must review (mandatory review), assuming the athlete or the NADO makes a request to WADA (Code Article 4.4.6):

  1. If an IF refuses to recognize a NADO TUE
  2. If a NADO disagrees with an IF’s decision to grant a TUE

If the TUE is not recognized by an IF:

The international-level athlete and/or their NADO may refer the non-recognition to WADA for review.

An international-level athlete may also appeal an IF’s decision to the Court of Arbitration of Sport if this decision is not reviewed by WADA.

See ISTUE Guidelines - Chapter 9: Where to appeal a TUE decision and Chapter 23: Requesting a WADA TUE review

16. Where can an athlete appeal a decision made by WADA? Up

A decision by WADA to reverse or uphold a TUE decision may be appealed by the athlete, the NADO and/or the IF affected, exclusively to CAS.

See ISTUE Guidelines - Chapter 23: Requesting a WADA TUE review

17. Is the TUE granted by a NADO valid for an event or period of competition where the athletes falls under the jurisdiction of another NADO? Up

When a national-level athlete has a TUE granted by their NADO, it is valid only for National Events. However, that TUE is valid at the national-level on a global basis and does not need to be formally recognized by other NADOs.

See ISTUE Guidelines - Chapter 15: ADOs involved in the TUE process – 1.0 NADOs

18. Should athletes declare medications on the Doping Control Form (DCF)? Up

Yes, athletes are advised to declare any medications or supplements taken over the past 7 days and, (if a blood sample is collected), any blood transfusions received over the last 3 months.

19. Will the information in the athlete's TUE application remain confidential? Up

All the information contained in a TUE application, including the supporting medical information, and any other information related to the evaluation of a TUE request must be handled in accordance with the strict principles of medical confidentiality.

ADOs are subject to strict confidentiality requirements with respect to an athlete’s TUE information. Physicians who are members of a TUEC and any other experts consulted must be subject to confidentiality agreements. Physicians are also typically subject to a number of professional obligations to protect their patients’ confidentiality.

Under the International Standard for the Protection of Privacy and Personal Information (ISPPPI), ADO staff must also sign confidentiality agreements, and the ADO must implement strong privacy and security measures to protect athlete’s personal information.

See ISTUE Guidelines - Chapter 10: How the athletes’ personal information is dealt with throughout the TUE process?

20. What other resources on TUEs are available and where to find them? Up

Athletes should primarily contact their NADO or IF to get more information on TUEs.

WADA has developed a wide range of resources related to TUEs that athletes and anti-doping organizations can consult. These resources can be accessed via WADA website or WADA Anti-Doping Education and Learning platform (ADEL) and include:

  • International Standard for Therapeutic Use Exemptions (ISTUE)
  • ISTUE Guidelines
  • TUE Physician Guidelines
  • TUE Checklists
  • Code Implementation Support Program (CISP) on ADEL – ISTUE section
  • Various elearning courses and resources for athletes and Medical Professionals on ADEL