Two things about paying for USMLE Step 1 catch international candidates out, and neither is the headline fee. The organisation that registers an international medical graduate changed this year, and the amount leaving your account is not the amount on the fee page — there is a region surcharge, and if you test in India, a tax on top of that. This page sets out what is published, who to apply through and what the attempt rules cost you if a sitting goes wrong, alongside the Myndaq USMLE Step 1 course.
Who registers you
This is the part to get right before anything else, because applying through the wrong organisation wastes a cycle.
- Students and graduates of LCME- or COCA-accredited medical schools in the United States apply through the NBME.
- Students and graduates of medical schools outside the United States apply through the FSMB.
That second route is new. Under the USMLE service transition, from 12 January 2026 all USMLE Step exam services for international medical graduates — exam registration, score report delivery and customer service — are managed by the FSMB. A second phase on 26 January 2026 moved Step 3 services for US students and graduates from the FSMB to the NBME.
What did not change is ECFMG's role, and this is the distinction that matters. ECFMG continues to determine whether an international medical graduate is eligible for ECFMG Certification, and eligibility for Certification remains a core requirement for an international graduate to take the USMLE at all. Step 1 and Step 2 Clinical Knowledge continue to be required by ECFMG to meet the medical science examination requirement for Certification. So an international candidate is dealing with two bodies, not one: ECFMG for certification eligibility, the FSMB for the exam itself.
What it costs
The published application fee for Step 1 for 2026 and 2027 is US$695, and it is the same figure whether you apply through the NBME or the FSMB.
On top of that:
- Region fee. There is a US$210 region fee for exams taken outside the United States and Canada. For an international candidate testing at home, this is not optional — it is simply part of the price of the exam.
- India tax. Candidates selecting India as their testing region are charged an 18% tax, which, effective 4 December 2024, is collected and remitted directly to India under the Indian government's notification covering OIDAR services.
So the figure an Indian candidate should budget against is not $695. It is $695 plus the $210 region fee, plus 18% applied as the notification requires — check the total your registration shows you before you commit, because that total, not the headline, is what determines whether a second attempt is affordable.
Fees are non-refundable and non-transferable. That is the USMLE program's own wording, and it is the reason the eligibility-period rules below are a money question and not an administrative one.
Eligibility: who may sit Step 1
You must be in one of these categories both when you apply and on the day you test:
- a medical student officially enrolled in, or a graduate of, a US medical school programme leading to the MD degree accredited by the LCME;
- a medical student officially enrolled in, or a graduate of, a US medical school leading to the DO degree accredited by the COCA;
- a medical student officially enrolled in, or a graduate of, a medical school outside the US that is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements.
That last condition is the one to verify early. It is not enough for your school to exist in the World Directory; the listing has to show it as meeting ECFMG eligibility requirements. Check it before you pay, not after.
The eligibility period, and why rescheduling costs money
When you apply you select an eligibility period during which you intend to test. Registration produces a scheduling permit, and your appointment is booked with Prometric inside that window.
The rules that carry a cost:
- You may reschedule within your eligibility period, but you must pay a fee if you make the change during the 45 calendar days before your scheduled appointment.
- Any rescheduled date must still fall within your eligibility period.
- Scheduling may not be available more than six months in advance, and test dates are first-come, first-served — the USMLE program does not guarantee test centre availability.
- If you do not test within your original or extended eligibility period, you must reapply with a new application and new fees.
Read those together and the practical advice writes itself: choose an eligibility period you can genuinely test in, schedule early within it so you keep room to move, and treat the 45-day boundary as a real deadline rather than a formality.
Attempt limits — the rule that ends a career path
These limits are absolute, and candidates underestimate them because the ceiling sounds generous until an incomplete attempt counts against it.
- If you have attempted a Step four or more times, including incomplete attempts, and have not passed, you are ineligible to apply for any Step in the USMLE sequence. Not that Step — any Step.
- Attempts at the formerly administered Step 2 Clinical Skills count toward the limit.
- You may not take the same Step more than three times within a 12-month period.
- A fourth attempt must be at least 12 months after your first attempt at that examination and at least six months after your most recent attempt.
Note the words "including incomplete attempts". Starting a test you are not ready for and walking out does not reset anything; it consumes one of four. Combined with non-refundable fees, the cost of sitting unprepared is a fee you will not get back and an attempt you cannot recover.
Many US state medical boards additionally require the whole USMLE sequence to be completed within a set time frame, and those requirements are state-specific and published by the FSMB rather than by the USMLE program.
Quick answers
How much does USMLE Step 1 cost?
The published application fee for 2026 and 2027 is US$695, plus a US$210 region fee for exams taken outside the US and Canada. Candidates testing in India also pay an 18% tax collected and remitted to India.
Do I still apply through ECFMG?
Not for the exam. From 12 January 2026 the FSMB manages Step exam registration, score reporting and customer service for international medical graduates. ECFMG still decides eligibility for ECFMG Certification, which remains a requirement for an international graduate to take the USMLE.
Can I get a refund if I cannot sit?
No. Fees are non-refundable and non-transferable. You may reschedule within your eligibility period, but a change made in the 45 calendar days before the appointment attracts a fee, and missing the eligibility period entirely means reapplying and paying again.
How many times can I take Step 1?
Four in total, counting incomplete attempts. Reaching four attempts without passing makes you ineligible for any Step in the sequence. You may not sit the same Step more than three times in a 12-month period.
Does my medical school qualify me to apply?
Only if it is listed in the World Directory of Medical Schools as meeting ECFMG eligibility requirements. Confirm the listing shows that status before paying anything.
