Increase Font Size || Decrease Font Size

Appeals and Exceptions: Requesting Coverage Step by Step

Step 2: Request a redetermination.

If your formulary exception request is denied, request a redetermination. In this step a doctor at your plan who was not involved in the original denial must review the case again.

How to Request:You or your appointed representative must make this request in writing to your plan. The letter you received from your plan in response to your formulary exception request will tell you where to send your request. There is no special form to use. A simple letter saying that you want to appeal further should be enough. For a sample letter, click here. Your health care provider is not allowed to do this for you unless he or she is your appointed representative.

Timeframe: You must request a redetermination within 60 days of receiving a denial of your formulary exception request.

Decision: A decision must be made and sent to you as soon as your clinical condition requires, but no later than 72 hours (24 hours for an expedited request).