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Appeals and Exceptions: Sample Appeal Letter

This sample appeal letter is provided for informational purposes only. Every plan has different rules and procedures for appeals, and this sample letter may not meet the requirements of your plan. DO NOT USE THIS LETTER WITHOUT FIRST CHECKING THE SPECIFIC PROCEDURES OF YOUR PLAN FOR APPEAL LETTERS. You can find this information on the back of your pharmacy benefit ID card—the one you use when you pick up your prescriptions. Your ID number is on the front of your pharmacy benefit ID card. You may need to ask your health care provider to provide information explaining why the medicine is "medically necessary."

If you don't have a copy of the written prescription or the pharmacy receipt, list the name of the medication and the dose that you were prescribed. Double check with your pharmacist to make sure that you have spelled everything correctly since the names of many medications are similar.

Download a printable PDF.