Appeals and Exceptions: Writing a Letter of Appeal

If your request for a formulary exception has been denied, you will need to write a letter in order to request a redetermination. This letter can be very simple; however, it is probably good to include all of the following information in the letter so that you establish a written record.

• Your name, address, phone number, and Medicare ID number
• The date you are writing the letter
• The date you tried to fill the prescription
• The name and address of the pharmacy where you tried to fill the prescription
• The name, address, and phone number of the health care provider who wrote the prescription

You should also:

• Clearly state that you wish to request a redetermination.
• Include a copy of either the receipt, if you paid already, or the prescription, if you didn't. If you don't have either of these items, list the exact name and dosage of the medication of the medicine prescribed.
• State that the insurance company has permission to contact your health care provider if additional medical information is needed. (It would also be good to talk to your health care provider about how to respond to the reasons why the plan denied your benefit and let your health care provider know that you are filing an appeal and that he/she may get a call.)
• Indicate that you expect the plan to tell you everything you need to do so that your appeal can be processed. Also ask them to tell you how you can appeal further if they deny this appeal.
• Respond to the reasons the plan gave for denial in the letter denying your formulary exception request. For example, if the plan wants you to try a different medicine first, but you have a bad reaction to that medicine, you should explain this.
• Make a copy of your letter for yourself before you mail it.