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Appeals and Exceptions: Writing a Letter of Appeal
Click here to view a sample review letter. If you've made a call to the member services department of your plan
but insurance still will not cover the medication, then it is best to
submit your appeal in writing. This way you also have a written record
of the actions you took and the dates on which you took them. Be sure
to include the following information in your appeal letter to your pharmacy
benefit company:
- Your name
- Your address
- Your phone number
- You ID number
- The date
- The date you sought to fill the prescription
- The name and address of the pharmacy where you took the prescription
- The name, address, and phone number of the doctor who wrote the prescription
You should also:
- 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 for which the
prescription was written.
- Clearly state that you wish to formally appeal the denial of drug
coverage.
- State that the insurance company has permission to contact your physician
if medical information is needed to consider your appeal. (It would
also be good to let your physician know that he/she may get a call.)
- Indicate that you expect the plan to tell you about all steps you
may need to take for them to process your appeal. Also ask them to tell
you how you can appeal further if they deny this appeal.
- Ask them to clearly describe their decision and the basis for that
decision when they respond in writing.
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