Appeal: formulary exception
Asks your plan to cover a drug that is not on its drug list, or to lift a quantity limit, using your prescriber's reasons why the covered alternatives do not fit.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan denied a prescribed drug because it is not on the formulary (the plan's list of covered drugs), or because of a quantity or dose limit. You need the denial notice and your prescriber's reasons.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: formulary exception Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] that denied coverage of [The drug your prescriber ordered, with the dose] under [Name of the health plan] (member ID [Member ID], reference number [Claim or reference number]) because it is not on the plan's drug list, the formulary. If the plan handles appeals and formulary exceptions separately, I ask you to treat this letter as both. I ask you to cover [The drug your prescriber ordered, with the dose], as prescribed by [Your prescriber's name and specialty].
The plan gave this reason: [The reason the plan gave]
The covered alternatives the plan points to, and my experience with them, are: [The covered alternatives the plan points to, and what happened if you tried them] My prescriber's reasons for saying these are not right for me are: [Why your prescriber says the alternatives are not right for you]
I ask the plan to consider these reasons, to identify the clinical criterion or policy it relied on and how it applied it to my situation, and to tell me what a formulary exception request must show so that my prescriber and I can send anything that is missing.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. If the decision rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the field of my condition who was not consulted on the first decision. Please consider every record and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review by an independent organization and may complain to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter 2. Pharmacy or medical records showing alternatives I tried 3. Letter from my prescriber explaining why the alternatives are not right 4. The prescription
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter
- Pharmacy or medical records showing alternatives I tried
- Letter from my prescriber explaining why the alternatives are not right
- The prescription
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls. If your prescriber says waiting could seriously harm you, ask for an expedited appeal, which must be decided within 72 hours.
- Ask your pharmacy whether it can hold the prescription or give a short supply while you appeal. The plan decides whether it will pay for it.
- If the plan says no again, or does not answer in time, ask for external review (also called independent review), which is a review by reviewers outside the plan. For most job-based and individual plans you have at least four months after you receive the final denial to ask. Check the date on your notice, which controls.
- The sources used for this letter do not set out a federal formulary exception test, so the letter relies on your plan's own drug coverage rules and the appeal rules. Check the denial notice for any separate exception process and its deadline.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
Sources
Denial reasons this answers
- Denial reason
Drug not on the formulary
The drug your doctor prescribed is not on the plan's list of covered drugs. You can ask for an exception. Your prescriber will need to state why this drug, and not the covered ones, is right for you.
- Denial reason
Quantity or dose limit
The plan covers your drug but only up to a set amount or on a set schedule. If your prescriber ordered more, you can ask the plan whether it has an exception process for this limit. It turns on your dose, your history and what happens at lower amounts.