September 22, 2017
Drug Non-Formulary 

This drug non-formulary appeal letter template can be edited to fit your denial. For assistance with a completely researched, tailored letter, call the helpline @ 920.664.9407.
 
Your name and address
 
Date 
 
Address of Claims review department 
RE: Name of Insured:
Plan ID #:
Claim #: 
 
Dear Claims Review Department:
 
I am writing to you in regards to a claim submitted by [Medical Provider/Pharmacy] for [patient].  The charges were for a medication prescribed by [Physician Name] on [Date] and filled on [Date].  The total cost of the claim is [Claim dollar total].  [Health Plan] has denied payment for this prescription medication stating it was not included in the health plan’s formulary.  
 
This prescription drug is medically necessary for the indicated medical condition as recommended and prescribed by this physician.  There are no alternative medications that are appropriate for this medical condition.  Not taking this medication will result in a deterioration of the medical condition.  We are requesting that [health plan] reconsider this denial due to these circumstances and cover the cost of the prescription medication.
 
Optional:  This prescription medication is the most cost effective treatment for this condition.  Being unable to take this medication may result in increased physician visits and potentially additional trips to the hospital.
 
We are enclosing a letter of medical necessity from the prescribing physician.  Please review this information and contact us or the physician if there is additional supporting information you require to make a decision.  Thank you for your time and assistance in this matter.
 
Sincerely,
[Insured Name]
 
Enclosures:
A statement of medical necessity from your medical provider
At least (2) articles from medical journals indicating the effectiveness of the use of this medication
Any additional supporting documentation



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