A formulary exception asks your plan to cover a drug it does not normally cover, or to cover a higher-tier or quantity-limited drug at a better level. It works when the formulary alternatives have failed you, are not tolerated, or would be harmful, and your prescriber can say so. This letter requests the exception and attaches the prescriber’s supporting statement, which is the key piece. The deadline and the exact submission channel are on your denial letter or plan documents, so confirm them first.
Before you appeal
- The denial or rejection notice (from the plan or the pharmacy) with the exact reason and any code.
- Your prescriber’s supporting statement explaining why the requested drug is needed and why each formulary alternative is ineffective, not tolerated, or harmful.
- The drug name, strength, and dosage requested, and the formulary alternatives that were tried or are inappropriate.
- Your clinical records showing prior trials, reactions, or contraindications.
- Your member ID, group/RxBIN/PCN numbers if shown, and the date of the denial.
The letter
[Your full name]
[Your address]
[City, State ZIP]
[Phone] | [Email]
[Date]
[Insurance company / Part D plan - Pharmacy Appeals / Coverage Determinations]
[Address from your denial letter]
Re: Request for formulary exception (coverage determination)
Member: [Name] Member ID: [number] Group #: [number]
Drug requested: [name, strength, dosage]
Claim/reference number: [number] Date(s) of service/fill: [dates]
Denial date: [date] Denial reason/code: [as stated on the notice]
To the Pharmacy Appeals Department:
I am requesting a formulary exception so the plan will cover [drug name,
strength, dosage] as prescribed by my treating provider. This request applies
to a drug that is [not on the formulary / on a higher tier / subject to a
quantity limit].
My prescriber has determined that the formulary alternatives are not
appropriate for me. The enclosed supporting statement explains that
[the preferred/covered drug(s) were tried and were ineffective / caused
[adverse reaction] / are expected to be harmful or are contraindicated for my
condition]. The requested drug is medically necessary for my treatment of
[diagnosis].
I ask the plan to approve coverage of the requested drug at the appropriate
cost-sharing level and to send me a written decision.
Enclosed in support:
- Prescriber's supporting statement
- Copy of the denial / rejection notice
- Relevant clinical records showing prior drug trials and reactions
If my health could be seriously harmed by waiting, I am also requesting an
expedited decision.
Thank you,
[Your signature]
[Your printed name]
How to send it
Submit through the plan’s coverage-determination or drug-exception process named on your notice (member-services line, fax, or portal), and keep a dated copy of everything, including the prescriber’s statement. If waiting could seriously harm your health, request an expedited decision. For Medicare Part D, once the plan has the prescriber’s supporting statement, a standard exception decision is generally due within about 72 hours and an expedited one within about 24 hours; ACA plans must offer a formulary exceptions process with comparable timeframes.
Notes. Medicare Part D exception and coverage-determination timeframes are set by CMS rules (standard about 72 hours, expedited about 24 hours after the prescriber’s supporting statement); ACA-compliant plans must provide an exceptions process with similar standard and expedited timelines. Confirm your plan type, since the exact path differs. See also the step-therapy exception if you were required to fail another drug first, the medical-necessity appeal, and the general internal appeal letter if the exception is denied. This is general information, not legal, medical, or insurance advice.