Letter

Formulary exception request

Your plan dropped your insulin or device from its covered drug list, or it was never on there. Send this before you accept the switch.

Before you send this

Your member ID and group number from your insurance card
The exact name, strength, and form of the drug you need
The names of any alternatives you have already tried and what happened
Your prescriber willing to co-sign or submit their own statement

[DATE]

[INSURER NAME]

Attn: Pharmacy Appeals / Coverage Determinations

[INSURER ADDRESS OR FAX]

Re: Request for formulary exception

Member name: [YOUR NAME]

Member ID: [MEMBER ID]

Group number: [GROUP NUMBER]

Date of birth: [DOB]

Drug requested: [DRUG NAME, STRENGTH, FORM]

Prescriber: [PRESCRIBER NAME, NPI, PHONE]

To whom it may concern,

I am requesting a formulary exception so that [DRUG NAME] is covered under my plan at the standard cost-sharing tier.

I have [type 1 diabetes / insulin-dependent diabetes], diagnosed in [YEAR]. I depend on insulin to survive. I have been stable on [DRUG NAME] since [DATE OR YEAR].

The formulary alternatives are not appropriate for me for the following reasons:

[Delete the ones that do not apply.]

- I have already tried [ALTERNATIVE DRUG] and experienced [SPECIFIC OUTCOME: hypoglycemia, loss of glycemic control, allergic reaction, hospitalization].

- [ALTERNATIVE DRUG] is contraindicated for me because [REASON].

- Switching insulins mid-regimen carries a documented risk of severe hypoglycemia and diabetic ketoacidosis, both of which require emergency care.

- The alternative is not compatible with my [insulin pump model / CGM system], which is [DEVICE NAME].

My prescriber supports this request and is submitting a statement of medical necessity under separate cover.

Please treat this request as [standard / EXPEDITED]. I am requesting expedited review because a delay would seriously jeopardize my health.

Please send your determination in writing, including the specific plan language you relied on. If this request is denied, please treat this letter as my request for a written denial and the appeal instructions for my plan.

Sincerely,

[YOUR NAME]

[PHONE]

[EMAIL]

[MAILING ADDRESS]

Enclosures: copy of insurance card, prescription, prior records if available

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