When your prescribed medication isn't on your insurer's formulary, you can request a formulary exception. This requires demonstrating that formulary alternatives are inadequate for your specific clinical situation.
Letter Template: Formulary Exception
[Your Name]
[Your Address]
[City, State ZIP]
[Date]
[Insurance Company Name]
[Pharmacy Appeals Department]
[Address]
Re: Formulary Exception Request
Member Name: [Your Name]
Member ID: [Your ID Number]
Medication: [Drug Name, Dosage, Frequency]
Prescribing Provider: [Doctor Name, NPI]
Dear Pharmacy Appeals Committee:
I am requesting a formulary exception for [medication name]
prescribed by Dr. [name] for my treatment of [diagnosis].
CLINICAL JUSTIFICATION
[Explain diagnosis and why this specific medication is needed]
FORMULARY ALTERNATIVES TRIED AND FAILED
- [Drug 1]: Used [dates], result: [inadequate, side effects, etc.]
- [Drug 2]: Used [dates], result: [etc.]
- [Drug 3]: Contraindicated because [reason]
WHY NON-FORMULARY MEDICATION IS NECESSARY
[Clinical reasons specific to your case — drug interactions,
tolerability, mechanism of action differences, etc.]
SUPPORTING DOCUMENTATION
- Letter from Dr. [Name]
- Medical records showing failed trials
- [Clinical studies, if applicable]
I request coverage of [medication] at the formulary
(preferred) tier cost-sharing level.
Sincerely,
[Your Name]
Tips
- Document every formulary alternative tried — with specific dates and outcomes
- Get your specialist involved — pharmacists and specialists carry more weight for specialty drugs
- Check for manufacturer assistance — many drug makers have copay cards or patient assistance
- Tiering exceptions — even if covered, you can appeal for a lower tier (lower cost)
- Part D Medicare: Coverage determination process for Part D has specific rules