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Appeal letter templatesAppeal letter template: GLP-1 excluded from your plan's formulary
For requesting a formulary exception when the drug isn't on your plan's covered list at all. The key is documenting why covered alternatives don't work for you.
Template, not legal or medical advice.
Square brackets mark what you (or your clinician) fill in. Clinical claims must come from
your own prescriber and records — this page just saves you the blank-page problem.
[Date] [Insurance company name] Formulary Exception / Appeals Department RE: Formulary exception request Patient: [Patient name], DOB: [DOB], Member ID: [ID] Medication: [Drug name] To whom it may concern: I am requesting a formulary exception for [drug name], prescribed by [prescriber] for [diagnosis, ICD-10]. 1. The formulary alternatives — [list them] — are inappropriate in my case because: [documented intolerance, contraindication, prior failure with dates, or clinically meaningful difference such as a cardiovascular outcomes indication the alternative lacks]. 2. My prescriber's supporting statement is attached, citing the clinical evidence for this specific agent. 3. [If applicable:] I have been stable on this medication via [samples/cash pay/prior coverage] since [date]; switching presents documented risk. Please respond within the timeframe required by my plan. If denied, provide the clinical basis, reviewer credentials, and external review instructions. Sincerely, [Your name, contact information]
How to use this template
- Copy it (button above) and fill every [bracket] with your details.
- Bring it to your prescriber — the clinical justification must be theirs, drawn from your records.
- Send via the method on your denial letter or your plan's PA fax/portal, and keep a dated copy.
- Use our cost calculator while you wait — cash-pay options may bridge the gap.