Prescription Drug Appeal Letter Free Download


Prescription Drug

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Health Symphony Appeal Letter

For Prescription Drug Denial

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] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment for this claim for my prescription drug stating it was not medically necessary and therefore, not authorized for payment.

This prescription drug is medically necessary for my condition and is recommended and prescribed by my physician. I have researched your drug formulary and it does list this medication. I am requesting that [health plan] reconsider this denial due to these circumstances and cover the cost of my prescription medication. Your continued denial of this claim will lead to a further deterioration of my health. There are no acceptable alternative medications for my medical condition.

I am enclosing a letter of medical necessity from my physician who prescribed this medication. Please review this information and contact me or my 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
A copy of the health plan’s formulary listing the medication