Letters that get you help

Ask your doctor to help with a free-drug program

Most drugmaker free-drug programs need your doctor to sign part of the application and send the prescription. Bring or send this with the program’s form.

• Print the program’s application from its website first
• Fill in your part before you give it to the doctor’s office
• Ask the office how they prefer to send it (fax or online portal)

Dear Dr. [DOCTOR’S NAME],

I can’t afford my prescription for [MEDICATION NAME]. The maker offers a patient assistance program, [PROGRAM NAME], that provides the medication free to people who meet its income limits.

I have filled in my section of the attached application. Could you please complete and sign the prescriber section and send it to the program as it directs?

The program’s fax number or website is: [FAX NUMBER OR WEBSITE].

Thank you for helping me stay on this medication.

Sincerely,
[YOUR NAME]
[DATE OF BIRTH]
[PHONE NUMBER]

Ask your doctor about a lower-cost alternative

Use this when a medication costs too much and you’d like to know if a generic, biosimilar, or covered alternative would work for you.

• Your plan’s drug list (formulary) shows which drugs it covers at the lowest cost
• Bring your plan’s drug list or member ID
• Never stop or switch a medication without talking to your doctor first

Dear Dr. [DOCTOR’S NAME],

My prescription for [MEDICATION NAME] costs me about [AMOUNT] a month, which is hard for me to afford.

Could you let me know whether any of these would be safe and effective for me?

- A generic or biosimilar version
- A similar medication my plan covers at a lower cost (my plan is [PLAN NAME])
- A different dose or supply that costs less

I don’t want to stop taking my medication, so I’d appreciate your advice on the best option.

Thank you,
[YOUR NAME]
[DATE OF BIRTH]
[PHONE NUMBER]

Appeal a denied prescription (job or marketplace plan)

Use this if your health plan refuses to cover a medication. This is called an internal appeal. Ask your doctor for a letter explaining why you need the drug and include it.

• You have 180 days from the denial notice to file
• Plans must decide within 30 days for a drug you haven’t received yet, and faster for urgent cases
• If the plan says no again, you can ask for an independent external review

Source: HealthCare.gov: internal appeals

[DATE]

[INSURANCE COMPANY NAME]
Attn: Appeals Department
[ADDRESS FROM YOUR DENIAL LETTER]

Re: Request for internal appeal
Member name: [YOUR NAME]
Member ID: [MEMBER ID]
Claim or reference number: [NUMBER FROM DENIAL LETTER]
Medication: [MEDICATION NAME AND DOSE]

To whom it may concern,

I am appealing your decision dated [DATE OF DENIAL] to deny coverage for [MEDICATION NAME], prescribed by Dr. [DOCTOR’S NAME].

My doctor prescribed this medication because [REASON, e.g. other drugs did not work or caused side effects]. A letter from my doctor explaining why it is medically necessary is enclosed.

Please reverse the denial and cover this medication. If you need more information, please contact me or my doctor at [DOCTOR’S PHONE].

Sincerely,
[YOUR NAME]
[PHONE NUMBER]

Enclosures: denial letter, doctor’s letter, [OTHER RECORDS]

Appeal a Medicare drug plan decision

Use this if your Medicare drug plan (Part D) won’t cover a medication. First ask the plan for a coverage determination or exception. If it says no, send this appeal (a redetermination).

• You have 65 days from the denial notice to appeal
• Plans usually decide within 7 days, or 72 hours if waiting could seriously harm your health
• For an exception, your prescriber must include a statement of the medical reason

Source: Medicare.gov: appeals in a drug plan

[DATE]

[DRUG PLAN NAME]
Attn: Redeterminations
[ADDRESS FROM YOUR DENIAL NOTICE]

Re: Request for redetermination
Name: [YOUR NAME]
Medicare Number: [NUMBER ON YOUR MEDICARE CARD]
Plan member ID: [MEMBER ID]
Address: [YOUR ADDRESS]
Medication: [MEDICATION NAME AND DOSE]

To whom it may concern,

I am asking for a redetermination of your decision dated [DATE OF DENIAL] not to cover [MEDICATION NAME].

My prescriber, Dr. [DOCTOR’S NAME], has determined that I need this medication because [REASON]. Their supporting statement is enclosed.

[IF URGENT: I am requesting an expedited (fast) decision because waiting could seriously harm my health.]

Please contact me at [PHONE NUMBER] if you need more information.

Sincerely,
[YOUR NAME]

Enclosures: denial notice, prescriber statement