HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Health plans have "formularies" or lists of the prescription drugs that are covered by the plan. Sometimes, a "non-formulary" drug, one that is not on the plan's formulary list, is needed to treat a patient. Your health plan or medical group should have a procedure for your doctor to request coverage of a non-formulary drug for you. (California HMOs are required to have such a procedure as of July 1, 1999.) You should always begin by talking to your doctor about your health care and prescription drug needs. If necessary, contact your medical group and health plan customer service departments. If you have talked to your doctor, medical group, and health plan, and have not been able to resolve your problem, you might want to write a letter to your medical group or health plan. You can use this sample letter if you need a prescription drug that is not on your health plan's formulary or if you are taking a prescription drug that has been dropped from your health plan's formulary. Be sure to add your own facts to this letter.

Here are some tips for using this letter:

• All of the language suggested may not apply to you. Use only the parts of the letter that are appropriate based on your facts.
• Places where you can insert your information are identified by brackets ("[ ]"), and the description of the information to add is underlined. You should delete the brackets and the sample description, and fill in your own information, where it applies.
• The letter includes advice to you that is in parenthesis ("{ }"), with the text of the advice in italics. You should delete these sections from your letter.
• The sample letter is addressed to the "Customer Service Department." Your health plan may use a different name for the department that receives complaints, grievances and appeals from its members. Check your health plan documents or member handbook [usually called the Evidence of Coverage (EOC) or Summary Plan Description (SPD)], or call your medical group or health plan, to find out to whom your letter should be sent.
• Check your health plan documents or member handbook (EOC or SPD) for your plan's requirements for filing a complaint, grievance or appeal. You should follow your health plan's procedures, including any time limits, when you file a complaint, grievance or appeal.
• There are different laws that apply to different types of health care coverage. The laws that apply in your circumstances may depend on where you live, what type of health plan you have, and how you get your coverage. Check your EOC for information about the agency that regulates your health plan, then check with the agency to see what set of laws apply to your case. Remember, it is not necessary to quote the law in your letter, but doing so may help make your case stronger. 

For example, the legal standards that relate to nonformulary prescription drugs for Californians in Health Maintenance Organizations (HMOs) are found in California Health & Safety Code §§ 1367.20, 1367.21, 1367.215, 1367.22, 1367.24. These sections of the law apply only to licensed California health plans regulated by the California Department of Corporations. Beginning July 1, 1999, your plan must have an speedy process for plan doctors to request non-formulary prescription drugs for patients. The time in which your plan must respond must be included in your Evidence of Coverage. Unlike regular appeals and expedited appeals, requests for pain management medications for terminally ill patients must be decided within 72 hours. See Cal. Health & Safety Code § 1367.215.  

• If your need for treatment is urgent, you may have special rights to have your case decided quickly. Contact your health plan or check your plan member handbook for information on "expedited review" or "urgent appeals." The section of the sample letter in UNDERLINED BOLD CAPITALIZED ITALICS is a sample of language that can be used in cases involving an immediate and serious threat to health.
• Attachments - You should attach to your letter copies of any information that helps explain your case. Support from your doctor is usually very important if you are requesting your health plan or medical group to cover a certain procedure or treatment. See the Health Right's Hotline's "How to Appeal a Health Plan or Medical Group Decision" and "Learning About Your Medical Condition" for more information on what you may want to attach to your letter. At the end of the letter are examples of the sort of attachments you might want to include. In some cases, a letter may have no attachments; in other cases, there may be many.
• Sending Copies - You should consider sending copies of your letter to others who may be helpful in resolving your problem. Suggestions for who you might want to send copies to are listed at the end of the letter. You should decide who might be helpful in resolving, and who you would like to know about, your problem. It is not likely to be appropriate for you to send copies of your letter to all who are listed on the sample letter under the "cc."

Health Rights Hotline
Sample Letter to Request Coverage of a Non-formulary Prescription Drug
(see tips for using this letter)

[Date]

[Your Medical Group OR Health Plan]
Customer Service Department
[address]

Dear Customer Service Department:

I am writing to request that [name of medical group OR health plan] cover the cost of my prescription for [name of medication]. [Name of medical group OR health plan] has denied coverage for [name of medication] because it is not included on the health plan's formulary. However, [name of medication] is medically necessary for my condition, is recommended and prescribed by my doctor, and there are no alternative drugs on the formulary that are suitable for me. In addition, I have been taking [name of drug] for [time period in months or years], and a change of medication could have detrimental effects on my health. Thus, the plan should cover the cost of [name of medication] in my case.

I am attaching documentation of my medical condition, and information supporting the medical necessity of [name of medication]. Please let me know if any additional information will be helpful to my request for coverage of [name of medication]. I can be reached at [telephone number].

Thank you for your immediate attention to this matter.

Sincerely,

[your name]

cc: {Possible individuals and/or groups to whom you can consider sending copies of your letter:}

[Health Plan Medical Director]
[Medical Group Medical Director]
[Your primary care physician]
[Your specialist]
[Your employer or insurance broker]
[Your state regulatory agency]

Attachments: {Material and documentation you can consider attaching:}

• Copy of letter from [doctor/specialist] supporting medical necessity;
• Copies of medical records;
• Medical journal articles supporting medical necessity of care sought (see Health Rights Hotline's "How to Appeal a Health Plan or Medical Group Decision" and "Learning About Your Medical Condition");
• Copies of sections from Evidence of Coverage concerning prescription drug coverage.