Sample Exceptions Letter
This sample letter is intended to provide an example of the types of information that may be included
when sending an exceptions letter for a Mitsubishi Tanabe Pharma America, Inc. medication you seek to
prescribe to a patient’s insurance company. Use of the information in this letter does not guarantee that
the health plan will provide reimbursement for the medication. Use of this sample letter is completely
voluntary by the healthcare provider and/or patient and is not intended to be a substitute for, or to
influence, the independent medical judgment of the physician.
Helpful tips
• You may consider including an exceptions letter (like the example on page 2 of this document) if
coverage is denied because the medication is not on your patient’s health plan formulary or for
another reason
• An exceptions letter should be signed by both the physician and the patient
• Be sure to include an appropriate International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) that matches your patient’s diagnosis
• When you download this document, make certain to delete page 1 of this document
Example Checklist Summary
❑ Exceptions form recommended by health plan
❑ Example chart notes
− Date of initial diagnosis
− Reason for the medication or treatment
− Recommended treatment plan
− Pertinent laboratory, diagnostic, and imaging tests and results
− Patient’s clinical response
− Brief description of the patient’s recent symptoms and conditions
− Previous therapies the patient has undergone for the symptoms associated with
their condition, and the patient’s response to these therapies
❑ A copy of the Prescribing Information for the medication
Sample Format for an Exceptions Letter
[Insert Your Practice/Physician Letterhead]
Attn: [Insert Medical Director Name]
RE: [Insert Patient Name] DOB: [Insert Patient’s Date of Birth]
[Insert Name of Insurance Company] Policy Number: [Insert Patient Policy Number]
[Insert Address] Claim Number: [Insert Patient Claim Number]
[Insert City, State ZIP Code]
[Date]
Dear [Insert Contact Name]:
[Insert Patient Name] has been under my care for [Insert Diagnosis] [Insert ICD-10-CM Code] since
[Insert Date]. This letter outlines my conclusion of medical necessity for [medication] for this patient.
Below, this letter outlines [Insert Patient Name]’s medical history, prognosis, and treatment rationale.
[NOTE: Exercise your medical judgment and discretion when providing a diagnosis and
characterization of the patient’s medical condition. You may want to include:]
Summary of Patient’s Medical History:
• [Patient’s diagnosis, date of diagnosis, condition, and history]
• [Previous therapies used for treating the symptoms associated with the condition]
• [Patient’s response to these therapies]
• [Brief description of the patient’s recent symptoms and conditions]
• [Summary of your professional opinion of the patient’s prognosis and why medication is medically
necessary for this patient]
On behalf of [Insert Patient Name], we appreciate your reconsideration. If coverage is still in question,
I request an expedited exception and review of this documentation by a neurologist specializing in the
treatment of ALS.
Please call my office at [Insert primary phone number] if I can be of further assistance or you require
additional information. I look forward to receiving your timely response and approval of this claim.
Sincerely,
[Insert Physician Name and Participating Provider Number]
[Insert Patient/Legal Representative Signature, if required]
Enclosure:
[Insert a PDF of the Prescribing Information for medication]
For US audiences only.
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Jersey City, NJ 07310
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