Items marked in red would be changed based on the patient’s needs.

Today’s Date

Your name (physician)
Practice name
Practice street address
City, State, Zip
Practice phone number
Practice fax number

Troyen Brennan, M.D.

Executive Vice President and Chief Medical Officer

CVS Health
One CVS Drive
Woonsocket, Rhode Island 02895

Re:Denial of coverage for Enbrel for (patient name)
Patient health insurance identification number
Patient date of birth

Dear Dr. Brennan,

I am writing to appeal your denial of coverage ofEnbrelfor the treatment of(patient name) psoriasis.

I recently prescribed this patient Enbreland it was denied due to a change in the 2017 formulary. I have reviewed the patient’s diagnosis, care plan and clinical guidelines for treatment and request a formal appeal of your denial for Enbrel.

When treating a patient with psoriasisit is necessary to have access to the full spectrum of accepted treatments as patients may not be able to use one particular treatment due to lack of response and the potential for side effects.

Enbrel is not only approved and effective for psoriasis and psoriatic arthritis, but it is a mistake to switch patients who are doing well on Enbrel to a drug that has greater risk of malignancy and infection.

(Patient name) has been stable on Enbrel for (insert time period).Withdrawal of medication for psoriasis patients, particularly when abrupt can exacerbate quiescent disease and result in psoriasis that is resistant to prior effective therapy.

I have previously prescribed this patient the following therapies:

  • (name of drug with dosage and frequency) from (date) to (date). The patient had an adverse reaction to this medication, which included (list reason for stopping treatment).
  • (name of drug with dosage and frequency) from (date) to (date). The patient had an adverse reaction to this medication, which included (list reason for stopping treatment).

Additionally, I request that you review the following evidence showing how this medication can be effectively utilized to treat psoriasis:

  • American Academy of Dermatology Psoriasis Guidelines:

On behalf of (patient name), I would appreciate your prompt reconsideration of this denial. Please feel free to contact me at (practice phone number) for any additional information you may require. I look forward to receiving your response and approval of coverage for this medication.

Sincerely,

(Physician name and credentials)