Tricare appeal: Drug not on formulary, plan excludes obesity drugs.

The appeal letter (copy and edit)

Copy the body below and paste it into your clinician's portal or word processor. Replace every [BRACKET] placeholder with patient-specific data. Attach the original denial letter, the original PA submission, and any new documentation that directly addresses the denial reason. The letter is from your clinician to the plan, signed by your clinician.

[Today's date]

Tricare
Prior Authorization Appeals Department
Submitted via: Express Scripts Tricare (https://militaryrx.express-scripts.com) or fax 1-866-684-4488

Re: APPEAL of prior authorization denial
Patient: [Patient full name]
Member ID: [Plan member ID]
Date of birth: [Patient DOB]
Original PA reference number: [Reference number from denial letter]
Date of denial: [Denial letter date]
Date of this appeal: [Today]

To the Tricare Appeals Review Department,

I am the treating clinician for [Patient name]. I am writing to formally appeal the denial dated [denial date] of my prior authorization request for [drug name] in the indication of [indication name].

The denial reason cited

The denial cites: "Drug not on formulary, plan excludes obesity drugs". The plan's specific stated rationale was: [quote exact language from the denial letter].

This appeal directly addresses that specific reason.

Clinical context

[Insert 2-3 sentences summarizing the patient's clinical picture: BMI, age, comorbidities, prior treatment history and why this medication was prescribed.]

Direct rebuttal to the denial reason

The denial cites formulary exclusion of the requested medication. I am requesting that the plan re-evaluate this request under the [cardiovascular indication via SELECT trial labeling / OSA indication via SURMOUNT-OSA trial labeling / T2D indication via FDA labeling], for which the medication is FDA-approved separately from the obesity indication. The patient has documented [CV disease / OSA / T2D] with ICD-10 [code], qualifying for coverage under this non-obesity indication. Documentation is attached.

Patient-specific supporting findings

  - [Current weight, height, BMI with date measured]
  - [Comorbidity ICD-10 codes and the date each was documented]
  - [Prior treatment trials with dates and outcomes]
  - [Any lifestyle intervention documentation]
  - [Any specialty consultation supporting the requested treatment]

Supporting evidence

  - SELECT trial NEJM 2023 (Wegovy CV indication) for patients with established cardiovascular disease
  - SURMOUNT-OSA trial 2024 (Zepbound OSA indication) for patients with moderate-to-severe OSA
  - ADA 2026 Standards of Care (Ozempic, Mounjaro for T2D)
  - Plan's own formulary exception policy (most plans have a documented medical-necessity exception process)

Procedural points

Per Tricare's own appeals process, I am submitting this appeal within the 90 days from denial notice window from the denial notice. I am requesting:

  1. A formal first-level internal appeal review of this denial
  2. Written notification of the appeal decision within the statutory turnaround
  3. If the denial is upheld at first level, automatic escalation to second-level internal review
  4. If the denial is upheld at second level, external review per state insurance law

I am available to discuss this case with the plan's medical director at [Prescriber phone] or [Prescriber email]. A peer-to-peer review is available at your request.

Conclusion

The patient meets the FDA-labeled criteria for this medication and indication. The clinical rationale is documented in the attached records. The denial reason cited does not reflect the documented clinical picture. I respectfully request that this denial be overturned and the prior authorization granted.

Thank you for your attention to this appeal.

Sincerely,

[Prescriber full signature]
[Prescriber printed name, credentials]
[Prescriber NPI]
[Practice name and address]

Attachments:
  - Original denial letter
  - Original prior authorization submission
  - Updated patient measurements and labs
  - Documentation directly addressing the denial reason cited
  - All clinical records supporting the requested treatment

Evidence to cite in the appeal

• SELECT trial NEJM 2023 (Wegovy CV indication) for patients with established cardiovascular disease
• SURMOUNT-OSA trial 2024 (Zepbound OSA indication) for patients with moderate-to-severe OSA
• ADA 2026 Standards of Care (Ozempic, Mounjaro for T2D)
• Plan's own formulary exception policy (most plans have a documented medical-necessity exception process)

The direct-rebuttal paragraph

The paragraph below is the heart of the appeal letter. It is what makes this appeal different from a generic re-submission. Adapt the bracketed clauses to the patient's specific findings.

The denial cites formulary exclusion of the requested medication. I am requesting that the plan re-evaluate this request under the [cardiovascular indication via SELECT trial labeling / OSA indication via SURMOUNT-OSA trial labeling / T2D indication via FDA labeling], for which the medication is FDA-approved separately from the obesity indication. The patient has documented [CV disease / OSA / T2D] with ICD-10 [code], qualifying for coverage under this non-obesity indication. Documentation is attached.

Other appeal templates for Tricare

Same denial reason, other plans

Disclaimer

John Samaras, Founder and editorI started GLP Chart after overpaying for a GLP-1 myself. Based in Austin, Texas. About this site · LinkedIn · Contact