CoPay Reduction Request

Dear {Medicare plan administrator}:

Please consider this letter my formal Statement of Support for a lower co-pay for my patient {Student Name}, who has a Part D Medicare plan issued through your company. Due to how {drug name} is categorized on the tiering system, the cost is {amount}. This is beyond what their family can affordably shoulder, and they are forced to choose between taking their medication regularly and meeting all their other financial obligations.

Please grant a tiering exception to {Name}. This drug is critical to their {ongoing health/survival/quality of life/etc.}, and drugs on lower tiers are {ineffective/dangerous} for this patient.

I have attached the standard Coverage Determination Request Form and am available for further discussion if needed.

Sincerely,

{Physician Name}

Attachment: Coverage Determination Request Form

Index of Hardship Letter Examples