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[Your Name] [Your Address] [City, State ZIP Code] [Your Phone Number] [Your Email Address] [Date] [Insurance Company Name] Appeals Department [Insurance Company Address] [City, State ZIP Code] RE: APPEAL FOR GLP-1 MEDICATION COVERAGE DENIAL Member Name: [Your Full Name] Member ID: [Your Policy/Member ID Number] Group Number: [If applicable] Date of Birth: [Your DOB] Claim/Reference Number: [From denial letter] Medication: [Ozempic/Wegovy/Mounjaro/Zepbound] Prescribing Physician: [Doctor's name and credentials] Dear Appeals Review Committee: I am writing to formally appeal your denial of coverage for [specific GLP-1 medication] dated [date of denial letter]
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