If you got a letter saying Dupixent won’t be covered in 2026, you’re probably starting to look into what the other covered options are – and which ones might work for you. Let’s break it down. In this article, we’ll deep dive into the BCBS Federal Employee Plans (FEP Blue) formulary – what’s covered and not, what it means if you switch, and where the fine print matters (like age limits, boxed warnings, and off-label gaps). 

And remember – you don’t have to just switch. If Dupixent is working for you, especially if some of these alternatives don’t seem like a fit, you have the right to request an exception and get Dupixent covered.

First off - what exactly is on the FEP Blue Formulary for 2026?

Formularies are long and complicated. The FEP Blue formulary for 2026 clocks in at 175 pages – whew! Let’s skip to the important stuff. 

Before we go further – this isn’t medical advice. We’re here to help you understand your formulary and what it means, and you should always speak to your doctor before making any medication adjustments or changes.

Excluded drugs - Dupixent‍

Here’s what the formulary says about Dupixent, and the options available.

The important part here: Preferred options may vary by indication. And what’s indicated for Dupixent has a lot of variation. Dupixent is an antibody that that binds IL-4 receptor-alpha (IL-4Rα), which is the shared “docking station” for two key inflammatory messengers, IL-4 and IL-13. This means it can impact the type of inflammation that drives many different diseases – from reducing esophageal stiffness in eosinophilic esophagitis to turning down the itch signal in prurigo nodularis.

Why it’s relevant? The alternatives may work in a different way and for some indications, not at all. For example, Fasenra might be a good substitute for Dupixent for a patient with eosinophilic asthma as it can similarly reduce flares, but it wouldn’t be effective for someone with eczema – Fasenra doesn’t work on the pathways related to itch, skin barrier, or other inflammatory eczema symptoms.

What’s covered for which indication?

Don’t worry – you don’t have to dig through 175 pages of a formulary PDF to find out what you can take for what. Here are which alternatives are FDA-approved for each condition:

Not sure what these alternatives mean for you? Let’s break it down one by one – find your condition below to learn more about the specific alternatives and what to consider. 

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Atopic Dermatitis (Eczema)

What Dupixent alternatives are covered by FEP Blue for Asthma?

• Adbry (tralokinumab): This IL-13–only antibody is FDA-approved for patients over the age of 12 with moderate-to-severe AD. 
• Ebglyss (lebrikizumab): Another IL-13–only antibody; also FDA-approved for ages 12 and up as well as over 40 kg (88 lbs). 
• Rinvoq (upadacitinib): Oral JAK-1 inhibitor that is FDA-approved for AD in adults and adolescents over 12 (weight-based). Rinvoq carries boxed warnings including serious infections, malignancy, MACE, thrombosis.

How they differ from Dupixent (why it matters):

• Efficacy: Dupixent blocks IL-4 and IL-13 pathways, where Adbry/Ebglyss blocks only IL-13 – that narrower target can matter for some patients’ itch/inflammation profiles, meaning Adbry/Ebglyss may be less effective.
• Side effects: Rinvoq is a systemic immunomodulator with boxed warnings; many patients do well on it, but the risk profile and monitoring requirements are higher to avoid potentially serious complications.

Formulary flags:

• Kids under 12: There is no FDA-approved systemic alternative to Dupixent in this age group; Adbry, Ebglyss, and Rinvoq are all 12+. If your under-12 child is covered by FEP Blue and is taking Dupixent, there is no approved alternative for them to switch to. An appeal for Dupixent coverage will highlight this to show you should stay covered.
• Risk: Rinvoq’s boxed warning applies across indications; discuss risks and monitoring with your prescriber before switching. If you don’t want to risk these potential side effects by switching, you can make that argument in your appeal.

Documentation commonly required for coverage approval:

• Failure of or intolerance to topical steroids or calcineurin inhibitors (like tacrolimus)
• Baseline severity score (EASI, vIGA, POEM, or SCORAD)
• If you're currently on Dupixent: improvement shown by severity scores
• Evidence that you've been adherent to treatment

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Asthma (type-2/eosinophilic or allergic)

What Dupixent alternatives are covered by FEP Blue for Asthma?

• Fasenra (benralizumab): This IL-5Rα antibody depletes eosinophils to help reduce flares in certain types of asthma. It’s FDA-approved for eosinophilic asthma for patients over the age of 6.
• Nucala (mepolizumab): Similar to Fasenra, this IL-5 antibody also lowers eosinophils. It’s FDA-approved for eosinophilic asthma eosinophilic asthma for patients over the age of 6.
• Xolair (omalizumab): An Anti-IgE antibody that’s FDA-approved for allergic asthma with positive allergy testing, in patients over the age of 6.
  

How they differ from Dupixent (why it matters):

• Mechanism targeting: Fasenra/Nucala work best when eosinophils drive your asthma. Xolair helps if you have allergic asthma with high IgE/sensitization. Dupixent, on the other hand, blocks IL-4/IL-13 (type-2 inflammation) and can help both allergic and eosinophilic patterns, including patients who are oral-steroid dependent. So if your asthma control on Dupixent is tied to type-2 inflammation, a switch to one of these alternatives isn’t always comparable.
  Cross-condition control: If you have eczema or nasal polyps in conjunction with Asthma, Dupixent treats those too. IL-5 or anti-IgE drugs won’t help the skin or polyps, meaning you may have to try multiple drugs concurrently to address more symptoms.

Formulary flags:

• No “one-size-fits-all”: If you’re not allergic (for Xolair) or not eosinophilic (for IL-5/IL-5R drugs), these switches may be a poor fit – we can highlight this in your appeal to stay on Dupixent.
• Anaphylaxis warning (Xolair): Carries a boxed warning and may require post-injection observation. Some providers prefer Dupixent for a lower risk option.

Documentation commonly required for coverage approval:

• Eosinophil counts showing eosinophilic asthma, OR need for daily oral steroids
• History of asthma exacerbations or hospitalizations in the past year
• Failure of inhaled corticosteroids combined with long-acting bronchodilators
• If you're currently on Dupixent: fewer exacerbations or symptom improvement

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Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) 

What Dupixent alternatives are covered by FEP Blue for Nasal Polyps?

• Nucala (mepolizumab): This IL-5 antibody reduces eosinophils, which can help with shrinking polyps, congestion, and reducing flares. It’s FDA approved for adults (18+)
• Xolair (omalizumab): Anti-IgE antibody that reduces edema and mucus to improve nasal polyp symptoms. It’s also FDA-approved for adults (18+)
  

How they differ from Dupixent (why it matters):

• Pathway targeting: Dupixent (IL-4/IL-13) directly targets type-2 signaling in polyp disease; Nucala focuses on eosinophils; Xolair targets allergic IgE pathways. If you’re non-allergic or your eosinophils aren’t elevated, your response to those alternatives may be weaker than to Dupixent.
• Symptom bundle: Dupixent often improves smell/taste and congestion in patients with type-2 inflammation patterns; results with IL-5/IgE agents can depend on the root cause of your symptoms.

Formulary flags:

• Allergy requirement (Xolair): Typically needs proof of allergic sensitization.
• Cross-condition control: If Dupixent is stabilizing both your polyps and comorbid eczema/asthma, a switch may help sinuses but not skin/airways the same way. This is important when weighing overall disease control.
• Anaphylaxis warning (Xolair) and phenotype mismatch (for either alternative) are legitimate concerns to document – these can help you make your case to stay on Dupixent if it’s working for you.

Documentation commonly required for coverage approval:

• Failure of at least two nasal steroid sprays and one oral steroid course
• Persistent symptoms despite 3+ months of treatment
• If you're currently on Dupixent: symptom improvement

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COPD

What Dupixent alternatives are offered by FEP Blue for COPD?

• Nucala (mepolizumab): This IL-5 antibody reduces eosinophils, which can lower airway inflammation, exacerbations and steroid bursts. It’s FDA approved for adults (18+)

How it differs from Dupixent (why it matters):

• Pathway: Nucala targets IL-5 to lower eosinophils. Dupixent targets IL-4/IL-13, a different part of type-2 inflammation that’s impactful in COPD for some patients. Depending on your biomarker profile and history (ex: frequent flares despite triple inhalers), one may fit better than the other.

Formulary flags:

• Varying mechanisms: Your COPD may be driven by pathways beyond eosinophils, so some patients who respond to Dupixent might not do as well on pure IL-5 blockade like Nucala and vice versa. Without a head-to-head study, it’s hard to know at scale – and if Dupixent is working for you, you shouldn’t have to risk that uncertainty.
• Cross-condition control: If Dupixent is also controlling eczema (AD), EoE, prurigo nodularis or bullous pemphigoid, switching to Nucala won’t cover those diseases. You and your doctor may worry about flares outside the lungs. 

Documentation commonly required for coverage approval:

• Eosinophil counts showing eosinophilic COPD
• Failure of standard COPD medications (inhaled steroids, bronchodilators)
• History of exacerbations despite treatment
• If you're currently on Dupixent: fewer exacerbations or symptom improvement
  

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Chronic Hives / Chronic Spontaneous Urticaria (CSU)

What Dupixent alternatives are offered by FEP Blue for CSU?

• Xolair (omalizumab): An anti-IgE antibody that’s been a long-standing FDA-approved biologic for CSU after antihistamines fail. Approved in patients 12 and up.

How it differs from Dupixent (why it matters):

• Mechanism: Xolair targets IgE, which is the “allergic” part of CSU; Dupixent targets IL-4/IL-13, getting more at the root cause of the reaction. Some patients respond to one pathway but not the other – especially if autoimmunity plays a role.
• Logistics: Xolair dosing differs and sometimes observation is recommended. Response can be rapid or gradual, meaning it might take you some time to get back to a controlled state for your CSU,

Formulary flags:

• Boxed warning for Xolair: Xolair carries a risk of anaphylaxis – it’s important to consider, and you can argue in an appeal that you don’t want to take that risk by switching.
• Kids under 12: There is no FDA-approved systemic alternative to Dupixent in this age group as Xolair is only for 12+. If your under-12 child is covered by FEP Blue and is taking Dupixent, there is no approved alternative for them to switch to. An appeal for Dupixent coverage will highlight this to show you should stay covered.

Documentation commonly required for coverage approval:

• Persistent hives despite trying at least two different antihistamines
• Urticaria Activity Score (UAS) showing severity
• Failure of or intolerance to Xolair (if tried)
• If you're currently on Dupixent: improvement in hives and itching

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Eosinophilic Esophagitis (EoE)

What Dupixent alternatives are covered by FEP Blue for EoE?

• On-label: None equivalent. Dupixent is the only FDA-approved biologic for EoE, meaning that stopping coverage is asking patients to switch to an off-label drug.

Why it matters:

• If Dupixent is working for you, you have a strong case to appeal – and you should. It doesn’t mean the off-label option won’t work for you (as always, discuss in detail with your provider), but you shouldn’t be made to switch off a stable medication that’s working for you – especially to one that hasn’t been approved for your condition.

Documentation commonly required for coverage approval:

• Diagnosis confirmed by endoscopy and biopsy showing elevated eosinophils
• Failure of proton pump inhibitor (PPI) therapy
• If you're currently on Dupixent: symptom improvement

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Prurigo Nodularis 

What Dupixent alternatives are covered by FEP Blue for Prurigo Nodularis?

• On-label: None equivalent. Dupixent is the only FDA-approved biologic for Prurigo Nodularis, meaning that stopping coverage is asking patients to switch to an off-label drug.

Why it matters:

• If Dupixent is working for you, you have a strong case to appeal – and you should. It doesn’t mean the off-label option won’t work for you (as always, discuss in detail with your provider), but you shouldn’t be made to switch off a stable medication that’s working for you – especially to one that hasn’t been approved for your condition.

Documentation commonly required for coverage approval:

• Diagnosis and disease severity
• Failure of phototherapy or conventional systemic treatment
• If you're currently on Dupixent: symptom improvement

‍

Bullous Pemphigoid 

What Dupixent alternatives are covered by FEP Blue for Bullous Pemphigoid?

• On-label: None equivalent. Dupixent is the only FDA-approved biologic for Bullous Pemphigoid, meaning that stopping coverage is asking patients to switch to an off-label drug. There’s evidence that some steroids and immunosuppressants can help but often have higher systemic risks in older adults – and their safety/efficacy hasn’t been approved for BP. 

Why it matters:

• If Dupixent is working for you, you have a strong case to appeal – and you should. It doesn’t mean the off-label option won’t work for you (as always, discuss in detail with your provider), but you shouldn’t be made to switch off a stable medication that’s working for you – especially to one that hasn’t been approved for your condition.

Documentation commonly required for coverage approval:

• Diagnosis confirmed by biopsy
• Failure of high-potency topical steroids, oral steroids, and/or antibiotics/dapsone
• If you're currently on Dupixent: symptom improvement

So… do I have to switch from Dupixent to something else? 

The short answer: No.

If the “covered alternatives” don’t match your age, diagnosis, phenotype, or safety profile – or you’re stable on Dupixent – you have a strong case to get Dupixent covered again by submitting a formulary exception. 

Under federal rules, members can request exceptions to get clinically appropriate drugs covered, even if they’re not on the plan’s drug list. And if you’re in an active course of treatment, you can request an expedited decision – so you can get back on what works, fast.

How to appeal:

Claimable partners with Dupixent to make it as easy as possible for you to appeal:

• You fill out a short survey to tell us about your medical and personal history.
• We help you make the strongest case: we do the research, draft a personalized letter, include the exact FDA labels, safety language, and clinical precedents that support your diagnosis/phenotype, and get it mailed and faxed where it needs to go.
• For Dupixent appeals, our tool is free to use if you're on a commercial plan (including FEP Blue).

Bottom line

Drug lists can make switches look simple – but specifics about your condition and symptoms, age limits, boxed warnings, and off-label gaps mean the “covered alternative” isn’t always equivalent. 

If Dupixent is the right fit—and especially if you’re stable on it—build the case and appeal. And if you need a hand turning your medical story and the right evidence into a winning exception, Claimable is here to help.

Get started today

“Will not be covered starting January 1, 2026”.

‍If these words look familiar, you’re not alone. In November, thousands of people with BCBS FEP plans began receiving formulary change letters or other coverage notices letting them know that a medication that’s working for them – Dupixent – will no longer be covered in the new year.

It can be anxiety-inducing. When you’ve found a treatment that works for you, the thought of changing can be daunting. The good news? You don’t have to. Here’s three steps to take the minute that letter hits your mailbox to keep your coverage, and stay on what works for you.

What to do now (before Dec 31)

1. Ask for a 90-day refill (or “vacation override”).
   Check with your pharmacy to see if you can get your last 2025 refill as a 90-day supply. This can help you stay on treatment while new coverage is reviewed.
   
   
2. Start your formulary exception – and label it “urgent” if you qualify.
   You have a legal right to request an exception when your plan says something won’t be covered. If granted, you’ll be covered again (usually for the full plan year).
   
   If you’re currently taking Dupixent, your request will qualify as “urgent” – meaning that your plan has to make a decision in 72 hours. In practice, we usually find this is closer to 5-7 days, but it’s still the fastest way to get coverage back.
   
   
3. Make a plan with your doctor to request a new approval in January
   If your formulary exception is approved, you’ll be covered in the new year! But to get ahead of things, speak to your doctor now and let them know that you’re in the process of requesting the exception for Dupixent.
   
   If your exception isn’t approved, your doctor or pharmacy will need to submit a new authorization request for Dupixent on January 1 and you can submit another exception request after that happens.  

What happens on Jan 1, 2026

If you haven’t been granted an exception, here’s what you can expect in the new year with a coverage change:

• At the pharmacy: If you try to fill your prescription, the pharmacist will let you know that it’s no longer covered by your plan and see if you want to pay cash price. This can be $3000 or more without coverage, so know the sticker shock is coming and plan ahead.
• If a PA is required: Your prescriber can submit a new Prior Authorization (PA) on or after Jan 1. If the PA or exception is denied, request a pre-service reconsideration.

This is why getting ahead of the timeline matters. You can request the formulary exception the minute the coverage notification letter hits your mailbox – so you can confirm new year coverage before January 1 and skip the pharmacy headaches and PA complexity.   

A realistic timeline to stay covered

Start now

• Request a 90-day supply of your medication.
• Get your formulary exception request submitted (use our step by step guide here, or get started fast by using Claimable)

If your first exception request is denied

• Request a reconsideration of the request. When you make this second request, it’s required to be reviewed by a qualified clinician.
• If you still disagree, you can escalate to have your request reviewed independently by the Office of Personnel & Budget Management.  

On January 1 (if you still don’t have coverage)

• Have your doctor submit a new Prior Authorization for Dupixent.
• If that gets denied, file a new formulary exception request.

Any time after your request has been submitted

• Request your claim file and relevant plan documents – you have a federal right to obtain all the documents they’ve used in making decisions about your request, and you can use this to strengthen your case.  

Need help with the process?

Use our Dupixent appeal tool for the fastest, easiest way to get your exception request drafted and filed. Fast, easy, and free for eligible patients.

If you’re currently taking Dupixent and got a 2026 “not covered” notice, you might be wondering – do I have to switch medications and start all over again? 

The short answer: No. Many people don’t know this, but when insurance denies your meds or asks you to change to something else, you don’t have to just accept a switch. Under federal law as well as FEP Blue’s own policies, you have rights that protect you and can help you get coverage back for the medication that’s working for you.

BCBS Formulary Exception Process
The Formulary Exception process allows members to apply for coverage of a non-covered drug if they have tried and failed the covered drug(s). If the exception is approved, the non-covered drug will be covered.

Let’s break down your essential rights – and how to use them to stay covered.

Your rights overview – what you can ask for:

• Right to request a formulary exception. You (not just your doctor) may ask the plan to cover a non-formulary drug (one that isn’t on their “covered list”) when it’s clinically appropriate. If the exception is granted, typically coverage must be provided to the end of the plan year (not just a one-time fill).
  
• Right to an expedited decision if you’re mid-treatment. If you are already taking the medication or if delay poses a risk of serious harm, the plan must issue an expedited decision on your formulary-exception request within 72 hours when you are undergoing a current course of treatment using a non-formulary drug.
  
• Right to clear notices and to access your file. FEP denial notices must identify what was denied and why, and must provide any policies or criteria used upon request. You are also entitled to review and obtain copies of all materials the plan relied on. We strongly recommend requesting your claim file with every denial to verify the plan’s rationale and proper handling.
  
• Right to reasonable reconsideration timelines. For non-urgent pre-service disputes when you are not already on treatment, you have 6 months to request reconsideration. The plan then generally has 30 days to respond unless you request an urgent/expedited review.
  
• Right to a qualified reviewer. For appeals, FEP must consult a clinician with appropriate training and expertise who was not involved in the initial decision to assess the medical necessity of your treatment.
  
• Right to escalate to OPM (final FEHB review). If the appeal is denied—or the plan does not follow required claims procedures—you may take your case to the U.S. Office of Personnel Management for final administrative review. Expedited formulary-exception requests are typically resolved within 72 hours and may be submitted at the same time as your internal review. Standard OPM reviews generally take 30 days. 

How to use these rights to get covered

The important stuff. Lean on your rights as a member of the plan to hold your insurer accountable – you deserve timely responses, fair determinations, and appropriate coverage. Here’s how to make it happen.

1) Ask for a formulary exception

Tell the Plan you’re appealing the non-coverage notice and requesting a member reconsideration/formulary exception for Dupixent based on medical necessity. 

If you’re currently on Dupixent (or delay could seriously harm you), mark it Urgent—pre-service to trigger the expedited review timeline. 

Follow our step-by-step guide for exactly how to do this – or use Claimable to make it easy.

2) If they reject your exception request, ask for your claim file

You’re entitled to a review that considers everything you submit and – when medical judgment is involved – uses a clinician with relevant expertise who wasn’t part of the original decision. You can also review and copy all relevant materials at no charge.  

3) Escalate to OPM for a final decision

For non-urgent pre-service issues, you have 6 months to request reconsideration; the Plan must decide within 30 days (with defined clocks if it asks you for more info). Urgent pre-service reconsiderations, including for any  are due in 72 hours. If the Plan upholds the denial—or doesn’t follow required processes—you may appeal to OPM. For urgent pre-service claims, you can request simultaneous OPM review.   

What counts as a strong basis to keep Dupixent?

Federal rule §156.122(c) says plans must have a way to get an exception to access clinically appropriate non-formulary drugs; “exigent circumstances” include being in a current course of treatment. 

If you have previously tried alternatives that were failed, were intolerable, are contraindicated, are off-label for your diagnosis/age, or carry unacceptable risks versus your stable response on Dupixent, that’s a compelling medical necessity to document. 

Your notices must be understandable and specific FEP notices (EOBs and adverse determination letters) must identify the claim, list key details (date of service, provider, amount), and inform you that diagnosis/procedure codes are available on request. Use this to pinpoint exactly what the plan relied on – and what evidence to add. 

It sounds a bit complicated – because, frankly, it is. There’s a lot of insurance, legal, and clinical complexity to wade through to get it right. That’s why we’re here.

How to appeal easily and effectively‍

Use Claimable. Our free service for Dupixent will draft your appeal, source the exact regulations and provisions, compile clinical evidence tailored to your condition, and file by fax/mail for you – plus handle your OPM escalation if needed.

If you still want to DIY it – or just understand the nuts-and-bolts steps – dig into our step-by-step FEP Blue appeal guide for Dupixent here.

Sources

• Formulary exception & expedited decision (24h/72h) — 45 C.F.R. § 156.122(c): standard & expedited exception processes, decision deadlines, and duration of coverage.
  
• FEP Blue Standard/Basic 2026 Brochure (official plan rights & timelines) — pre-service decision/reconsideration timelines; simultaneous OPM review for urgent claims; notice and file-access rights; disputed claims process.         

Use your rights - and get covered

You have the right to ask for Dupixent to stay covered now, to get a fast answer if you’re mid-treatment, to a qualified, fair review on a clear timetable, and to a final OPM review if needed. Use those rights so you don’t have to start 2026 on the wrong medicine. We’re here to help make it happen.

Start your appeal now

‍

If you're on Dupixent and got a notice saying it won't be covered in 2026, don't settle for switching. Under the BCBS Federal Employee Plans (FEP Blue), you can appeal the coverage decision as a member and request a formulary exception to keep Dupixent covered when it's medically necessary.

But filing an appeal isn't always easy or obvious – in fact, the process is often buried in PDFs and plan documents. Let's make it easy: Follow our step-by-step guide for exactly what you need to do to appeal and request a formulary exception – and get it approved.

Choose your path: You can take the DIY route to appeal yourself, or use the fully-guided Claimable experience (free for qualifying Dupixent patients with commercial insurance, including FEP Blue). We'll draft your appeal letter requesting a formulary exception, source all the right evidence, and mail and fax it all with just a few minutes of your time.

Note: Your doctor can also file a medical exception form on your behalf, but many providers face time constraints. We recommend filing a member appeal yourself to ensure it gets done quickly.

Quick summary:

• Appeal timing: If you got the notice letter, don't wait until the coverage change kicks in on January 1. You have up to 6 months to file your appeal, but we recommend filing now to avoid coverage gaps.
• Where to send: Mail your appeal to Service Benefit Plan, P.O. Box 52080, Phoenix, AZ 85072-2080 or fax to 1-877-378-4727
• Urgent cases: If you're already taking Dupixent, mark your appeal "Urgent—pre-service." FEP must issue a decision within 72 hours (realistically 5-7 business days).
• What to send: Follow our member appeal guide below to request a formulary exception. (Your doctor can also file a medical exception form, but we recommend filing a member appeal to ensure timely action.)
• Escalation options: If your appeal is denied, you can request reconsideration, then escalate to OPM for final administrative review.

Step 1 — Prepare (documents, addresses, and your case theory)

Gather documents:

• Your coverage notice and any denial letters received when trying to refill.
• Your insurance card and and member ID.
• Relevant medical records: therapies tried, dates/durations, outcomes (failure, intolerance), and any contraindications.

Decide urgency: If you’re in a current course of treatment or delay could seriously jeopardize health/function, you can file as Expedited (72 hour mandate, 5-7 day reality).

Sketch your case: Note why Dupixent is appropriate for your diagnosis and why the listed alternatives are not (failures, intolerance, phenotype/label mismatch, age limits). Take a moment to reflect: How Dupixent has helped you, and what your experience was on other treatments. Personal impact and details about symptoms and benefits are key for a strong appeal/

Need help? Check out our alternatives breakdown and condition-specific blog posts for a deeper dive.

Step 2 (Optional) — Ask your doctor to write a Letter of Medical Necessity (LOMN)

Your doctor writes the LOMN; you submit it with your appeal. Ask for a short, specific letter that includes:

• Diagnosis & severity (objective measures where applicable).
• Prior therapies (names/dates/doses) and outcomes (failure, intolerance, etc.).
• Contraindications/risks with covered alternatives
• Why Dupixent is appropriate for you now (phenotype fit, stability, clinical goals).
• Risk of switching or treatment interruption (flares, ER visits, disease regression, etc).
• Current response if you’re already on Dupixent (what’s improved, what’s prevented).

Shoot them a message in your portal to make the ask – try our sample message below for a quick and effective request. Tip: Make it as easy as possible for your provider with Dupixent’s template – just drop the link into a message to them in your prescriber portal. 

Hi Dr. [Name],
I received a notice that Dupixent won’t be covered in 2026. I’m filing a member reconsideration / formulary exception request and need a brief Letter of Medical Necessity on your letterhead.

Could you please include:

• Diagnosis & severity (scores/tests if used)
• Prior therapies with dates and outcomes (failure/intolerance/contraindication)
• Why Dupixent is appropriate for me now
• Risks of switching/interrupting treatment (health risks, function loss)
• If I qualify for an urgent review (current treatment, serious disease)
• Current response on Dupixent (if applicable)

Of note, FEP Blue is suggesting I use one of these covered alternatives—so providing specific details about these medications is important: Adbry, Ebglyss, Fasenra, Nucala, Rinvoq, and Xolair. For reference, you can also review the Prior Authorization Form, Dupixent FEP Criteria and Medical Exception Form.

Here’s a Dupixent-specific template you can use. If possible, please upload the letter and any relevant chart notes or history so I can attach it to my appeal.

Template link: https://www.dupixenthcp.com/dam/jcr:9c7e414d-99b5-40a1-acd0-b77173536029/US.DUP.25.04.0698-DMW%20AD%20Sample%20Appeal%20Letter-%20Letter%20of%20Medical%20Necessity.doc

Thank you so much!

Step 3 — Build your request

Write your formulary exception request letter. Include:

Subject: Member Appeal Requesting Expedited Reconsideration of Adverse Benefit Determination — Dupixent Non-Coverage (effective 1/1/2026)
Opening: You’re appealing the plan’s non-coverage notice and requesting continued coverage based on medical necessity. It’s urgent becasue you are at risk of a gap in treatment, so add “Urgent—pre-service.”
Details to include: Your diagnosis and documentation; response on Dupixent; prior therapies + outcomes; clinical evidence supporting medical necessity; why listed alternatives are not appropriate for you; policy and legal precedent if you have it.
Attach: LOMN, key chart notes, the coverage notice.

Submit your packet as soon as possible (must be within 6 months) – to the address shown on your EOB/plan materials for pharmacy claims (Retail/Mail Service/Specialty Drug Program). Keep a copy and proof of delivery.

How to put it together:

• The DIY route: Assemble your appeal letter and supporting documents into a single PDF document. Include a 1-page summary on top.
• The guided option (Claimable): You fill out a short survey to provide all the relevant info; we draft the letter, cite all the evidence, mail and fax for you (free!).

Step 4 — Know the timelines (so you can escalate on time)

• If you’re currently taking Dupixent: This qualifies as urgent and the plan must decide within 72 hours of receiving your exception request (though in practice many take 5-7 days to notify you of decision).
• Otherwise: For non-urgent appeals, the plan decides within 30 days of receiving your reconsideration (if it asks for more info, you have 60 days to supply it; then the plan decides within 30 days of when that info was due/received).

If you disagree with the plan’s reconsideration – or it doesn’t decide on time – go to Step 5.

Step 5 — Escalate to OPM (the final FEHB review)

If the plan upholds the denial (or misses its deadline), you can request a final administrative review by OPM. Deadlines are strict (e.g., 90 days after the Plan’s reconsideration denial; 120 days if the Plan failed to respond on time). Your OPM packet should include your statement of why the Plan is wrong, supporting medical documentation, and copies of all correspondence.

• The DIY route: If your first request is denied and you want to escalate to OPM on your own, you’ll re-submit your appeal and all its documentation along with a statement supporting why you believe the initial decision was wrong.
  When you’re ready, send it to U.S. Office of Personnel Management, Healthcare & Insurance, Federal Employees Insurance Operations, FEHB 1, 1900 E Street NW, Room 3425, Washington, DC 20415-3610. Find more details and instructions on page 141 of the 2026 FEHB FEP Standard and Basic Plan Brochure.‍
• The guided option (Claimable): Once you tell us that your first request was denied, we automatically initiate the OPM review process – updating your statement and documents, clearing it by you for review, and putting it in the mail.

FAQs

Who should file my appeal—me or my doctor?
Either you, your designee, or your doctor can file. Even the most dedicated providers face limits on how much time they can spend fighting denials. Claimable ensures your exception includes all the clinical evidence, policy requirements, and legal protections that give your case the strongest chance of success—details that often get missed when providers are overwhelmed. If needed, your insurer can contact your provider directly to submit additional forms and documents.

How long does the appeal process take?
It depends on the type of appeal — but the sooner you file, the sooner you’ll hear back. Insurers often exceed legal deadlines. Claimable ensures your appeal is filed quickly and that mandated timelines are clearly documented, so any delay is on them, not you.

• Formulary exception appeals: Must decide within 72 hours if a delay affects current treatment or could harm your health. Reality: Often takes 5–7 business days.
• Prior authorization appeals: Must decide within X days (expedited) or 7–15 days (standard). Reality: Usually 1–2 weeks, unless actively escalated.
• Post-service appeals (after a claim is denied): Must decide within 30 days for internal review, 45+ days for external review. Reality: Commonly 6–10 weeks, sometimes longer.

What if I already switched?
You can still appeal to restore coverage for Dupixent – ensure your doctor documents if switching caused negative or harmful symptoms or is unsafe/inappropriate for you, and include this information  in your appeal.

How long do I have to appeal an denial from BCBS FEP?
The appeal window is 6 months after the initial denial.

What counts as an urgent pre-service appeal?
Under 45 CFR § 156.122(c)(2), you have the right to request an expedited formulary exception review when exigent circumstances exist—either when my health condition may seriously jeopardize my life, health, or ability to regain maximum function, or when I am currently undergoing treatment using the non-formulary drug. The plan must make a coverage determination and notify you and your physician within 72 hours, and if approved, must provide coverage for the duration of the exigency—as long as your urgent medical condition persists or your current course of treatment continues.

Where do I mail an FEP or OPM appeal?

• Initial appeal to FEP:
  
  • Fax (fastest): 1-877-378-4727‍
  • Mail: Service Benefit Plan, P.O. Box 52080, Phoenix, AZ 85072-2080

• OPM escalation (if denied):
  
  • Email (fastest): FEDCLASS_APPEALS.INTERNET@opm.gov
  • Mail: U.S. Office of Personnel Management, Healthcare & Insurance, Federal Employees Insurance Operations, FEHB 1, 1900 E Street NW, Room 3425, Washington, DC 20415-3610
• Important ⚠️: Fax or email is strongly recommended. Mail can take 2-3 weeks for delivery, which could delay your decision and cause coverage gaps.
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• Where can I learn more?
  
  • FEP Blue: Dispute a claim page – summarizes 6-month window, urgent 72-hour clock, and “address on your EOB”.  
  • More detail: Your Guide to Disputing a Claim – dives in on member rights, deadlines, and where to send your appeal.

The easiest way to file your BCBS FEP formulary exception request

It’s to use Claimable! We hope this guide has been useful if you’d like to go at appealing on your own. But if you’d like help, we’re here to make it quick, easy, and effective – and thanks to our partnership with Dupixent, it’s 100% free for qualifying commercial insurance members.

With Claimable, you can:

• Easily create your formulary exception request letter, in line with all of FEP’s standards and our proven formula for winning appeals.
• Source and cite the exact plan provisions and clinical precedents that strengthen your case.
• Automatically fax and mail – no downloads, no post office.
• Escalate if needed – because we’ll keep fighting for you all the way to a win.

Ready to get started? Begin your appeal here.

In early November, many FEP Blue members opened a letter saying Dupixent won’t be covered next year. The options? Switch to an alternative medication, or pay full price. 

At Claimable, we help people fight insurance denials every day. Forced switches like this one are all too common in our world, and that means we know exactly what to do when they happen.

Let’s break down these switch letters, what to do if you got one, and how to use Claimable to file your formulary exception so you don’t have to switch. Already have the letter? Sign up here to be notified the minute you can start filing your appeal with Claimable – coming late November

Quick Summary: What you need to know

• Coverage is changing for Dupixent on some FEP Blue formularies in 2026.
• You can ask the plan to keep covering Dupixent by filing an appeal to request a formulary exception.
• You can appeal now. You don't have to wait until
• If you’re currently taking Dupixent, your appeal qualifies for expedited review – plans should issue a decision within 72 hours upon receipt.
• It’s possible to get a 90-day refill after three 30-day fills, which could help you prevent care gaps by contacting the CVS Specialty Pharmacy Program at 1-888-346-3731.
• If the initial appeal is denied, FEHB members can seek an external review by OPM.  

What your letter says—translated

The notice you received follows a predictable pattern. Here’s each section, decoded.

"A drug you’ve filled will not be covered for FEP Blue members starting January 1, 2026."

What it means: This is the formulary change; Dupixent is no longer covered. Unless you take action, claims for Dupixent will not be approved on Jan 1.

What to do now: Begin your formulary exception appeal so coverage is in place before the new year.

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"If you fill this prescription in 2026, you will pay the full cost of the drug."

What it means: Your pharmacy will charge you cash price at the counter unless an exception is approved. For Dupixent, this can be in the thousands of dollars per fill.

What to do now: Upload your letter when you start your Claimable appeal; if your initial appeal is denied, we’ll continue to escalate your appeal all the way through plan reconsideration and final OPM review to make sure you don’t get stuck with sticker shock at the counter.

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"Speak with your Provider about your prescription choices / there are other covered drugs that you can consider."‍

What it means: They're suggesting alternatives like Adbry, Ebglyss, Fasenra, Nucala, Rinvoq, and Xolair—but you don't have to switch if alternatives are less effective, tolerable or are unsafe. For some conditions (EoE, prurigo nodularis, bullous pemphigoid), Dupixent is the only FDA-approved treatment—these alternatives aren't even approved for your condition.

What to do now: Talk to your doctor about getting medical records that show you’ve tried and failed alternatives and/or a letter of medical necessity that supports why Dupixent is right for you. 

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Specialty Pharmacy Program details

What it means: Generally, this shouldn’t be a change – it’s just a reminder of how pharmacy dispensing works under your plan.

What to do now: If you’re eligible for a 90-day fill, put in a request for one now. That way, you’ll have a backup plan if there’s any gaps or delays in getting coverage.

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"Provider can submit a formulary exception at fepblue.org/claim-forms."

What it means: What they don't tell you is that you can file yourself. FEP's policy explicitly allows "members to apply for coverage of a non-covered drug." You don't have to wait for your provider. Claimable ensures your exception includes all the clinical evidence, policy requirements, and legal protections for the strongest case.

What to do now: Get ready to appeal by signing up for notifications the minute they launch—expected 11/27/25.  

Your rights (and why timing matters)

Federal rules require plans to offer a way to request access to clinically appropriate non-formulary drugs. When you’re on current treatment or a delay could harm you, the plan should process an expedited exception and issue a decision within 72 hours of receiving it, with most patients notified within 5-7 days of the decision.

FEP also has a unique safety net: after the plan’s reconsideration, you can ask OPM (the federal agency that oversees FEHB) to review the case.  

Why is FEP Blue suddenly denying Dupixent?

Plans update their formularies – lists of drugs covered on their plan – every year. When a drug comes off that list, coverage stops unless you switch to a covered option or get an exception approved. 

Formulary changes are largely cost control measures for insurers, and they can happen when they deem a medication to be too expensive or, in the case of the recent CVS Caremark Zepbound to Wegovy formulary change, receive a rebate from a rival manufacturer. 

This is called non-medical switching—forcing patients to change medications for financial reasons, not medical ones. While many states have laws restricting this practice, federal employee plans like FEP Blue aren't bound by state insurance laws, and Congress hasn't passed federal protections yet.

But you still have rights. Federal regulations require plans to offer a formulary exception process when switching would be clinically inappropriate. Your appeal invokes that right—demonstrating that Dupixent is medically necessary and that the suggested alternatives won't work for you.

Two things to do today:

1. Start your appeal. With Claimable, you can draft and submit your request in minutes (free for qualifying Dupixent patients).
2. Request medical records. Ask your doctor for documentation showing failed alternatives and why Dupixent is medically necessary.

Understanding your options: Will I be forced to switch to something else?

Not automatically. The key is demonstrating why the alternatives won't work for you—and that forcing you to switch would be clinically inappropriate.

Here's how to build a strong case:

1. Explain why you can't take alternatives:
   
   • You've already tried and failed similar treatments (document drugs, dates, outcomes)
   • Alternatives were never effective, or lost effectiveness over time (therapeutic failure)
   • You experienced negative or harmful side effects with alternatives (adverse events)
   • Alternatives are contraindicated with another medication or condition, have an applicable FDA warning, or otherwise pose clinical risks for you
   • Switching could cause disease flares or setbacks
2. Showcase where Dupixent is uniquely appropriate
   
   • For EoE, prurigo nodularis, or bullous pemphigoid: Dupixent is the only FDA-approved treatment—the suggested alternatives (Adbry, Ebglyss, Fasenra, Nucala, Rinvoq, Xolair) aren't even approved for these conditions
   • For other conditions: Age restrictions, disease phenotype, or lack of on-label alternatives may make Dupixent the only appropriate option

When supported by strong clinical evidence and proper documentation (like in a Claimable appeal), you have a strong chance of winning your exception.

How to file an FEP Blue formulary exception for Dupixent

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1) Gather the essentials (10–15 minutes)

• Your coverage change letter (the one saying Dupixent won’t be covered in 2026)
• Plan details (Basic/Standard/Focus, member ID)
• Treatment history: drugs tried/failed, bad side effects, contraindications, ER visits
• Medical records or letter of medical necessity from your doctor (if available)

2) Draft your exception request.
Write a formal letter that includes:

• Your diagnosis and treatment history
• Why Dupixent works for you and alternatives don't
• Clinical evidence supporting medical necessity
• Policy/legal citations backing your rights to continued coverage

Seem daunting? Claimable drafts a comprehensive formulary exception request—including all clinical and policy evidence—from a short survey. Free for qualifying Dupixent patients with commercial insurance.

3) Submit your exception appeal

• DIY route: Follow the process detailed on pages 138-142 of the 2026 Standard and Basic Plan Brochure
• Easier path: File directly through Claimable in just a few clicks. No uploads, downloads, or post office visits. 

4) Request expedited review if you're currently on Dupixent‍

If you're currently taking Dupixent or a delay could harm you, federal law requires expedited review with a decision within 24-72 hours (though realistically it takes 5-7 business days). Claimable automatically flags this when you qualify.
‍
5) If your initial request is denied‍

You can request plan reconsideration, and FEHB members can escalate to final administrative review by OPM under the disputed claims process. Claimable guides you through each escalation step—we keep fighting until you win.

6) If approved but your copay is still too high

You may be eligible for Dupixent's copay assistance program, subject to program rules and federal restrictions. Contact Dupixent directly or ask your pharmacy about eligibility and enrollment: https://www.dupixent.com/support-savings/copay-card

Get started now

How Claimable helps (free for qualifying Dupixent patients!)

Claimable appeals succeed in over 80% of cases. Here's how we help:

• Custom appeal: We build a fully personalized, expert-backed formulary exception request for your unique situation
• Complete filing: We instantly submit it via fax and mail with all required documents, clinical evidence, and policy citations your plan needs
• Expedited review: We request fast-track decisions when you qualify and monitor deadlines
• Full escalation: If denied, we guide you through reconsideration and OPM review—we keep fighting with you.

Free for Dupixent patients with commercial insurance (including FEP Blue) through our partnership with Dupixent's patient support program.

Sources & helpful links

• Prior Authorization Form and Dupixent FEP Criteria
• Medical Exception Form for FEP Blue Focus, Basic and Standard
• 2026 Formulary for FEP Blue Focus, Basic and Standard
• 2026 Plan Brochure for FEHB FEP Blue Focus, Basic and Standard
• 2026 Plan Brochure for PSHB FEP Blue Focus, Basic and Standard
• Your right to an exception and expedited decisions (45 CFR 156.122(c))
• Specialty Pharmacy Program details and contact info
• FEHB/OPM review (FEHB Handbook and program materials)
• Authorized Representative Designation Form

The bottom line – you don't have to switch from Dupixent

A coverage change letter isn't the end of the road—80% of Claimable appeals succeed.

Formulary changes harm patients who've spent years finding stable, effective treatment. You don't have to accept this. Challenge the decision, get your doctor's support, and file your exception.

Claimable builds and files your Dupixent exception for free* for qualifying patients. But that’s not your only choice. If you’re one of the thousands of people who got the Dupixent letter, take a breath. What’s happening here is called a formulary change, and you can challenge it – and win. Many people in scenarios like this one will be able to keep coverage by filing something called a formulary exception.

*Free for Dupixent patients with commercial insurance (including FEP Blue) through our partnership with Dupixent's patient support program.

Get started now

On July 1, CVS Caremark began forcing patients to switch from Zepbound to Wegovy – and we quickly took action to help folks fight back by appealing. With many patients protected by step therapy and non-medical switching laws, we were confident in their cases. The majority of these denials should have been overturned easily. 

They weren’t. 

Our team quickly started noticing an unusual – and troubling – pattern. Appeals were getting denied at a high rate and at unusual speed. Denials were coming back not in the standard hours or days, but in minutes – all following the same script and formula, returned with almost identical responses. Same wording. Same rationale. Same disregard for the patient’s actual medical needs.

Under federal law, every appeal is supposed to get a full, fair, individualized review by a human reviewer. These weren’t reviews. They were copy-paste auto-replies. This falls well outside of what we’ve been used to from insurers, and it raised serious legal concerns. 

Seeing the patterns in the data

The appeals process is typically fragmented, with individual patients and providers rarely compiling or comparing notes. Spotting trends is nearly impossible. But by handling hundreds of appeals specifically for CVS’s Zepbound forced-switch patients, Claimable had a unique vantage point. We saw systemic, policy-wide denials unfolding in real time. These weren’t a few isolated cases; we were seeing a consistent, repeated pattern of patients being denied their legal rights.

We immediately began supporting second-level appeals and escalation to independent review, including a detailed opinion from our Senior Legal Advisor, D. Brian Hufford, Esq., of The Hufford Law Firm PLLC, to help patients fight for the coverage they deserved.  More appeals began to succeed – but not nearly enough. 

Our success rate doubled after escalating cases with stronger legal arguments, but it remained below our usual benchmarks. That wasn’t good enough. We knew something was deeply wrong. So even while individual appeals were starting to work, it was clear that this broader pattern of systemic denials raised bigger legal questions – questions that went beyond what the appeals process alone can fix.

So with Brian, we began investigating additional options.

The CVS Caremark Zepbound lawsuit and your right to a full, fair, individualized review

Working closely with patients we’d supported through their appeals, Brian took the evidence to Berger Montague, a firm that specializes in healthcare class action litigation.

On September 3, 2025, they filed a class action lawsuit against CVS Caremark on behalf of patients in ERISA-governed employer-sponsored health plans whose coverage for Zepbound was denied and whose appeals were rejected based on medical necessity.

The lawsuit alleges that CVS Caremark wrongfully denied coverage by issuing denials that appeared to rely on templated language, despite patients meeting the plans’ criteria for medical necessity. Filed under ERISA, the suit alleges that CVS Caremark:

• Breached its fiduciary duties by prioritizing financial gain over medical appropriateness or plan obligations;
• Engaged in prohibited transactions by entering formulary agreements that benefit its own bottom line;
• Violated the terms of employer health plans by denying coverage for an FDA-approved, medically necessary treatment – while steering patients toward non-equivalent or off-label alternatives; and
• Ignored federal claims procedure standards by failing to provide timely, transparent, and individualized appeal reviews.

The complaint asks the court to issue injunctive relief, requiring CVS to change its policies going forward. It also seeks other appropriate equitable relief if those remedies are found insufficient to fully address the harm to patients. 

Advocacy doesn’t end with the appeal

Since July 1st, we’ve helped hundreds of patients file appeals for Zepbound denials. That’s only a tiny slice of the hundreds of thousands of patients affected. But it’s enough to spot the trend and push for accountability.

To be clear: Claimable isn’t a party to this suit. The relief it seeks isn’t on our behalf. But for us, being a patient-first company means taking a root cause approach to solving problems whenever possible. In this case, it meant going beyond the appeals process we operate within and connecting patients to legal options they might not otherwise access.

We built Claimable to make appealing easier and more successful. But just as importantly, we built it to expose what’s really happening behind the scenes. Denials don’t happen in isolation, and neither can our response.

That’s why we’re proud to support a broader movement for change, alongside legal teams, advocacy organizations, and policy leaders. Appeals are one piece. Litigation is another. Legislative reform is critical too. The only way to deter unjust denials is to challenge them—again and again—until insurers and pharmacy benefit managers face real consequences for saying no without cause.

What’s next for Zepbound appeals 

Legal action takes time, and we’ll be watching closely as this case makes its way through the courts. But while the system may be slow, we’re not slowing down. We will continue helping patients appeal these Zepbound forced switches – and we’ll keep evolving our strategies as new evidence and appeal precedents emerge.

We hope this lawsuit sends a clear message: insurer misconduct that puts patients at risk will not go unnoticed or unchallenged.

Our job isn’t just to make paperwork easier and arguments stronger. It’s to fight back when something feels wrong. To listen to patients. To advocate. To act.

And we won’t stop until everyone gets the care they need and coverage they deserve.

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