If you're on Dupixent and got a notice saying it won't be covered in 2026, don't settle for switching. Under 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 FEP Blue denial?
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 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.
• 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.
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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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