If your insurance denies coverage for a prescription medication, you have the right to appeal. The appeals process involves multiple levels, from internal review to independent external review. About half of all drug coverage appeals are successful, so persistence pays off. This guide walks you through every step of the appeals process.
Key Facts
Check Your Specific Plan's Formulary
Coverage varies by plan. Use our formulary checker tool to look up your exact copay and restrictions.
Open Formulary CheckerSources and standards behind this page
Drug coverage in the United States is governed by published rules rather than by any one insurer's summary, and the sources below are the primary ones. They are linked so a reader can check a claim without taking this page's word for it.
- FDA Orange Book publishes the therapeutic-equivalence ratings that decide whether a generic may be substituted for a brand-name drug.
- FDA generic drug facts sets out what "generic equivalent" means and what a manufacturer must prove.
- CMS prescription drug coverage defines the rules a Medicare drug plan formulary must follow and how it may change mid-year.
- Medicare.gov drug coverage (Part D) states what a Part D plan is required to offer a member.
- CMS prescription drug appeals documents the coverage-determination and exception process when a drug is denied.
This page describes how coverage and formularies work. It is not medical advice, and a reader's own plan documents and prescriber decide what applies to them.
Frequently Asked Questions
Include: your name, member ID, prescription details, denial reference number, your doctor's statement of medical necessity, clinical evidence supporting the drug (studies, guidelines), why alternatives are not appropriate, and your request for coverage. Attach supporting medical records, lab results, and a letter from your prescriber. Keep a copy of everything.
Most plans allow 60 to 180 days from the denial date to file an appeal. Medicare Part D allows 60 days. Check your denial letter for the specific deadline and instructions. Do not wait until the last minute, as gathering documentation takes time. Request an expedited appeal if you need the medication urgently.
An external review is an independent review by a third-party organization not affiliated with your insurer. You can request it after your internal appeal is denied. The external reviewer's decision is binding on the insurer. ACA-compliant plans and Medicare both offer external review rights. There is typically no cost to you for the review.
Related Resources
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