Over half of insured patients were told their medications aren't covered in 2024. Insurance companies excluded 600+ drugs from coverage. But you can fight back—and win.
A prescription coverage denial happens when your health insurance company refuses to pay for a medication your doctor prescribed. You might receive a rejection letter, get turned away at the pharmacy, or find out your drug suddenly isn't covered anymore.
These denials don't mean you can't get the medication—they mean your insurance won't help pay for it unless you appeal. The problem? Nearly half of Americans whose insurance denies coverage simply go without the drug, unaware they have a legal right to challenge the decision.
Denials take many forms. Your drug might not be on your plan's formulary (the list of covered medications). It might require prior authorization that your doctor hasn't obtained. Your insurer might demand you try cheaper alternatives first through "step therapy" protocols. Or your medication might be placed in a high-cost tier with unaffordable copays.
What's changed recently? The three major pharmacy benefit managers—Caremark/CVS Health, Express Scripts/Cigna, and OptumRx/UnitedHealth—have exploded their exclusion lists from fewer than 100 drugs in 2014 to over 600 in 2024. That's a six-fold increase in just a decade, affecting treatments for everything from diabetes and heart disease to cancer and rare disorders.
Here's what you need to know: one in three Americans with health insurance will be prescribed a medication this year that their insurer won't cover. But fewer than 1% of people ever appeal. Those who do appeal win more than half the time. This guide will show you exactly how to be in that winning 50%.
Find out your chances of winning a prescription coverage appeal based on your specific situation.
Get an estimate of your potential compensation
Your insurance plan maintains a formulary—a list of covered drugs. If your medication isn't on this list, it won't be covered. Formularies change annually and sometimes mid-year. What was covered last month might not be covered today. The 600+ drugs excluded in 2024 include treatments for diabetes, heart disease, and cancer. Solution: Request a formulary exception with your doctor's support explaining why this specific drug is medically necessary.
Your doctor must get pre-approval from your insurer before prescribing. This process adds an average 31-day delay and requires extensive paperwork. 94% of patients experience delays from PA requirements. Physicians report spending an average of two business days per week on prior authorizations. Solution: Ask your doctor's office if they can submit an expedited PA request if you have urgent medical needs.
Insurance requires you to try cheaper drugs and prove they don't work before covering your doctor's original prescription. Nearly 40% of specialty drugs face step therapy requirements. This can delay effective treatment by months and cause disease progression. Solution: Request a step therapy exception, especially if you've previously tried and failed the required medications or if trying them would cause harm. 36 states have laws protecting patients from harmful step therapy delays.
Your drug might be covered but placed in Tier 4 or 5 with copays of $400-$800 per month instead of the $10-$50 you can afford. Insurers can move drugs to higher tiers mid-year with 60 days' notice. Solution: Request a tiering exception to move the drug to a lower tier, demonstrating that lower-tier alternatives are ineffective or contraindicated for your condition.
Your plan covers the drug but limits how many pills you can get per month. If your doctor prescribes 60 tablets but your plan only covers 30, you're denied the full prescription. This is common for pain medications, migraine treatments, and certain chronic disease medications. Solution: Have your doctor submit a quantity limit exception with clinical justification for the higher dose.
The drug is covered, but only for certain conditions or age groups. For example, your plan might cover a medication only for FDA-approved uses, not "off-label" uses. Or it might cover a pediatric vaccine only for children, denying coverage for an adult who needs it. Solution: Request an exception with medical literature supporting the use of the medication for your specific condition and age.
Your doctor prescribed a brand-name drug, but your insurance will only cover the generic version. In most cases, generics work fine. But some patients have allergies to inactive ingredients in generics, or certain conditions (like epilepsy or thyroid disorders) require brand consistency. Solution: If you have a medical reason you need the brand version, your doctor can request a brand-medically-necessary exception.
⚠️ Warning: Prior Authorization Can Cause Serious Harm
34% of physicians report that prior authorization delays have led to serious adverse events for their patients, including hospitalization (24%), permanent disability, and even death (8%).
Prior authorization is the insurance industry's gatekeeping process where your doctor must get permission before prescribing certain medications. What started as a cost-control measure for expensive drugs has exploded into a bureaucratic nightmare affecting 94% of patients.
Here's how it works: Your doctor writes a prescription. The pharmacy submits it to your insurance. Instead of approval, you get a denial saying "prior authorization required." Your doctor must then submit extensive paperwork proving the medication is medically necessary, often including your medical records, lab results, and justification for why cheaper alternatives won't work. The insurance company reviews this—sometimes taking weeks—and may still deny it, requiring an appeal.
The numbers are staggering. The average wait time for prior authorization is 31 days compared to 27 days for the same medications when no authorization is required. For initially denied medications, patients wait a median of 50 days—nearly two months—before getting their prescribed treatment. During this time, chronic diseases progress, pain goes untreated, and mental health conditions worsen.
The impact on physicians is equally severe. 93% of doctors report prior authorization delays patient care. They spend an average of two business days per week on PA paperwork. Many employ full-time staff whose sole job is fighting with insurance companies for medication approvals.
What can you do? First, ask if your medication requires PA before leaving your doctor's office. Your doctor's staff can often submit the PA immediately, shaving days off the process. Second, if you're told to wait for PA approval but your condition is urgent, request an expedited review. Third, don't wait passively—call your insurance company every few days to check status. Fourth, if denied, appeal immediately with your doctor's help.
Most importantly, know your rights. For Medicare Part D, plans must respond to standard PA requests within 72 hours and expedited requests within 24 hours. Many states have similar laws for commercial insurance. If your insurer misses these deadlines, file a complaint with your state insurance department.
Step therapy—also called "fail first"—is an insurance policy that requires you to try and fail on cheaper medications before they'll cover the drug your doctor originally prescribed. It's one of the most frustrating barriers patients face.
Here's a typical scenario: Your rheumatologist diagnoses you with rheumatoid arthritis and prescribes a biologic medication that's shown excellent results in clinical trials. Your insurance denies it, saying you must first try methotrexate (an older, cheaper drug) for 3-6 months and prove it doesn't work. Only after you've "failed" on methotrexate will they consider covering the biologic. Meanwhile, your disease progresses, your joints become more damaged, and your quality of life plummets.
Nearly 40% of specialty drug coverage policies include step therapy requirements. The protocols vary dramatically from plan to plan, even for the same condition. What's required to "fail" also varies—some plans require documented side effects, others require a specific duration of treatment, and some require you to try multiple drugs in sequence.
36 states have passed step therapy reform laws that strengthen patient protections. These laws typically require insurers to grant exceptions when:
Check if your state has step therapy protections. Some states require insurers to respond to exception requests within 72 hours (24 hours for urgent requests).
Your insurance plan's formulary is divided into tiers, each with different out-of-pocket costs. The tier your medication is placed in can mean the difference between a $10 copay and a $600 copay. Here's how it typically breaks down:
Typical Copay: $10-$20
Most generic drugs, lowest cost. These are the insurer's preferred medications for each condition.
Typical Copay: $30-$50
Generic drugs not on the preferred list. Still affordable but higher cost-sharing.
Typical Copay: $80-$150
Brand-name drugs on the formulary with negotiated pricing. Some have generic alternatives.
Typical Copay: $200-$400 or 25-40% coinsurance
Brand drugs not preferred by the plan. High cost-sharing to encourage generic use.
Typical Copay: $400-$800 or 25-50% coinsurance
High-cost specialty medications (biologics, cancer drugs, rare disease treatments). Often require specialty pharmacy and prior authorization. Some plans cap specialty copays at $150-$200/month.
If your medication is in Tier 4 or 5 but there's a similar drug in Tier 2 or 3 that doesn't work for you, you can request a tiering exception to pay the lower-tier copay.
What you need:
Formulary coverage: Plans must cover at least 2 drugs in each therapeutic category and class
Exception requests: You have the right to request coverage of non-formulary drugs with a 72-hour decision timeframe (24 hours if expedited)
5-level appeals process: Guaranteed access to multiple levels of independent review if denied
Transition fills: If your drug is removed from the formulary mid-year, you're entitled to a temporary supply while you appeal or switch medications
Protected classes: Part D plans must cover "all or substantially all" drugs in six protected classes (antidepressants, antipsychotics, anticonvulsants, immunosuppressants, antiretrovirals, and antineoplastics)
Internal appeals: All plans must offer an internal appeal process for denials
External review: If your internal appeal fails, you can request an independent external review at no cost
Expedited appeals: For urgent situations, insurers must decide internal appeals within 72 hours and external reviews within 4 business days
Essential Health Benefits: Plans must cover prescription drugs, though they can limit which specific drugs
Step therapy reform: 36 states have laws requiring insurers to grant exceptions to step therapy when medically appropriate
PA timelines: Many states require insurers to respond to prior authorization requests within specific timeframes (often 72 hours standard, 24 hours urgent)
Formulary changes: Some states require 60-90 days' notice before removing drugs from formularies or moving them to higher tiers
State insurance departments: You can file complaints with your state's insurance regulator if your insurer violates these timelines
⏱️ Important Deadlines
Standard exception: 72-hour decision | Expedited exception: 24-hour decision | Appeals: Must file within 60 days of denial
Call the customer service number on your insurance card. Tell them: "I need to request a formulary exception for [medication name]."
Ask them:
Get a reference number for your call and the name of the representative.
Your exception request MUST include a prescriber's supporting statement. Contact your doctor's office and ask them to write a letter that includes:
The letter should be on the doctor's official letterhead, signed and dated, with your name and insurance policy number clearly stated.
Submit the completed exception form and your doctor's supporting statement via the method your insurance company requires (fax, online portal, or mail).
Keep copies of everything. If faxing, get a confirmation page. If mailing, send certified mail with return receipt.
If this is an urgent situation, mark it as an "expedited exception request" and have your doctor explain why waiting could seriously harm your health.
For standard requests, your plan must decide within 72 hours. For expedited requests, they must decide within 24 hours.
You'll receive a written decision in the mail, but call to check the status after 48 hours (standard) or 12 hours (expedited).
If they miss the deadline, call and ask for the decision. File a complaint with your state insurance department if the delay is unreasonable.
If approved, the exception is typically valid for the remainder of the plan year (or the duration of treatment if specified by your doctor).
Take the approval letter to your pharmacy. Keep a copy for your records.
If you paid out-of-pocket for the medication while waiting for the decision, submit a claim for reimbursement (minus your normal copay).
The denial letter will include instructions on how to appeal. You typically have 60 days from the denial date to file an appeal.
Don't wait. File your appeal immediately following the process below for Medicare Part D or commercial insurance.
More than 50% of appeals succeed, especially when your doctor provides strong medical justification.
Medicare Part D has a clearly defined 5-level appeals process. Each level offers an independent review, and you can escalate to the next level if your appeal is denied. Here's how it works:
Timeline: 7 days standard, 72 hours expedited
Who decides: Your Medicare Part D plan reviews the denial.
How to file: Submit a written request within 60 days of the denial. Include your name, Medicare number, the drug name, and reasons for appealing. Attach your doctor's supporting statement.
What happens: The plan assigns someone who wasn't involved in the original denial to review your case. They'll look at your doctor's statement and any new medical evidence.
Next step if denied: You automatically receive information about Level 2 appeals with your denial letter.
Timeline: 7 days standard, 72 hours expedited
Who decides: An independent company hired by Medicare (not your insurance plan).
How to file: File within 60 days of your Level 1 denial. The Level 1 denial letter includes the IRE contact information and forms.
What happens: The IRE reviews all the information from Level 1 plus any additional evidence you submit. They make an independent decision.
Next step if denied: If your drug is worth at least $190 in 2025, you can appeal to Level 3.
Timeline: 90 days | Minimum value: $190 (2025)
Who decides: An Administrative Law Judge from the Office of Medicare Hearings and Appeals (OMHA).
How to file: File within 60 days of your Level 2 denial. You can request a phone hearing, video hearing, or in-person hearing.
What happens: You (or your representative) can testify and present evidence. You can bring witnesses, including your doctor. The ALJ makes an independent legal decision.
Next step if denied: Appeal to the Medicare Appeals Council (Level 4).
Timeline: 90 days
Who decides: The Medicare Appeals Council, part of the Department of Health and Human Services.
How to file: File within 60 days of the ALJ decision.
What happens: The Council can decide your case itself, send it back to an ALJ for another hearing, or deny your request for review (which means the Level 3 decision stands).
Next step if denied: Federal District Court (Level 5).
Timeline: Varies | Minimum value: $1,810 (2025)
Who decides: A federal judge.
How to file: File a lawsuit in U.S. District Court within 60 days of the Level 4 decision.
What happens: This is a formal lawsuit. You'll likely need an attorney. The court reviews whether Medicare law was properly applied.
Reality check: Very few cases reach Level 5. Most are resolved at Levels 1-3.
If you have private insurance through your employer or the ACA marketplace, the appeals process is different from Medicare Part D but still offers multiple levels of review. The Affordable Care Act requires all plans to provide an internal appeal and external review process.
Timeline: Plans must decide within 30 days for standard appeals, 72 hours for urgent appeals
How to file: Follow the appeal instructions in your denial letter. Most plans accept appeals by mail, fax, or online portal. Include your doctor's supporting statement and any additional medical evidence.
Who reviews: Someone at your insurance company who wasn't involved in the original denial, typically a doctor or pharmacist.
What to include: Personal information (name, policy number), the denied medication name and dosage, reasons why you disagree with the denial, your doctor's supporting statement, and any clinical studies or medical literature supporting your case.
Timeline: Independent Review Organization (IRO) must decide within 45 days for standard reviews, 72 hours for urgent reviews
When available: If your internal appeal is denied, or if your insurer takes too long to decide
Who reviews: An Independent Review Organization (IRO) assigned by your state or the federal government. These are outside companies with no financial relationship to your insurance plan.
Cost: Free to you. The insurance company pays the IRO's fees.
Binding decision: In most states, the IRO's decision is binding—if they approve your appeal, your insurer must cover the medication.
You can request an expedited (fast) appeal if waiting for a standard decision could seriously jeopardize your health or ability to regain maximum function.
Examples of urgent situations: You're in severe pain, you're being discharged from the hospital and need the medication immediately, waiting could cause permanent disability, or your condition is rapidly worsening.
How to request: Call your insurance company immediately, state that you need an "expedited appeal" or "urgent appeal," and have your doctor submit a statement explaining why the delay would harm you.
Timelines: Insurers must decide expedited internal appeals within 72 hours and expedited external reviews within 72 hours as well.
Sarah was diagnosed with stage 3 breast cancer. Her oncologist prescribed Kadcyla (ado-trastuzumab emtansine), a targeted therapy with excellent results for her specific cancer type. Her Medicare Part D plan denied it, saying it wasn't on the formulary. Her out-of-pocket cost: $8,400/month. She filed an exception request with her oncologist's supporting statement explaining why this specific drug was medically necessary based on her HER2-positive status. Level 1 denied. She appealed to Level 2 IRE within a week. The independent reviewer approved the exception after reviewing clinical trial data her doctor submitted. She received retroactive coverage for the two months she'd been paying out-of-pocket while appealing, recovering $16,800.
James's rheumatologist prescribed Humira for his worsening rheumatoid arthritis. His insurance required step therapy: fail on methotrexate first (3-6 month trial). The problem? James had already tried methotrexate five years ago under a previous insurance plan and had severe liver complications. His doctor submitted an expedited step therapy exception request with documentation of the previous methotrexate trial and liver enzyme test results showing toxicity. The insurer approved the exception in 48 hours, allowing James to start Humira immediately instead of waiting months and risking permanent joint damage. Estimated savings: $1,200 plus irreversible health damage avoided.
Linda had been taking Jardiance for type 2 diabetes for three years with excellent results (A1C dropped from 8.9 to 6.2). In January 2024, her Medicare Part D plan moved Jardiance from Tier 2 ($15/month copay) to Tier 4 ($95/month copay). She was stable on the medication and other Tier 2 alternatives hadn't worked in the past. Her endocrinologist submitted a tiering exception request explaining she'd already failed on metformin and glipizide, and switching medications now could destabilize her well-controlled diabetes. The plan approved the exception, allowing her to continue paying $15/month instead of $95/month—saving $960 annually.
Robert was discharged from the hospital after a heart attack. His cardiologist prescribed Entresto (sacubitril/valsartan) to prevent heart failure progression. The insurance required prior authorization, typically taking 7-14 days. Robert's doctor called the insurance company and explained that Robert was at high risk for rehospitalization without immediate medication. She submitted an expedited PA request with his hospital discharge summary, echocardiogram showing reduced ejection fraction (35%), and a letter explaining the medical urgency. The plan approved it within 24 hours instead of the standard two-week wait. Robert started his medication on schedule, avoiding a potential $30,000+ hospital readmission.
[Your Name]
[Your Address]
[City, State ZIP]
[Phone Number]
[Email Address]
[Date]
[Insurance Company Name]
[Insurance Company Address]
[City, State ZIP]
RE: Appeal of Prescription Drug Denial
Policy Number: [Your Policy Number]
Member ID: [Your Member ID]
Medication: [Drug Name and Dosage]
Denial Date: [Date of Denial Letter]
Denial Reference Number: [If provided]
Dear [Insurance Company] Appeals Department:
I am writing to formally appeal your denial of coverage for [medication name and dosage] prescribed by my physician, Dr. [Doctor's Name], on [date of prescription]. This medication is medically necessary to treat my [condition/diagnosis].
Reason for Denial: According to your denial letter dated [date], you denied coverage because [state their reason: not on formulary, prior authorization required, step therapy required, etc.].
Why This Decision Should Be Reversed:
[Choose the appropriate paragraph based on your situation:]
For Formulary Exceptions: While [medication name] is not on your formulary, the covered alternatives ([list them if known]) are not appropriate for my condition because [explain why: tried and failed, contraindicated, allergies, etc.]. My physician has provided a supporting statement explaining the medical necessity of this specific medication.
For Step Therapy Exceptions: Although your plan requires I first try [alternative medication], this would not be appropriate in my case because [I have previously tried this medication with poor results/it is contraindicated due to my medical history/delaying effective treatment would cause harm]. My physician's supporting statement provides detailed medical justification.
For Prior Authorization Appeals: My physician submitted a prior authorization request on [date] with full medical justification. The denial was based on [state reason]. However, [medication name] is medically necessary because [explain unique aspects of your condition, why alternatives failed, etc.].
Supporting Documentation Enclosed:
I am requesting [an expedited review / a standard review] of this denial. [If expedited: My condition requires immediate treatment, and waiting for a standard review would seriously jeopardize my health because [explain].]
Please review this appeal and approve coverage for [medication name] as prescribed by my physician. I look forward to your response within [7 days for Medicare Part D Level 1 / 30 days for commercial insurance / 72 hours for expedited reviews].
Thank you for your prompt attention to this matter. If you need any additional information, please contact me at [phone number] or [email].
Sincerely,
[Your Signature]
[Your Typed Name]
Enclosures: [List all documents you're including]
Your doctor's supporting statement is the most important piece of your appeal. Insurance companies are far more likely to approve exceptions when a physician provides detailed medical justification. Here's what makes a strong supporting statement:
💡 Tip: Make It Easy for Your Doctor
Most doctors want to help but are overwhelmed with paperwork. To make it easier: (1) Ask if their office has a standard template for insurance appeals; (2) Provide them with a copy of the denial letter and any forms your insurance requires; (3) Write down the key points you want included (previous medications tried, side effects, dates); (4) Offer to draft a letter they can review and edit if that helps their workflow. Many doctors' offices have dedicated staff who handle insurance appeals—ask to speak with them directly.
While your appeal is pending, you might need your medication immediately. Here are ways to reduce costs or get access while waiting:
GoodRx, SingleCare, and other discount cards can reduce cash prices by 50-80%. Sometimes the discounted cash price is cheaper than insurance with denied coverage. Check all discount cards—prices vary by pharmacy and card. These work even if you have insurance (but you can't use insurance and the card together).
Most drug manufacturers offer programs providing free or low-cost medications to qualifying patients. Visit the drug manufacturer's website or ask your doctor's office. Some have income limits, others are available regardless of income. Applications can be approved in 24-72 hours for urgent situations.
Ask your doctor if they have samples. Drug reps often provide samples to physicians. This can bridge you for 2-4 weeks while your appeal is processed. Be direct: "I'm appealing my insurance denial and need samples to tide me over for the next few weeks."
Cash prices vary wildly between pharmacies. Call local independent pharmacies, not just chains. Costco (no membership required for pharmacy) often has the lowest prices. Mail-order pharmacies sometimes offer better pricing. Ask about 90-day supplies for additional discounts.
Many brand-name drugs have manufacturer copay cards reducing your out-of-pocket to $0-$25/month, even if insurance denies coverage. Check the drug's official website or ask your pharmacist. Note: Not available for Medicare patients by law, but available for commercial insurance.
Ask your doctor if it's safe to split higher-dose pills to save money (e.g., buying 20mg pills and splitting them if you take 10mg). Or ask if a lower dose could work temporarily while appealing. Never do this without your doctor's approval—some medications can't be split safely.
More than 50% of prescription drug appeals succeed, but fewer than 1% of patients ever appeal. You have legal rights. Your medication is worth fighting for.
Have questions? Need help with your appeal? Contact us for guidance.