First: Figure Out Which Kind of Plan You Have
The appeal process that protects you depends on your plan type, and conflating them is the most common way people miss a deadline or use the wrong process. Four tracks cover almost everyone: an employer-sponsored group health plan (governed by ERISA), an ACA marketplace or other non-grandfathered individual plan (also ERISA-adjacent rules for private plans, plus ACA external review), Medicare Part D, and Medicaid (state-run, with state-specific timelines).
For ERISA-governed employer and most non-grandfathered individual plans, the federal claims-procedure regulation (29 CFR § 2560.503-1) requires the plan to give you at least 180 days from the adverse benefit determination notice to file an internal appeal. The plan must decide that internal appeal without deferring to the original denial, using a reviewer who wasn't involved in (and isn't subordinate to whoever made) the original decision, and must consult an appropriately qualified health professional for any medical-judgment-based denial (which most prior authorization denials are).
If your plan is non-grandfathered and subject to the ACA's internal claims and external review rules (45 CFR § 147.136), a final internal denial unlocks external review: an independent review organization (IRO), accredited and financially unconnected to your plan, gets the final say. The federal minimum deadline to request external review is 4 months from the final internal denial notice, and if the IRO overturns the plan's decision, that decision is binding on the plan -- not just advisory. verify your plan's specific external-review deadline, since some states or plans set a shorter or longer window than the federal floor
What a Successful Appeal Actually Gets You
This is a coverage decision, not a damages claim -- the relief is the medication being covered, not a cash payment
Internal appeal overturned
The plan reverses its own denial and authorizes coverage -- the most common form of successful resolution, often faster than escalating to external review.
External review / IRE overturns the plan
A binding decision by an independent reviewer (IRO for ACA plans, IRE for Medicare Part D) that the plan must cover the drug -- this outcome is enforceable, not just a recommendation.
Retroactive reimbursement
If you paid out of pocket for the medication while the appeal was pending and later win, most plans and Medicare Part D allow you to seek reimbursement for the covered cost (subject to plan terms and, for Part D, a slightly longer decision window for reimbursement requests).
Medicare Part D and Medicaid Run on Different Clocks
Medicare Part D uses its own multi-level appeal system, separate from the ERISA/ACA process above. Level 1 is a "redetermination" by your plan sponsor, and you must request it within 65 days of the coverage determination notice. The plan must decide a standard redetermination within 7 days (14 days if you're seeking reimbursement for a drug you already paid for), or within 72 hours if your doctor certifies an expedited review is medically necessary. If the plan upholds the denial, Level 2 is a reconsideration by an independent review entity (IRE), on a similar 7-day/72-hour timeline, followed by further levels (an ALJ hearing, the Medicare Appeals Council, and federal court) for larger disputes. verify current dollar thresholds for escalating past Level 2, which are adjusted periodically
Medicaid prescription drug denials go through your state's "fair hearing" process instead, and the filing deadline is set by your specific state -- commonly somewhere between 30 and 90 days from the notice (examples on record: Arizona and Georgia around 30 days, Illinois and New York around 60 days, California, Nevada, Oregon, and Florida around 90 days). verify your specific state's current Medicaid fair-hearing deadline before relying on any of these examples For fee-for-service Medicaid drug denials specifically, a right to a fair hearing generally exists within 60 days of the notice, but confirm this against your own state's current rules.
If your plan is grandfathered (not subject to ACA rules) or self-funded in a way that doesn't participate in the federal external review process, your internal appeal may be your only plan-level option -- some states also run their own independent external review programs that can apply where the federal one doesn't. verify whether your specific plan participates in a federal or state external review program
How to Appeal, Step by Step
Identify your plan type first -- it determines your deadline and your process
Identify your plan type
Employer/ERISA group plan, ACA marketplace/individual plan, Medicare Part D, or Medicaid -- each has a different appeal track and deadline, described above.
Get your prescriber's support in writing
A letter from your prescribing physician explaining medical necessity, prior treatments tried, and why the alternative the plan suggests isn't appropriate is often the single most influential piece of evidence in a prior authorization appeal.
File the internal appeal within your plan's deadline
For ERISA/ACA plans, this must be at least 180 days from the denial notice; for Medicare Part D, 65 days; for Medicaid, commonly 30-90 days depending on your state -- confirm your specific deadline from the denial notice itself.
Request expedited review if delay could harm your health
All four tracks have an expedited process (as fast as 72 hours, or 24 hours for some initial Medicare Part D coverage determinations) when your doctor certifies that waiting for the standard timeline could seriously jeopardize your health.
Escalate to external review if the internal appeal is denied
For ERISA/ACA plans, request external review within 4 months of the final internal denial. For Medicare Part D, the plan automatically forwards an upheld denial to the independent review entity (IRE) for Level 2. For Medicaid, request your state's fair hearing.
Documents to gather
- The denial notice itself, including the specific reason given and the appeal deadline it states
- A letter of medical necessity from your prescribing physician
- Records of any prior medications tried and their outcomes (step-therapy history)
- Your plan's Summary Plan Description or Evidence of Coverage (for the appeal procedure specifics)
- Receipts if you paid out of pocket while the appeal was pending
Timelines and Limitation Periods
Four different clocks depending on your plan type -- confirm which one applies to you from your denial notice
These are federal minimums or commonly-cited examples; your plan or state may set a different specific figure, and Medicare/Medicaid thresholds are periodically adjusted. Confirm your exact deadline from your denial notice. verify
| Jurisdiction | Limitation Period |
|---|---|
| ERISA/ACA plan -- internal appeal | At least 180 days from the adverse benefit determination notice |
| ERISA/ACA plan -- external review request | 4 months (federal minimum) from the final internal denial notice verify your plan's specific window |
| Medicare Part D -- Level 1 redetermination | 65 days from the coverage determination notice |
| Medicaid -- fair hearing request | Commonly 30-90 days depending on your state verify your state's specific deadline |
Realistic Outcomes and Caveats
Appeals backed by a specific, detailed letter of medical necessity from your prescriber -- addressing exactly why the plan's preferred/formulary alternative isn't appropriate for you -- succeed at a meaningfully higher rate than appeals based only on the patient's own account.
Many prior authorization denials are resolved at the internal appeal stage without needing to reach external review, especially when the prescriber engages directly (a "peer-to-peer" review call between your doctor and the plan's medical reviewer is often available and can resolve things faster than a written appeal alone).
External review / IRE decisions are binding, but reaching that stage takes time even under the fastest applicable deadlines -- if you have an urgent medical need, use the expedited/urgent review path rather than the standard one.
This page can help you identify the right process and deadline, but it cannot predict whether your specific appeal will succeed, and coverage decisions turn heavily on your plan's specific formulary rules and your documented medical history.
Common Pitfalls
Using the wrong appeal track for your plan type
A Medicare Part D redetermination request and an ERISA internal appeal are different processes with different forms and deadlines -- confirm your plan type before filing.
Missing the internal appeal deadline before external review is even possible
External review is only available after a final internal denial -- missing your plan's internal appeal window can close off the stronger, binding external review option entirely.
Submitting a generic appeal letter instead of a specific medical-necessity argument
A prescriber letter that speaks directly to your documented history (prior drugs tried, why they failed or weren't appropriate) carries far more weight than a general request to reconsider.
Not requesting expedited review when medically justified
If waiting for the standard timeline could seriously harm your health, ask your doctor to certify an expedited/urgent appeal -- this can cut the decision window to 72 hours or less.
Assuming Medicaid deadlines match Medicare or ERISA deadlines
Medicaid fair-hearing deadlines are set state-by-state and can be considerably shorter (some states around 30 days) than the ERISA/ACA or Medicare Part D windows.
Organize Your Prescription Coverage Appeal
Use the calculator to identify your plan type and organize your appeal evidence before contacting your plan or prescriber.
Organize Your Prescription Coverage Appeal
Use the calculator to identify your plan type and organize your appeal evidence before contacting your plan or prescriber.
This stays in your private workspace until you choose a next step. It does not submit a claim on your behalf on its own.
Official and Legal References
ERISA/ACA vs. Medicare Part D vs. Medicaid
ERISA-governed employer plans and ACA-regulated individual plans share a federal internal-appeal floor (180 days) and, for non-grandfathered plans, binding external review (4-month federal minimum to request it). Medicare Part D runs its own multi-level system with much shorter, faster clocks (65 days to appeal, 7-day/72-hour decisions). Medicaid appeals go through a state fair-hearing process with state-set deadlines that can be considerably shorter. Identify which track governs your specific plan before you rely on any of these timeframes.
Frequently Asked Questions
Real edge cases, answered in plain language
My prior authorization was denied -- is that the final word?
Can my doctor request an urgent appeal?
What if I already paid out of pocket for the medication?
Organize Your Prescription Coverage Appeal
Use the calculator to identify your plan type and organize your appeal evidence before contacting your plan or prescriber.