Insurance companies deny coverage for millions of prescriptions annually. Learn how to appeal denials, navigate prior authorization, and access the medication you need.
Estimate your chances of successfully appealing your prescription coverage denial
Enter your situation details to see how likely your appeal is to succeed
Prescription coverage denial occurs when your health insurance refuses to pay for a medication your doctor prescribed. This can happen because the drug isn't on your plan's formulary (approved drug list), requires prior authorization, or the insurance deems it 'not medically necessary.'
According to 2025 data from Surescripts, 94% of patients experience delays in care due to prior authorization requirements, and 78% of patients abandon their prescribed treatment altogether when faced with coverage obstacles. These denials affect millions of Americans annually and can have serious health consequences.
The good news: More than 50% of prescription drug denials are successfully overturned on appeal. However, fewer than 1% of patients ever appeal their denials, meaning most simply go without their medication or pay thousands of dollars out-of-pocket unnecessarily.
Understanding your rights and the appeal process is critical. Whether you have Medicare Part D, commercial insurance, or Medicaid, federal and state laws provide robust protections for patients to challenge coverage denials and access the medications they need.
You have the right to appeal if you meet any of these criteria
If you're currently taking a medication that was previously covered and your plan removes it mid-year or denies refills, you have enhanced appeal rights. Medicare Part D requires 'transition fills' for beneficiaries in long-term care facilities or with chronic conditions.
For commercial insurance, the Affordable Care Act prohibits plans from removing drugs from formularies mid-year without 60 days' notice (except for safety or generic availability reasons). You can appeal to continue coverage during this transition period.
Different situations require different processes—here's what you need to know
Request coverage for a drug not on your plan's formulary. Requires doctor's supporting statement. Expedited requests decided in 24 hours for urgent needs.
Request lower cost-sharing for a formulary drug that's on a high-cost tier. Doctor must prove alternatives on lower tiers won't work or have failed.
Override PA requirements when delay would cause serious harm. Requires urgent medical justification. Standard PA decisions take up to 72 hours; expedited take 24 hours.
Step-by-step guide to successfully appealing your denial
Understand exactly why your coverage was denied
Your doctor's support is the most critical factor in appeal success
Build the strongest possible case
Follow your insurance plan's specific process
Don't give up after the first denial
Know your deadlines—missing them can forfeit your right to appeal
Plan must decide within 7 days (standard) or 72 hours (expedited). This is your appeal with your drug plan directly (called a 'redetermination').
Independent Review Entity (IRE) must decide within 7 days (standard) or 72 hours (expedited). File within 60 days of Level 1 denial.
Level 3: Administrative Law Judge ($190 minimum value). Level 4: Medicare Appeals Council. Level 5: Federal Court ($1,900 minimum). Each has 60-day filing deadline.
Plan must decide within 72 hours (urgent) or 30 days (non-urgent). Some states require shorter deadlines. Check your plan's Summary of Benefits and Coverage.
After internal appeal denial, you have 4 months to request independent external review. Reviewer must decide within 45 days (72 hours for urgent cases).
Standard exception requests: plan must decide within 72 hours. Expedited exceptions (urgent medical need): plan must decide within 24 hours. No filing deadline—you can request anytime.
Everything you need to know about prescription coverage denials and appeals
Don't let insurance denials prevent you from getting the medication you need. More than 50% of appeals succeed when properly filed with strong medical justification.