What to Do When Insurance Denies Your Prescription

Common Prescription Denial Reasons

• Not on formulary: Your medication isn't on the plan's approved list
• Prior authorization required: Doctor needs to justify the prescription
• Step therapy: Must try cheaper medications first
• Quantity limits: Plan restricts how much you can get
• Specialty tier: Very high cost-sharing

How to Appeal

1. Ask about formulary alternatives — sometimes a covered drug works equally well
2. Request a formulary exception — if alternatives won't work for you
3. Get prior authorization — your doctor submits clinical justification
4. Appeal step therapy — if you've tried and failed on cheaper drugs
5. File a coverage determination — formal request for exception

Tips for Prescription Appeals

• Your prescriber is your strongest ally — they initiate most medication appeals
• Include documentation of tried-and-failed medications with specific reasons
• For specialty medications, manufacturer patient assistance programs can provide temporary supplies during the appeal
• Request expedited pharmacy appeals when delay would harm your health

Patient Assistance Programs

Most pharmaceutical manufacturers offer patient assistance programs for denied medications. These can provide free or reduced-cost medication while your appeal is pending.