Start with the denial notice
- Save the full denial notice, pharmacy rejection, and any Explanation of Benefits (EOB).
- Mark the notice date, the reason for denial, the appeal deadline, and the address, fax number, portal, or phone method it names.
- Ask the plan whether the decision is a formal coverage determination, what documents it relied on, and whether a prescriber statement or representative form is needed.
Official sources: Medicare.gov: Appeals in a Medicare drug plan; HealthCare.gov: Internal appeals
What to gather
Match your supporting records to the reason in the denial. Your prescriber can help identify which clinical information is relevant.
The decision and plan details
Keep the denial notice or pharmacy response, EOB if one was issued, insurance or Medicare card details, claim or case number, and the plan document or formulary section cited in the decision.
The exact prescription request
Write down the drug name, strength, dosage form, prescribed directions, pharmacy, and whether you are asking for coverage before filling it or payment back for a drug you already bought.
Information from your prescriber
Ask your prescriber which records address the plan’s stated reason. Depending on the case, that may include a supporting statement, relevant clinical notes, prior medicines tried and their results, or why an alternative may not work for you.
Your submission trail
Keep a copy of what you send, proof of delivery or portal confirmation, and notes of calls with dates, times, names, and reference numbers. Keep your original records and follow the plan’s directions about any original forms it requires.
Official sources: Medicare.gov: Appeals in a Medicare drug plan; HealthCare.gov: Internal appeals; U.S. Department of Labor (DOL): Filing a Claim for Your Health or Disability Benefits
If you have a Medicare Part D drug plan
If the pharmacy has rejected a prescription but you do not yet have the plan’s coverage decision, ask the plan for a coverage determination. For a drug you have not received, you or your prescriber can generally make that request by calling the plan, writing a letter, or sending its request form. If you are asking for an exception, your prescriber must provide a statement explaining the medical reason. A request for repayment for a drug already bought must be made in writing.
After an initial denial, the first formal appeal is a Level 1 redetermination by your plan. Medicare.gov says you, your representative, or prescriber must request it within 65 days of the date on the initial denial notice. Include your name, address, Medicare Number, the drug, why you disagree, and any supporting information. Follow the method and instructions in that notice.
If the plan upholds the denial, Level 2 is reconsideration by an independent reviewer. Medicare.gov says to request it within 60 days of the Level 1 decision. The notice should explain how to continue. Medicare Part D has additional appeal levels; use each decision letter for the next step and deadline.
If waiting for the standard 7-day decision on a coverage appeal could seriously jeopardize your life, health, or ability to regain maximum function, ask for an expedited appeal and contact your prescriber. Medicare says an expedited Level 1 decision is due within 72 hours when the fast-review criteria are met.
Official sources: Medicare.gov: Appeals in a Medicare drug plan
If you have commercial coverage
Use the internal appeal method, form, and deadline in your plan’s denial notice and coverage documents. HealthCare.gov describes an internal appeal process with a 180-day filing window. For an ERISA-covered employer group health plan, the U.S. Department of Labor says patients have at least 180 days to appeal. These examples do not set one deadline for every commercial plan: the plan type, state, and decision can change the applicable steps.
If the plan issues a final denial, check that notice for external-review eligibility and instructions. HealthCare.gov says a written request under the federal external-review process is due within 4 months after the denial notice or final determination. Eligibility, the reviewer, and the process used can depend on the plan and state, so confirm the deadline and destination in your notice.
For an employer plan, check the Summary Plan Description (SPD) and claims procedure. You can ask the plan for relevant claim records and the criteria used in its decision. For other private coverage, use the member portal, Evidence of Coverage, formulary, or plan administrator identified in your paperwork.
Official sources: HealthCare.gov: Internal appeals; U.S. Department of Labor (DOL): Filing a Claim for Your Health or Disability Benefits; HealthCare.gov: External review
Prepare and submit your appeal
Address the reason in the notice directly. Briefly identify the decision and drug, explain what you believe the plan should reconsider, and attach relevant support from your prescriber or records. Ask the plan how to authorize a representative if someone will act for you.
Use the submission method and recipient in the notice, meet the deadline shown there, and keep a complete copy with proof of delivery. If the decision is unclear or records are missing, ask the plan how to obtain the information it relied on. Read the next decision carefully for the result and any next appeal level.
Official sources: Medicare.gov: Appeals in a Medicare drug plan; HealthCare.gov: Internal appeals; U.S. Department of Labor (DOL): Filing a Claim for Your Health or Disability Benefits
When waiting could affect your health
Tell the plan and your prescriber promptly if waiting for a standard decision could seriously harm your health. Ask whether your request qualifies for expedited handling and how to submit it. Medicare Part D and commercial coverage have different urgent-review rules; use the plan’s instructions rather than assuming the same deadline applies.
Official sources: Medicare.gov: Appeals in a Medicare drug plan; HealthCare.gov: Internal appeals; HealthCare.gov: External review
Official sources
For broader steps after a health-plan denial, read the general health-insurance appeal guide. For Nivellark’s administrative support for denied-therapy cases, see denied-therapy case support.