How to Appeal a Prior Authorization Denial for Your Medication

When your doctor prescribes a medication and your insurance denies coverage, it’s not just a paperwork hiccup-it’s a health risk. You might be staring at a $1,200 monthly bill for a drug your body needs, or worse, you’ve already started the treatment and now it’s being cut off. The good news? Prior authorization denials are overturned in more than 8 out of 10 cases when you appeal. The bad news? Only 1 in 9 people even try. If you’ve gotten a denial letter, don’t give up. This isn’t about fighting the system-it’s about using the system the way it was meant to work.

Understand Why Your Medication Was Denied

The denial letter from your insurer isn’t just a rejection-it’s a roadmap. Most denials fall into three buckets: incomplete paperwork (37%), lack of medical necessity (48%), or the drug isn’t covered at all (15%). You can’t fix what you don’t understand. Open that letter. Circle the exact reason they gave. Did they say "insufficient documentation"? That means they didn’t get the right records. Did they say "not medically necessary"? That means they don’t believe your condition justifies this drug. Look for phrases like "alternative therapies failed" or "off-formulary medication." These aren’t random words-they’re your next steps.

Gather Every Piece of Paper That Matters

Your appeal isn’t a letter. It’s a case. And every case needs evidence. Start with your medical records. Your doctor’s notes, lab results, and past treatment logs are your strongest weapons. If you’ve tried other drugs first and they didn’t work-or made you sick-that’s critical. Insurers require proof of failure. One patient reversed a Humira denial by including a two-page timeline showing exactly which drugs were tried, when, and what side effects occurred. Include dates, dosages, and outcomes. Don’t assume your doctor already sent everything. Call your provider’s office and ask for a full copy of your file, especially any documentation tied to the denied drug’s diagnosis code (ICD-10) and procedure code (CPT). About 41% of denials happen because of simple clerical errors, and most of those can be fixed with better paperwork.

Get Your Doctor On Your Side

Your doctor doesn’t just write the prescription-they have to defend it. Insurers listen to doctors more than they listen to patients. Ask your doctor to write a letter specifically for the appeal. It should state: your diagnosis, why this drug is the best option, why alternatives failed, and why delaying treatment could cause harm. Keck Medicine found appeals with physician letters have a 32% higher success rate. Don’t let your doctor say, "I already submitted it." Make sure they know this is a formal appeal and that they need to address the insurer’s exact reason for denial. If they’re busy, offer to draft a template. Most doctors will sign off if it’s clear and concise. The Obesity Action Coalition’s template includes space for: diagnosis, prior treatment history, clinical rationale, and expected outcomes. Use it.

Follow the Exact Appeal Process for Your Insurer

Every insurer has its own rules. CVS/Caremark requires appeals to be faxed to 1-888-836-0730 and includes a checklist: full patient name, ID number, date of birth, drug name, and clinical info. UnitedHealthcare requires online submission through their provider portal. Humana accepts appeals by mail or phone. Miss one detail and your appeal gets tossed-even if everything else is perfect. Check your insurer’s website or call their member services and ask for the "prior authorization appeal process guidelines." Write down their deadline. Federal law gives you 180 days from the denial date to file, but many insurers set internal deadlines as short as 60 days. Don’t wait. Track every step. Keep a log: date you called, who you spoke to, what they said, what they promised. 78% of physicians say they have to call multiple times just to get an update.

Write a Clear, Direct Appeal Letter

Your letter should be short, factual, and focused. No emotions. No stories. Just evidence. Start with: "I am appealing the denial of [drug name] for [patient name] on [date of denial]." Then list the denial reason and respond to it point by point. If they said "no medical necessity," show them the clinical evidence proving it is necessary. If they said "alternative failed," list each alternative, the dates tried, and the outcome. Include your ICD-10 and CPT codes-89% of approved appeals include them. End with: "I request immediate approval of this medication to prevent further health deterioration." Sign it. Date it. Send it certified mail with return receipt, and keep a copy. Never rely on email or voicemail alone.

Know Your Rights and Deadlines

If your first appeal is denied, you don’t stop. You escalate. Federal law under ERISA says self-insured employer plans must respond within 60 days. Medicare Advantage plans must respond within 72 hours as of 2024. If you don’t hear back, follow up. If you’re still denied, you can request an external review. Healthcare.gov says you have up to 365 days to do this. But state rules vary-some only allow 60 to 180 days. Call your state’s insurance department to confirm. External reviews are handled by independent third parties. They’re more likely to side with you. In fact, nearly 60% of external reviews overturn prior denials. Don’t skip this step just because you’re tired. The system is designed to make you give up. Don’t let it win.

Track Everything-And Don’t Give Up

This process takes time. Most people spend 6 to 8 hours on their first appeal. That’s normal. Keep a folder-physical or digital-with every document, email, call log, and letter. Label everything. One patient lost their appeal because they couldn’t prove they’d sent the letter on time. They didn’t have a receipt. Don’t be that person. If your appeal is denied again, ask for a written explanation. Then go back to your doctor. Ask if there’s another drug on formulary that could work. Sometimes switching to a similar drug that’s already approved is faster than fighting for the original. But if your doctor says no-stick with the appeal. The reversal rate is 82%. That’s not luck. That’s proof the system works if you use it right.

What If You Can’t Afford the Medication While You Wait?

You don’t have to wait for approval to get your medicine. Most drug manufacturers offer patient assistance programs. For example, AbbVie (maker of Humira) and Eli Lilly (maker of Trulicity) have co-pay cards and free medication programs for qualifying patients. Call the drug’s manufacturer directly-don’t wait for your doctor to tell you. Pharmacies like CVS and Walgreens often have discount programs too. And if you’re on Medicare, ask about the Extra Help program for low-income beneficiaries. You might qualify for reduced costs even before your appeal is approved. Don’t let cost stop you from starting the process.