Medication and prescription denials
Drug denials happen at the pharmacy benefit (PBM) layer, separate from the medical benefit. They include non-formulary drugs, GLP-1s, specialty injectables, brand-name vs. generic, and prior-auth-required medications.
What gets denied
- GLP-1s (Ozempic, Wegovy, Mounjaro, Zepbound)
- Specialty biologics (Humira, Stelara, Dupixent)
- ADHD medications (Vyvanse, Adderall XR)
- Hepatitis C antivirals
- Hormone replacement therapy
- Compounded medications
- Off-label prescription uses
Common denial reasons
- Drug not on plan formulary (non-formulary)
- Step therapy: cheaper alternative not tried first
- Quantity limit exceeded
- Plan claims indication not FDA-approved
- Diagnosis ICD doesn't match approved indication
How we approach the appeal
Two paths: (1) tiering exception, request that the drug be moved to a covered tier; (2) formulary exception, request coverage of a non-formulary drug citing medical necessity. Manufacturer-published clinical packets accelerate exception filings.
Urgent: 24-72 hours. Standard: 72 hours for Medicare Part D, 15 days for commercial. Filing window: typically 60 days.
$200 – $20,000+ per month of medication
- · Denial letter from pharmacy benefit
- · Prescription / Rx record
- · Prescriber's notes on indication
- · Documentation of prior step-therapy trials
Got a medication denial?
Free 24-hour review. Send the denial letter and we'll tell you whether your case has a shot and what the next step would look like.
Start my appealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.