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.
The rule that controls this: Formulary tiering and exception rights, including the standard and expedited exception process ACA plans must offer under 45 C.F.R. § 156.122.
Last reviewed 13 September 2026 · General information, not legal or medical advice · Apellica is not a law firm
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
Medication and prescription denial? Let's appeal it.
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Medication denials by insurer
What each plan tends to cite, and the rule that controls it.
- Express Scripts medication denials
- UHC medication denials
- Aetna medication denials
- Cigna medication denials
- BCBS medication denials
- Humana medication denials
- Medicare medication denials
- Kaiser medication denials
- Ambetter medication denials
- Molina medication denials
- BCBS FEP medication denials
- Caremark medication denials
- OptumRx medication denials
- TRICARE medication denials
- WellCare medication denials
This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.