When the plan says no, give the patient somewhere to go

The denials you see

• Formulary exclusion and non-preferred tier
• Step therapy not completed
• Quantity limits and dose edits
• Prior authorization expired or not on file
• Site-of-care redirection to home infusion or a preferred vendor

The sentence at the desk

“The plan rejected the fill. Scan this: a free read of the rejection tells you whether an exception or appeal is available and what the prescriber needs to send.”

That is the whole workflow. The card carries a QR code with your referral code, the patient scans it while the denial is in their hand, and every start is attributed to your office.

What happens next

1. 1The patient uploads the denial letter (photos are read on their device; only the text is sent). A reviewer answers in writing, usually the same business day: appealable or not, which rule, what deadline.
2. 2If it can be won, Apellica prepares the internal appeal with the criteria demand, the record mapped to each criterion, and primary-source citations, then the external-review request if the plan holds.
3. 3Your office is asked once for what only it can supply: the prescriber's supporting statement for the exception (we send the plan's exception standard with the request). The plan's criteria come with the request so the letter is written in one pass.
4. 4The patient pays nothing upfront. If the appeal recovers coverage or money, the fee is 10% of the recovery; if not, nothing. Apellica is not a law firm and says so when a matter needs one.

What we will ask your office for

• The prescriber's supporting statement for the exception (we send the plan's exception standard with the request)
• The denial letter the patient received (the patient uploads it; you need do nothing)
• A letter of medical necessity written to the plan's criteria, once, when the appeal is being prepared; we send the criteria with the request
• Nothing else: no contract, no fee, no data feed

The numbers your patients should know

• Weight-control drug denials: 86% overturned in California IMR →
• Biologics decisions →
• The formulary, tiering and step-therapy exception →

Fewer than 1% of denied claims are appealed (KFF, 2024 HealthCare.gov filings). In California, independent reviewers sided with the patient in 52.5% of 42,710 decisions, and 72% in 2025 (DMHC). All research →

Your referral link

Codes use letters, digits and dashes; the suggested prefix for specialty and infusion pharmacies is rx-. Paste the link into the denial message you already send patients, or put the QR card at the desk.

https://apellica.com/start?ref=rx-yourname&utm_source=partner&utm_medium=referral&utm_campaign=rx-yourname

Questions specialty and infusion pharmacies ask

Other settings

• Imaging centers
• Oncology practices
• Infusion centers
• Surgical practices
• Physical and occupational therapy
• Behavioral health practices
• Hospitals and case management
• Billing departments and RCM teams
• Prior-authorization teams
• Clinics and pharmacies