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?
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Start Your AppealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.