How to Appeal Insurance Denials for Brand-Name Medications

When your doctor prescribes a brand-name medication and your insurance denies it, you’re not alone. Thousands of people face this every year-especially when insurers push for cheaper generics, even when those alternatives haven’t worked for you. It’s frustrating, confusing, and sometimes dangerous. But you can fight back. And you don’t need a lawyer to start. Here’s exactly how to get your brand-name medication covered when insurance says no.

Why Your Insurance Denied Your Brand-Name Prescription

Most denials happen because your plan’s formulary-the list of drugs they cover-doesn’t include your medication. Insurers often switch formularies without warning, dropping brand-name drugs to save money. Sometimes they say you need to try a generic first. But if you’ve already tried generics and they didn’t work-or made you worse-that’s not just inconvenient. It’s medically unnecessary.

According to the Centers for Medicare & Medicaid Services, 63% of prior authorization denials for specialty drugs involve brand-name medications. The reason? Cost, not clinical need. Insurers don’t always care about your history. They care about the bottom line. That’s why documentation is everything.

Step 1: Get the Exact Reason for Denial

Your insurance must send you an Explanation of Benefits (EOB) within five business days of denying your claim. Don’t ignore it. Open it. Look for the denial code or reason. Common phrases include:

• “Generic equivalent available”
• “Prior authorization not obtained”
• “Not medically necessary”
• “Formulary exclusion”

Write this down. You’ll need it for your appeal. If the EOB is unclear, call your insurer. Ask them to explain in writing. Get the name of the person you speak to and the date. Paper trails matter.

Step 2: Ask Your Doctor for a Letter of Medical Necessity

This is the single most important step. A letter from your doctor isn’t just helpful-it’s required. GoodRx analyzed over 1,200 denied claims and found that 78% of successful appeals included a detailed letter from the prescribing physician.

Your doctor’s letter should include:

• Your diagnosis and how the medication treats it
• Specific prior attempts with generics or other brand-name alternatives-and why they failed
• Any side effects you experienced with other drugs
• How this medication improves your daily life (sleep, mobility, pain levels, etc.)
• Your diagnosis code (ICD-10) and the drug’s CPT code
• A clear statement: “This medication is medically necessary for this patient”

Don’t assume your doctor knows what to write. Many clinics use templates. Ask your nurse or office manager if they have a prior authorization form. If not, print one from the American Medical Association’s website and give it to them. The more specific, the better.

Step 3: File Your Internal Appeal

Most insurers require you to appeal internally before going further. You have up to 180 days from the denial date to file, but don’t wait. The sooner you act, the faster you get results.

Your appeal letter should include:

• Your full name, date of birth, and insurance ID
• The date of denial and denial reference number
• A copy of the doctor’s letter
• Any lab results, specialist notes, or hospital records supporting your case
• A clear request: “I request coverage for [drug name] under my plan”

Send it by certified mail with return receipt. Keep a copy. Also email it if your insurer accepts electronic appeals. Follow up every 3-5 days. Kantor & Kantor’s data shows appeals with regular follow-up calls are processed 28% faster.

Step 4: Request an Expedited Review If You Need It

If your condition is urgent-like insulin dependence, epilepsy, or severe autoimmune disease-you can ask for an expedited review. Insurers must respond within 4 business days. You don’t need to prove it’s an emergency. Just say it clearly: “I am requesting an expedited appeal because stopping this medication could result in hospitalization.”

Call your insurer. Say: “I need an expedited review under Healthcare.gov guidelines.” Then follow up with a written request. Include your doctor’s note. If they refuse, note the date and name of the representative. You’ll need this later.

Step 5: If the Internal Appeal Fails, Go External

If your insurer says no again, you can request an external review by an independent third party. This is where success rates jump. CMS data shows internal appeals succeed in only 39% of brand-name cases. External reviews approve coverage in 58% of cases.

Who handles this depends on your plan:

• ERISA plans (61% of Americans): Contact the U.S. Department of Health and Human Services
• State-regulated plans: Contact your state’s insurance commissioner

You have 60 days from your internal denial to file. Submit the same documents you sent before-plus your internal denial letter. Include a note: “I am requesting an external review under the Affordable Care Act.”

When to Hire a Lawyer

You don’t need one to start. But if your case is complex, involves long-term medication, or you’ve been denied twice, consider legal help. Kantor & Kantor found that appeals drafted by attorneys have a 47% higher success rate than self-filed ones.

Why? Because insurers use legal language to deny claims. They hide behind ERISA rules. A lawyer knows how to counter those tactics. If you’re on Medicare, Medicaid, or a state plan, legal aid organizations often help for free. For ERISA plans, some attorneys work on contingency-they only get paid if you win.

Real Stories: What Works

One Reddit user, ‘DiabeticDad87’, got Humalog insulin approved after his child had multiple severe hypoglycemic episodes on generic insulin. He submitted a letter from his endocrinologist detailing blood sugar logs and ER visits. Approval came in 11 days.

Another patient on PatientsLikeMe spent six months fighting a denial for a brand-name migraine drug. The first two appeals failed. Only when he hired a lawyer and submitted 18 months of medical records did he win. Cost: $2,500. But he got his medication-and kept his quality of life.

What to Do While You Wait

Don’t stop your medication. Many drug manufacturers offer patient assistance programs. Eli Lilly’s Insulin Value Program has helped over 1.2 million people access brand-name insulin while appeals are pending. Check the manufacturer’s website. Ask your pharmacist. You might get free or low-cost medication until your appeal is resolved.

What Doesn’t Work

- Waiting too long to appeal. Time limits are strict.

- Sending vague letters. “I need this drug” isn’t enough.

- Not involving your doctor. Only 22% of appeals succeed without physician support.

- Assuming generics are always safe. They’re not. Many patients react differently to biosimilars or inactive ingredients.

What’s Changing in 2025

The Biden administration’s 2023 executive order pushed CMS to simplify the external review process. Medicare Part D plans now have real-time benefit tools that show coverage before you fill a prescription. That should cut denials by 15-20%.

But insurers are still overwhelmed. Physicians now spend over 13 hours a week on prior authorizations. That means delays. Your job is to stay ahead of them.

Final Tip: Document Everything

Keep a folder-digital or physical-with:

• Denial letters
• Doctor’s letters
• Call logs (date, time, name, summary)
• Emails
• Prescription receipts
• Lab results

If you go to court (rare, but possible with ERISA), this is your evidence. Even if you don’t, it keeps you organized. And peace of mind matters.

You’re not asking for luxury. You’re asking for the medication your body needs. Insurance companies have rules. But you have rights. Use them.

If you’re still stuck, contact your state’s Health Insurance Assistance Program (SHIP). They offer free counseling. You’re not alone in this fight.