How to Appeal Insurance Denials for Brand-Name Medications

When your doctor prescribes a brand-name medication and your insurance denies coverage, it’s not just a paperwork issue-it’s a health risk. You might be on a drug that works, and switching to a generic could mean more seizures, worse pain, or dangerous side effects. Insurance companies deny these prescriptions all the time, often because they want you to try cheaper alternatives first. But you don’t have to accept it. You have rights, and there’s a clear path to get your medication covered.

Why Your Insurance Denies Brand-Name Medications

Insurance plans use formularies-lists of approved drugs-to control costs. Brand-name medications are often excluded unless you prove a generic won’t work. In 2022, nearly 18% of prior authorization requests for specialty drugs were denied, and over 60% of those were for brand-name drugs. Insurers don’t always deny because the drug isn’t needed. Sometimes, they’re following a policy that prioritizes cost over clinical judgment.

Many patients are caught off guard. They’ve been on the same brand-name drug for years-maybe insulin, a biologic for rheumatoid arthritis, or a migraine medication-and suddenly, their plan drops coverage with no warning. Under ERISA-governed plans (which cover about 61% of Americans), insurers can change formularies with minimal notice. That’s why it’s critical to act fast when you get a denial letter.

What to Do Right After a Denial

The moment you get a denial, don’t wait. Start by reading your Explanation of Benefits (EOB). By law, insurers must send this within five business days. Look for the reason: “Generic equivalent available,” “Prior authorization not submitted,” or “Not medically necessary.” Write it down. This is your first piece of evidence.

Next, call your doctor’s office. Ask for a letter of medical necessity. This isn’t a form-it’s a detailed letter from your provider explaining why the brand-name drug is essential. GoodRx analyzed 1,200 cases and found that appeals with this letter had a 78% success rate. Without it, your chance of winning drops to under 25%.

The letter needs specifics:

• Your diagnosis and how the brand-name drug treats it
• Previous attempts with generics or alternatives-and what happened (e.g., “Patient had three severe hypoglycemic episodes on generic insulin”)
• Lab results, hospitalizations, or quality-of-life impacts tied to the medication
• Diagnosis codes (ICD-10) and prescription codes (CPT or HCPCS)
• Reference to the prior authorization number, if one exists

Doctors often use templates, but the best ones include real patient outcomes-not just “This drug works better.” Say: “Patient’s A1C dropped from 9.8 to 6.4 on Humalog after failing on insulin glargine.” That’s data. That’s convincing.

How to File an Internal Appeal

Your first appeal goes to your insurance company. You have 180 days from the denial date to file (120 days for Medicare, 60-90 days for Medicaid depending on your state). Don’t wait until the last minute. Most appeals fail because people delay.

Your appeal letter should include:

• Your full name, policy number, and member ID
• Date of denial and denial reference number
• Copy of the doctor’s letter of medical necessity
• Any supporting records: lab reports, pharmacy logs, specialist notes
• A clear request: “Please approve coverage for [brand-name drug] under my plan”

Send it certified mail or upload it through your insurer’s portal. Keep a copy. Call the insurer every few days to confirm they received it. Kantor & Kantor found that appeals with regular follow-up calls were processed 28% faster.

For urgent cases-like insulin, seizure meds, or cancer drugs-you can request an expedited review. You don’t need paperwork to ask. Just call and say: “This is an urgent medical need. My life is at risk without this medication.” Insurers must respond in 4 business days. Some states require them to respond in 24 hours.

What Happens If the Internal Appeal Fails

If your insurer says no again, you move to an external review. This is where your chances improve dramatically. Internal appeals succeed in about 39% of brand-name cases. External reviews? About 58% approval rate.

Who handles it? It depends on your plan:

• For non-ERISA plans (most state-regulated plans): Contact your state’s insurance commissioner’s office.
• For ERISA plans (employer-sponsored): File with the U.S. Department of Health and Human Services.

The external reviewer is independent. They don’t work for your insurer. They look at the same documents you submitted-and often, they’re more likely to side with the doctor.

The Bleeding Disorders Advocacy Alliance found that 68% of external reviews approved coverage when patients submitted full clinical documentation. That includes everything: lab results, treatment history, even letters from pharmacists.

Why ERISA Plans Are Tricky

If your insurance comes from your job, it’s likely governed by ERISA. That’s the 1974 federal law that says your plan isn’t subject to state insurance laws. It sounds technical, but here’s the real impact:

• You can’t sue your insurer in state court.
• You must exhaust all appeals before going to federal court.
• Even if you win in court, a federal judge decides-not a jury.

Kantor & Kantor’s data shows that appeals drafted by attorneys have a 47% higher success rate on ERISA plans. That’s not because lawyers are magic. It’s because insurers use legal loopholes to deny claims, and they’re trained to fight patients. A well-written appeal that cites federal regulations and case law makes a difference.

If you’re dealing with a complex case-like a rare disease drug or a medication that’s been denied twice-consider contacting a patient advocate or legal aid group. Many nonprofits help for free.

Real Stories That Worked

One Reddit user, “DiabeticDad87,” got his child’s Humalog insulin denied. He didn’t argue. He sent a letter with hospital records showing his child had three ER visits in six months from low blood sugar on a generic insulin. Approval came in 11 days.

Another patient on PatientsLikeMe spent six months fighting a denial for a brand-name migraine drug. The insurer said “triptans are available.” But the patient had tried seven different triptans-each caused nausea, dizziness, or heart palpitations. Only the brand-name drug worked. The appeal succeeded after hiring a lawyer. Cost? $2,500. Worth it.

A 2022 survey by the Patient Advocate Foundation found that 44% of people needed help from a provider or lawyer to get through the process. You’re not failing if you ask for help.

What You Can Do While You Wait

Appeals take time. You can’t stop your medication. Many drug manufacturers have patient assistance programs. Eli Lilly’s Insulin Value Program has helped over 1.2 million people get brand-name insulin while their appeal is pending. Check the manufacturer’s website. Ask your pharmacist. These programs often cover the full cost for up to a year.

Also, ask your doctor if they can prescribe a 30-day supply at a reduced cash price. Some pharmacies offer discounts on brand-name drugs if you pay out-of-pocket. It’s not ideal, but it’s better than going without.

What’s Changing in 2025

The Biden administration’s 2023 Executive Order on Healthcare Competition pushed CMS to enforce appeal rights more strictly. The 2023 Consolidated Appropriations Act now requires Medicare Part D plans to show real-time coverage info when a prescription is entered-so you know before you leave the pharmacy whether it’s covered. That should cut denials by 15-20%.

Some states are also passing laws to limit prior authorization. California now requires insurers to approve or deny requests within 24 hours for urgent cases. Other states are following.

But here’s the truth: the system is still broken. Physicians now spend over 13 hours a week just managing prior authorizations. Insurers are using AI to auto-denial more claims. That’s why your voice matters. The more people appeal, the more insurers have to change.

When to Walk Away

Not every denial is worth fighting. If your doctor says a generic would work just as well, maybe switch. But if you’ve tried alternatives and they failed-if you’ve had side effects, hospital visits, or worsening symptoms-then you have a strong case.

Don’t let fear of complexity stop you. You don’t need to be a legal expert. You just need to be persistent. Get the letter. Submit the appeal. Follow up. Ask for help. You’re not alone.