Navigating Insurance Denials for Medications

 

How to Fight Back — and What to Do When You Still Can’t Afford Your Meds

There’s nothing like the frustration of finally getting the right prescription — only to have your insurance deny it.

If you’ve ever gotten one of those confusing letters full of fine print and insurance-speak, you know the feeling.

Step 1: Understand Why They Said No

According to a 2022 report from the Kaiser Family Foundation, nearly one in four insured adults reported having a prescription drug claim denied by their insurance provider. These denials aren’t always based on clinical guidelines—in many cases, they’re tied to cost-control strategies that may overlook individual medical needs. Understanding the reason behind the denial is key to choosing the right response. Before you fight, know what you’re up against. Common reasons for denial:

• The drug isn’t on your formulary.
  This is a fancy way of saying the insurance company refuses to cover the medicine. This is not final, though.

• They want you to try other drugs first (step therapy).
  The "other drug" is almost always significantly cheaper. This is an attempt to save money that's couched as "standard patient care." You and your doctor can work together to decide if the step therapy is right for you or not.

• They claim it’s not “medically necessary.”
  This ambiguous category is meant to cover things like cosmetic medicines or truly optional treatments. Unfortunately, it often gets thrown around if your insurance company doesn't fully understand your true medical need.

• There was a paperwork error.

Step 2: Build Your Case & Appeal

Appealing a denial may sound intimidating, but it’s more common—and more winnable—than you might think. In fact, federal data shows that consumers win internal appeals roughly 40–50% of the time. The key is documentation, persistence, and partnering with your healthcare team.

If you’ve received a denial letter, start by reading it closely. It should include:

• A reason for the denial

• Instructions for appealing

• A deadline to submit documentation

If that information isn’t clear, call your insurance provider and request clarification. You have the legal right to an appeal, and insurance representatives are required to provide appeal instructions upon request.

Also worth noting: if your insurance is through your employer, your HR department may be able to advocate on your behalf or help you navigate the internal processes more smoothly. If the denial is unfair (and many are), appeal! Here’s how:

• Ask your doctor for a Letter of Medical Necessity.
  They can often submit this to insurance on your behalf, clearing many obstacles.

• Gather records showing treatments you’ve already tried (especially failures).
  You can often ask your doctor to submit this, as well.

• Meet all deadlines — they’re often short.

• If the first appeal fails, request an external review.
  This can be done via your insurance company and brings in an independent reviewer.

Step 3: Close the Copay Gap

Even when approval is granted, affordability can remain a barrier. Many life-changing medications—especially those for autoimmune disease, cancer, or mental health—come with copays that range from hundreds to thousands of dollars per month.

Here’s a breakdown of support options, including what they do and who qualifies:

• Manufacturer Copay Cards: Offered by many drug companies for brand-name medications. These cards reduce out-of-pocket costs for commercially insured patients (not for use with government insurance like Medicare or Medicaid).

• Patient Assistance Programs (PAPs): These income-based programs provide free or discounted medications to patients who meet financial criteria. Each manufacturer has different rules—check their website or call their patient support line.

• Nonprofit Grants: Organizations like the PAN Foundation or Good Days offer disease-specific grants to cover copays, coinsurance, or premiums. These can be especially helpful for Medicare recipients.

• Prescription Discount Tools: Platforms like GoodRx, SingleCare, or ScriptSave allow you to compare retail pharmacy prices and use digital coupons.

• Tier Exception Requests: If a medication is placed in a high-cost tier but there’s a medical reason you can’t use cheaper alternatives, your doctor can submit a tiering exception request to lower the copay.

Always double-check with your pharmacist—some of these options can be stacked or timed strategically for maximum benefit. Even if approved, some meds have sky-high copays. Options:

• Manufacturer copay cards

• Patient assistance programs for low-income patients

• Nonprofit grants (like from PAN Foundation)

• Prescription discount apps like GoodRx

• Request a tier exception if the med is placed in a higher copay tier than necessary

Pro Tip: Ask Your Pharmacist

Pharmacists are insurance ninjas — they know workarounds your doctor might not. Ask for options!

Bottom Line

Insurance denials aren’t personal—but they can feel that way. The system is often opaque, impersonal, and exhausting. But you are not powerless.

Organizations like the National Health Law Program and the Patient Advocate Foundation offer additional templates and support. And your healthcare providers are often more than willing to help—especially when you bring clear documentation and a willingness to advocate.

Remember, you have the right to access the treatment you and your provider believe is best. If the system pushes back, push back smarter—with facts, support, and persistence. Insurance denials aren’t the final word. With persistence, documentation, and creativity, you can get what you need.

Patient Empowerment Pulse is here to help. You’re not alone.
Support our work at ko-fi.com/patientempowermentpulse.