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 hiccup-it’s a threat to your health. You’ve been stable on this drug for months, maybe years. Switching to a generic might sound fine on paper, but in real life, it’s causing side effects, worsening symptoms, or even hospital visits. Insurance companies deny these prescriptions all the time, often because they’re cheaper to push generics-even when the science says the brand is necessary. The good news? You have rights. And if you know how to fight back, you can win.

Why Your Insurance Denies Brand-Name Medications

Insurance plans don’t deny brand-name drugs because they’re evil. They do it because they’re designed to save money. Most plans have a formulary-a list of approved drugs. Brand-name medications usually sit at the top of the cost ladder. Generics are cheaper, so insurers want you on them first. That’s not always wrong. But when a generic doesn’t work for you, or causes harm, the denial becomes dangerous.

In 2022, CMS found that 63% of all prior authorization denials for specialty drugs were for brand-name medications. That’s not random. It’s policy. Insurers change formularies without warning. One month you’re covered. The next, your prescription is rejected. You didn’t miss a payment. You didn’t change plans. But suddenly, your life-saving drug is off-limits.

The biggest trigger? Prior authorization. Your doctor has to jump through hoops just to get approval. Even if you’ve been on the drug for five years, the insurer might demand new paperwork. And if they say no, you have to appeal. No one tells you this upfront. That’s why so many people give up.

What You Need to Win Your Appeal

Winning an appeal isn’t about yelling or begging. It’s about proof. The single most important document is the letter of medical necessity from your doctor. GoodRx analyzed 1,200 appeal cases in 2023 and found that 78% of approvals came when the prescribing physician provided a detailed letter. Without it, your chances drop to under 20%.

Your doctor’s letter must include:

• Your exact diagnosis and how the brand-name drug treats it
• Specific failures with generic alternatives (e.g., "Patient experienced severe nausea and dizziness on levothyroxine, but stabilized on Synthroid after 6 months")
• Lab results or clinical notes showing deterioration after switching
• How the medication impacts your daily life-can you work? Sleep? Care for your kids?
• The prior authorization reference number and CPT/ICD codes

Don’t assume your doctor knows what to write. Many aren’t trained in insurance paperwork. Ask them directly: "Can you write a letter explaining why this brand-name drug is medically necessary for me?" Offer to draft it for them. Most will sign it if it’s clear and accurate.

The Two-Step Appeal Process

There are two stages to fighting a denial: internal appeal and external review. You must do both in order.

Stage 1: Internal Appeal
This is your first shot. You file directly with your insurance company. You have 180 days from the denial date to submit your appeal (120 days for Medicare). For urgent cases-like insulin, seizure meds, or cancer drugs-you can request an expedited review. Insurers must respond in 4 business days.

Your appeal letter should include:

• Your full name, policy number, and member ID
• The date of denial and denial reference number (from your Explanation of Benefits)
• A copy of the doctor’s letter of medical necessity
• Any lab reports, ER visits, or specialist notes
• A clear request: "I am requesting coverage for [drug name] as prescribed by my physician"

Call the insurer every 3-5 days. Ask for the claim number, who’s handling it, and when a decision is due. Kantor & Kantor’s data shows appeals with documented follow-up calls are processed 28% faster. Don’t wait for them to call you.

Stage 2: External Review
If your internal appeal is denied, you move to an independent reviewer. This is where things change. The National Association of Insurance Commissioners found that 58% of external reviews for brand-name drugs are approved-nearly 20 points higher than internal appeals.

Who handles this? It depends on your plan:

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

You’ll get a packet with forms and deadlines. Submit everything again-doctor’s letter, medical records, your appeal history. Don’t skip this step. If you don’t complete the external review, you can’t sue later.

What Works: Real Cases

One man in Ohio, "DiabeticDad87," posted on Reddit in January 2023 about his 10-year-old’s insulin denial. Humalog was taken off formulary. The generic didn’t control blood sugar. He submitted a letter from his pediatric endocrinologist detailing three hypoglycemic seizures in two months. Approval came in 11 days.

Another patient on PatientsLikeMe spent six months fighting a denial for a brand-name migraine drug. After two internal denials, she hired a lawyer. The external review approved coverage. Cost? $2,500. But she stopped missing work. Her headaches dropped from 15 days a month to 3.

The pattern? Success doesn’t come from patience. It comes from persistence and documentation. Patients who handled appeals alone had only a 22% success rate. Those with doctor support? 78%.

When You Need a Lawyer

If your plan is governed by ERISA (most employer-based plans are), you’re in a tougher spot. Federal law limits your options. You can’t sue unless you’ve exhausted every appeal step. And even then, your case goes before a federal judge-with no jury.

Kantor & Kantor, a law firm that’s handled insurance denials since 1985, found that appeals drafted by attorneys have a 47% higher success rate than those done by patients alone. Why? Insurers use legal loopholes. They misquote guidelines. They delay. They bury you in paperwork. An attorney knows how to counter each tactic.

You don’t need a lawsuit to start. Many firms offer free initial reviews. If your case is strong, they’ll help you file the appeal for free and only charge if you win. Look for attorneys who specialize in ERISA and health insurance denials. Don’t wait until you’re desperate.

What to Do While You Wait

Appeals take time. You can’t stop taking your meds. So what do you do in the meantime?

Many drugmakers offer patient assistance programs. Eli Lilly’s Insulin Value Program has helped over 1.2 million people get brand-name insulin while appeals are pending. Sanofi, Novo Nordisk, and others have similar programs. Go to the manufacturer’s website. Search for "patient assistance" or "copay card." You might get the drug for free or $35 a month.

Also, ask your pharmacist. They often know about bridge programs or samples your doctor can give you. Some pharmacies have partnerships with nonprofits that cover costs during appeals.

What’s Changing in 2025

New rules are slowly helping. The 2023 Consolidated Appropriations Act required Medicare Part D plans to show real-time coverage info before you fill a prescription. That should cut denials by 15-20%. The Biden administration also pushed CMS to enforce appeal deadlines more strictly.

But the biggest shift? AI. Insurers are using automated systems to approve or deny prescriptions. Some are getting smarter-learning from past appeals and clinical data. In the next five years, experts predict AI will reduce inappropriate denials by 30-40%. But until then, you still have to fight.

What Not to Do

Don’t ignore the denial. The clock starts ticking the day you get the letter. Waiting 90 days means you’re already behind.

Don’t accept "no" as final. Most people stop after the first denial. But the real win is in the second round.

Don’t try to switch doctors because your current one won’t write the letter. Find a new one who will. Your health matters more than loyalty.

Don’t pay out of pocket if you can avoid it. Use patient assistance programs. They exist for this exact reason.

Final Checklist Before You Submit

• Got your Explanation of Benefits (EOB)? Check for the denial reason and reference number.
• Has your doctor written a letter of medical necessity? It must include specific clinical failures with generics.
• Did you include your policy number, member ID, and drug name exactly as it appears on the prescription?
• Did you send the appeal via certified mail or online portal with a receipt?
• Did you call the insurer 3 days after sending to confirm receipt?
• Did you keep copies of everything? Email, letter, fax confirmation, call logs?

If you checked all these, you’ve already done better than 80% of people who get denied.