How to Appeal Insurance Denials for Brand-Name Medications

When your insurance denies coverage for a brand-name medication you’ve been taking for years, it’s not just a paperwork headache-it can threaten your health. Maybe your insulin, migraine treatment, or autoimmune drug was switched to a generic without warning. Maybe your doctor prescribed exactly what you need, but the insurer says it’s "not medically necessary." You’re not alone. In 2022, nearly 1 in 6 prior authorization requests for specialty drugs were denied, and over 60% of those were for brand-name medications. The good news? You have legal rights to fight back. And with the right steps, you can win.

Why Your Insurance Denied Your Brand-Name Medication

Insurance companies don’t deny brand-name drugs because they’re cruel. They do it because they’re trying to cut costs. Most plans have a list called a formulary-a catalog of drugs they’ll pay for. Brand-name drugs are expensive. Generics are cheaper. So insurers push generics first, even when they don’t work the same way for you.

You might get denied for one of three reasons:

• Formulary restriction: Your drug isn’t on the plan’s approved list.
• Prior authorization failure: Your doctor didn’t jump through the insurer’s hoops.
• Medical necessity denial: The insurer claims a cheaper drug would work just as well.

The last one is the trickiest. Insurers often say, "We’ve approved this generic-why not use it?" But if you’ve tried three generics and they made you sick, caused side effects, or didn’t control your condition, that’s not a choice. That’s a medical failure.

What You Need Before You Appeal

You can’t appeal without evidence. Start here:

1. Get your Explanation of Benefits (EOB)-this is the denial letter. It must say exactly why you were denied. Look for the code or reason listed. Write it down.
2. Call your doctor’s office and ask for a letter of medical necessity. Don’t settle for a note. This letter must be detailed. It needs:

• Your diagnosis and how the medication treats it
• Specifics on what happened when you tried generics or other alternatives
• Lab results, hospital visits, or side effects tied to previous treatments
• Why the brand-name drug is the only option that works for you
• Your doctor’s signature and license number

According to a 2023 analysis by GoodRx of 1,200 appeal cases, 78% of successful appeals had a strong letter from the prescribing doctor. Only 22% worked when patients tried alone. Your doctor isn’t just helping-they’re your strongest weapon.

How to File the Internal Appeal

This is your first official step. You have 180 days from the denial date to file under most private plans (Medicare gives you 120 days). Here’s how to do it right:

1. Write your appeal letter. Use this structure:

• Your full name, date of birth, policy number
• Date of denial and EOB reference number
• Exact name of the medication and dosage
• Reason for denial (copy it from the EOB)
• Medical justification (use your doctor’s letter as the core)
• Clear request: "I am requesting immediate coverage of [drug name] as medically necessary"

Don’t be vague. Say: "I experienced severe hypoglycemia on three generic insulins. My blood sugar spiked unpredictably. My doctor documented this in my chart on [date]. Only Humalog has stabilized my condition."

Send it certified mail with return receipt. Keep a copy. Don’t just email or call-paper trails matter.

Insurers must respond within 30 days for new prescriptions and 60 days if you’re already on the drug. For urgent cases-like insulin, seizure meds, or cancer drugs-you can request an expedited review. Call them, say it’s urgent, and then follow up with a written request. They must reply in 4 business days.

What If the Internal Appeal Gets Denied?

Most people stop here. Don’t. The next step is the external review-and it’s where you win more often.

External reviews are handled by independent third parties, not your insurer. And the numbers don’t lie: CMS found that 58% of external appeals for brand-name drugs succeed, compared to just 39% for internal ones.

Here’s how to start:

• If you’re on a non-ERISA plan (most individual, Medicaid, or Medicare plans), contact your state insurance commissioner’s office. They’ll assign an independent reviewer.
• If you’re on an ERISA plan (about 61% of employer-based plans), you must file with the U.S. Department of Health and Human Services. ERISA plans are federally regulated and harder to challenge in court later-so this step is critical.

Submit the same letter of medical necessity, plus your internal denial letter. Add a note: "I have exhausted internal appeals and request an external review under federal law."

The review takes 30 to 60 days. If they rule in your favor, the insurer must cover the drug immediately-and pay for any out-of-pocket costs you’ve already paid.

When to Call a Lawyer

If you’re on an ERISA plan and your external review fails, you’re out of options unless you sue. And that’s where things get complicated.

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 know the law. They use legal loopholes. They delay. They bury you in paperwork.

You don’t need a lawsuit right away. But if you’ve done everything-doctor’s letter, internal appeal, external review-and still got denied, contact a lawyer who specializes in ERISA and health insurance claims. Many offer free consultations.

Don’t wait. ERISA requires you to exhaust all appeals before you can sue. If you miss that window, you lose your right to challenge the denial in court.

Real Stories: What Works

One Reddit user, "DiabeticDad87," appealed a Humalog denial after his child had three emergency room visits from low blood sugar on generics. He sent the doctor’s letter with lab results showing dangerous glucose swings. Approval came in 11 days.

Another patient on PatientsLikeMe spent six months fighting a denial for a brand-name migraine drug. They tried everything-calls, letters, appeals. Only when they hired a lawyer did the insurer finally approve it. The legal fees were $2,500-but the drug cost $1,800 a month. They saved money long-term.

A 2022 survey by the Patient Advocate Foundation found 61% of people felt overwhelmed by the process. But 83% of those who got help from their doctor or a legal advocate succeeded.

What You Can Do Right Now

Don’t wait. Here’s your action plan:

1. Find your denial letter (EOB) and note the reason.
2. Call your doctor’s office TODAY and ask for a letter of medical necessity. Tell them it’s urgent.
3. Write your appeal letter using the structure above.
4. Send it certified mail to your insurer.
5. Call the insurer every 3 days to confirm they received it.
6. If denied internally, immediately file for external review.
7. If it’s an ERISA plan and you’re still denied, consult an attorney.

Some drug makers offer free bridge programs while you wait. Eli Lilly’s Insulin Value Program, for example, gives brand-name insulin at $35 a month to qualifying patients-even during appeals. Check your drug manufacturer’s website. They often have patient support lines.

What’s Changing in 2025

New rules are coming. The 2023 Consolidated Appropriations Act requires Medicare Part D plans to show you real-time coverage info before you fill a prescription. That should cut denials by 15-20%. The Biden administration is also cracking down on insurers who delay appeals.

But until then, the system still favors the insurer. You have to fight harder. The law is on your side-but only if you use it.