How to Appeal Insurance Denials for Brand-Name Medications

When your doctor prescribes a brand-name medication and your insurance says no, 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’re trying to cut costs, not because it’s medically unsafe. But you’re not powerless. You have rights, and you can win this fight-if you know how.

Why Your Insurance Denied Your Brand-Name Drug

Most denials happen because your plan’s formulary doesn’t include the drug, or they say a cheaper generic is "just as good." But that’s not always true. For some people, generics don’t work. Maybe you’ve tried them before and had bad reactions. Maybe your condition is too sensitive-like type 1 diabetes, epilepsy, or autoimmune disorders-where even tiny differences in absorption can be dangerous. Insurers know this, but they still push generics unless you push back hard.

According to CMS data from 2022, nearly 63% of prior authorization denials for specialty drugs are for brand-name medications. That’s not random. It’s policy. Insurance plans change formularies without warning, and suddenly, your stable medication is off coverage. If you’ve been on it for years, you’re not the problem-the system is.

What You Need Before You Appeal

You can’t just call and ask for a reconsideration. You need proof. The first thing you need is your Explanation of Benefits (EOB). Your insurer must send this within 5 business days of denying the claim. Read it carefully. It will say exactly why they denied it: "Generic available," "Prior authorization not met," or "Not medically necessary." Write down that reason. You’ll need it later.

Next, call your doctor’s office. Ask for a letter of medical necessity. This isn’t a form letter. It needs to be detailed. Your doctor should include:

• Your diagnosis and how the brand-name drug treats it
• Specific failures with generic alternatives (e.g., "Patient experienced three hypoglycemic episodes on generic insulin in the last 3 months")
• Lab results, dosage history, or clinical notes that prove the brand drug is essential
• How the drug impacts your daily life-can you work? Sleep? Care for your kids?
• Any relevant ICD-10 or CPT codes

GoodRx analyzed 1,200 appeal cases in 2023 and found that 78% of approved appeals had a strong letter from the prescribing doctor. Only 22% succeeded when patients tried to handle it alone.

How to File the Internal Appeal

Once you have your letter, it’s time to file your formal appeal. This is your first step inside the insurance company’s system. You have up to 180 days from the denial date to file, but don’t wait. The sooner you start, the faster you get results.

Your appeal letter should include:

• Your full name, date of birth, insurance ID number
• Claim or prior authorization number from the EOB
• Exact reason for denial (copy and paste it)
• Attached letter of medical necessity
• Any supporting records: pharmacy logs, ER visits, specialist notes
• A clear request: "Approve coverage for [drug name] as prescribed by [doctor]"

Send it by certified mail with return receipt. Keep a copy. Don’t just email it-paper trails matter. Insurance companies lose things. A certified letter proves you filed on time.

Call Every Day

This isn’t optional. After you mail your appeal, start calling the insurance company daily. Ask for the case number. Ask who’s reviewing it. Ask for a timeline. Most people give up after two or three calls. But Kantor & Kantor’s data shows appeals with daily follow-up are processed 28% faster.

If you’re told it’s "under review," ask: "What’s the next step? When will I hear back?" If they say "We’ll notify you," say: "I need a written response by [date]." Write down the name of every person you speak to. You’re not being pushy-you’re protecting your health.

What If They Say No Again?

If your internal appeal is denied, you move to the external review. This is where things get serious. This step is handled by an independent third party-not your insurer. And here’s the kicker: external reviews succeed 58% of the time for brand-name drug appeals, compared to just 39% for internal ones.

Who handles your external review depends on your plan:

• For ERISA plans (about 61% of employer-based insurance): Contact the U.S. Department of Health and Human Services
• For state-regulated plans (Medicaid, individual market): Contact your state’s insurance commissioner

You have 60 days from your internal denial to request external review. Don’t delay. Submit your entire file again-same letter, same documents. Add a short note: "I am requesting external review under federal and state appeal rights."

When to Hire a Lawyer

If your case involves an ERISA plan and you’ve been denied twice, it’s time to consider legal help. Kantor & Kantor, a law firm that’s handled insurance appeals since 1985, found that appeals drafted by attorneys have a 47% higher success rate than those filed by patients alone.

Why? Because insurers use legal language to bury claims. They cite obscure policy clauses. They misinterpret guidelines. An attorney knows how to counter that. They also know how to force the insurer to produce internal documents showing how they make these decisions.

You don’t need to sue right away. Many attorneys offer free consultations and will help you draft the external review letter for a flat fee. Some even work on contingency-only paid if you win.

Urgent Cases: Get Help Fast

If you’re running out of medication and your life is at risk-like insulin, seizure meds, or immunosuppressants-you can request an expedited review. You don’t need to wait 30 days. Federal rules say insurers must respond within 4 business days.

Call your insurer and say: "I am requesting an expedited appeal because my condition is life-threatening. I am at risk of [seizures, hospitalization, diabetic ketoacidosis]." Then follow up with a letter. Include your doctor’s statement that delay could cause serious harm.

In these cases, success rates jump to 72%. Insurers know they can’t risk a death on their record.

What to Do While You Wait

Appeals take time. Don’t stop taking your meds. If you’re running low, ask your doctor about patient assistance programs. Eli Lilly’s Insulin Value Program, for example, has helped over 1.2 million people get brand-name insulin while appeals are pending. Many drugmakers have similar programs.

Also, check if your pharmacy offers a bridge program. Some give 30-day supplies at low cost while you fight the denial.

What’s Changing in 2025

The rules are slowly getting better. The 2023 Consolidated Appropriations Act now requires Medicare Part D plans to show real-time coverage info before you even fill a prescription. That’s cutting denial rates by 15-20%.

The Biden administration’s 2023 executive order is pushing CMS to enforce appeal rights harder. And new quality metrics from the National Committee for Quality Assurance are now tracking how fast insurers respond. Plans that drag their feet could lose money.

But don’t wait for the system to fix itself. Right now, physicians spend over 13 hours a week just managing prior authorizations. You’re not the only one fighting. But you’re the only one who can fight for you.

Real Stories, Real Wins

One father in Ohio got his child’s Humalog insulin approved after 11 days by submitting a letter that listed every hypoglycemic episode in the past year. Another patient in Texas spent six months fighting a denial for a brand-name migraine drug. They lost twice-until they hired a lawyer. The third appeal was approved.

These aren’t rare. They’re common. But only if you act.

Next Steps

If you’re facing a denial today:

1. Get your EOB and write down the denial reason
2. Call your doctor’s office and ask for a letter of medical necessity
3. Write your appeal letter using the structure above
4. Send it by certified mail
5. Call the insurer every day until you get a response
6. If denied, request external review within 60 days
7. If it’s life-threatening, ask for expedited review immediately

This isn’t easy. But it’s necessary. Your health isn’t a cost center. It’s your life. And you have the right to fight for it.