If a plan denies coverage for a prescription, review the notice and contact the insurer to ask what review options, documents, and deadlines apply to your plan.
This guide suggests questions to ask the insurer and prescriber. Compare current pharmacy quotes on RxDiff while you review your options.
Ask the insurer to explain the specific reason for the decision, what plan terms apply, and which documents or next steps it requires.
Review your plan documents and the existing Healthcare.gov appeals guide. Applicable review options, eligibility, and timeframes depend on the plan and circumstances; confirm details with the insurer.
Check the denial notice and plan documents for instructions and applicable deadlines. Ask the insurer which process applies to your coverage.
An appeal of a Marketplace eligibility decision is separate from an appeal of an insurer's denial of a prescription. HealthCare.gov says you generally have 90 days from the date of your Marketplace Eligibility Notice to request an eligibility appeal; an insurer's prescription-denial appeal can have a different deadline. Check the notice for the process that actually applies to you.
Ask the insurer which review options are available and which documents it requests. Your prescriber can advise whether medical information is appropriate for your circumstances.
Keep copies of submissions and communications. Ask the insurer how it confirms receipt and what to do if you do not receive a response within the timeframe it provided.
Ask the insurer whether independent review is available and what process applies. The existing Healthcare.gov appeals guide may help you find official information; confirm your plan's requirements directly.
For Marketplace plans, HealthCare.gov says internal appeals are to be completed within 30 days for services not yet received and 60 days for services already received; for urgent situations the decision must come as quickly as the medical condition requires, at least within 4 business days. Other plans can differ.
Sources: HealthCare.gov: Internal appeals
Ask who conducts the review, what information is considered, and what effect a decision may have under your plan.
If timing may affect your care, contact the insurer and ask whether an expedited process is available, what criteria apply, and which documents are needed. Consult your prescriber about your health needs.
Ask the insurer about any further review or complaint options and ask your prescriber about alternatives appropriate for you. Compare current pharmacy quotes on RxDiff and review the GoodRx comparison page; confirm the final price and offer terms with the pharmacy.
Compare current quotes for your exact prescription while you ask your plan about review options.
Compare Prices on RxDiff →What should I do after a prescription coverage denial?
Read the notice and ask the insurer what review options, documents, and deadlines apply to your plan.
How long does an insurance review take?
Timeframes depend on the plan and request. Ask the insurer for the applicable deadline and whether any expedited process is available.
Can I request an independent review?
Ask the insurer whether it is available for your plan and what process and requirements apply.
Why might a prescription be denied?
Ask the insurer to explain the decision and identify the plan terms and information it relied on.
What should I do if I can't afford a prescription while reviewing a denial?
Ask your prescriber, pharmacist, and plan about options for your circumstances. Compare current pharmacy quotes and confirm the final price directly with the pharmacy.
Can I contact the insurer myself?
Ask the insurer whether you may submit the request directly and whether information from your prescriber is needed for your circumstances.
Medical Disclaimer: This content is for informational purposes only. Always consult your healthcare provider. Use RxDiff to compare current drug prices in your area.
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Affiliate Disclosure: This post contains affiliate links to DrHouse, a telehealth prescription service. RxDiff may earn a commission at no additional cost to you. Made in accordance with FTC guidelines.
Editorial disclosure: RxDiff Editorial Team guides are for prescription price and savings information. They are not medical advice. Verify current prices, eligibility, and health information with the pharmacy, prescriber, pharmacist, or official source.