3 Ways to Appeal Insurance Denials for Prescription Refills

By Ashley Hattle

Last Updated:

2 min read

“Your insurance provider will not cover your prescription refill.”

It’s a phrase nearly every person with chronic pain or a headache disorder fears; maybe it’s a phone call, a pharmacy app notification, or a face-to-face conversation with your pharmacist. No matter how the information is delivered, it strikes you in the gut. Panic rises in your chest. You yell, cry, scream—whatever works to release your frustration.

What can you do about the prescription denial?

You need this medication to function, to treat your pain. What bureaucrat decided that four pills or four injections a month is enough to treat a condition that plagues you multiple times every day? Why does their opinion trump your doctor’s orders? How can you fight this unjust decision? This issue is so pervasive that some patients give their medication to other patients whose insurance won’t cover the cost.

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Whether you have migraine disease, cluster headaches, or another painful condition, there are a few ways to appeal a health insurance coverage denial and avoid paying hundreds (thousands even) of dollars out of pocket.

This or That

Does insurance or the cost of medications get in the way of your migraine treatment?

Can your doctor appeal the insurance provider?

Your insurance card has a phone number for providers to call to appeal a decision on prescription coverage. Not only is this call line answered faster than the number for patients, but it’s also a streamlined process for physician’s offices to appeal an insurance policy on certain medications or seek pre-approval on a procedure. Ask your doctor to call on your behalf to increase the allotment for your treatment every month.

My primary care physician did this for me several times when I was entirely out of sumatriptan injections. I had already spent $900 out of pocket on them (which got me ten auto-injectors), and he convinced my insurance provider to cover double the usual allotment.

How can the pharmacist help?

I’ve broken down in sobs at the pharmacy more times than I care to remember. The issue was so common that when I was doing better and no longer needed to go to the pharmacy every day, the pharmacist called to check in on me. Similar to your doctor’s pull with your insurance company, your pharmacist can make a call to get them to cover another refill. It’s not a permanent fix, but it can work once or twice in your favor.

How can you appeal the denial?

A patient appeal is your slowest option. It can take weeks for an insurance representative to review your claim and get back to you with the decision. However, it could provide lasting coverage for more refills of your medication each month. Most, if not all, providers have an online appeal form for you to fill out, but they may want you to fax or mail them one. I’ve tried this a handful of times with sumatriptan injections or oxygen coverage and been denied every time. However, you could have more luck than I did.

Do you have advice for navigating health insurance denials for prescriptions? I’d love to hear about your experience in the comments!

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bcueww Member

I had this happen to me with my Emgality prescription. Luckily I have a really great doctor, and she filed an appeal for me. Unfortunately, they denied it a second time! BUT my doctor has really great staff also, and one of her nurses sent another appeal and got on the phone my insurance, and she was able to get them to approve. I was so appreciative and grateful as the Emgality has been working for me. For once in my life, I had a medication that was helping me have fewer headaches. So I hope anyone who has to go through this situation doesn't give up, and maybe you'll have a doctor or staff person who will fight for you also.
1. Holly Harding Member
 
 <inline-mention username="bcueww" user-id="3743526"/> - Thank you so much for sharing your story with us. You are lucky to have such a responsive doctor and staff. Unfortunately this isn't always the case- but you definitely demonstrate the importance of tenacity which is absolutely key in getting things moving. As we all know, tenacity doesn't always come easy when we are in the midst of fighting pain, so we must take it as best we can. Also if anyone who reads this doesn't have a doctor's office that is responsive, it might be time to find one, and we can help you do so. <a href='https://migraine.com/blog/the-mrf-directory-of-headache-and-migraine-specialists' target='_blank'>https://migraine.com/blog/the-mrf-directory-of-headache-and-migraine-specialists</a> Warmly, Holly (migraine.com team).
youniquelydebra Member

I’m insured with Humana Medicare. I got denied this year for frovatriptan. My doctor’s appeal got denied. I called the review board and cried and cried. The woman gave me the number for the Appeals Department. I called them and they have two options: rush and standard. I elected the rush option and stated my case. I said I have been taking this medication for 20 years and I have had terrifying reactions to Relpax and Imitrex. I felt like I was having a heart attack with rapid heartbeat and severe pain and pressure in my chest. The next day my prescription was approved!
1. Nancy Harris Bonk Member
 
 <inline-mention username="youniquelydebra" user-id="3717759"/>, Good for you!! With a bit of well deserved pressure they did the right thing!! Nicely done! I'm unable to take the pill form of triptans due to experience similar unwanted side effects you've mentioned. My doctor suggested I try the nasal spray form and viola - no issues! I do wonder if another delivery method is something to discuss with your doctor if this problem with insurance ever arises again? Wishing you a low pain day, Nancy Harris Bonk, Patient Advocate/Moderator
migraineur_n1lymx Member

I'm lucky that the health center I use due to low income sells me 18 generic rizatriptan for $10. What many of you may not know is your Dr/Drs. office can appeal by calling your insurance provider, I'm on Medicare but a seperate insurance handles my Part D. If it weren't for this option the deductible is so high there'd be no point to even having it. You have to make sure your Dr. asks for the approval to be faxed to your pharmacy and ask for a confirmation letter to be mailed to you from your insurance provider. Typically with meds you use all the time plus low income they should grant the lowest tier - tier 1 (but not all meds will go that low, try getting 3 month Rx's since the cost goes down) for a year, some only do it until the end of the current year and guess what? You have to keep track of when you need to have it done again, don't rely on your Dr. to do this. It's best to have the Dr. ask for the appeal to avoid the time insurance companies can take if they want to and sometimes you have to call them again hoping you get an experienced CS rep. Of course formularies change too and meds get put into higher tiers or they try to deny the med your Dr. asked for offering another version or generic but your Dr. doesn't have to put up with this either. The name of the game until our politicians decide to stop this nonsense is of course money. The insurance companies are betting you aren't paying attention and be very wary if your current company gets absorbed/merges with another one because the new company calls the shots. I'm getting a new Dr. at this center and can only hope to convince him to put my rizatriptan back up to 24 pr. month with refills as/if needed as my original "migraine specialist" prescribed. Sometimes it pays to find a good migraine Dr. since they know all about migraines and what we have to go through in dealing with that level of pain, triggers known or new, frequency that can't be predicted, ones that come back hours after you got rid of it or ones that come back day after day with breaks before it starts all over again. You may be thinking why did I stay with such an incompetent Dr.? $10 for 18 tabs of rizatriptan. We all deserve better than this!
1. migraineur_n1lymx Member
 
 <inline-mention username="Holly Harding" user-id="3755969"/> The testimony I read on this great site from others made me realize so many people don't know that they have options, possibly their Drs. don't even know that they can request any medications be put into lower tiers, I myself didn't know this for years since the insurance companies won't tell us anything but the standard "we'll review your case" and that's the newbie response which is why we have to be proactive/our own advocates so that they're getting hit from both sides ie; our Drs. and us will usually get results faster. Two days to 2 weeks for a decision? Just isn't realistic, our migraines don't wait. As much as I hate to say it if all of them from Drs. to insurance reps could experience our pain just once they'd be more sympathetic to our needs. We aren't making it up, we aren't in it for the meds, we just want much needed relief from the pain which isn't like the pain from anything else. I've been glad to see the stories from others asking things like "why do I wake up with migraines when I didn't encounter any of my triggers the day/night before going to sleep?" I've wondered that for years myself and is why I'm signed up to this site, we're all the best source of information, tips, advice out there, so keep reading and writing/sharing our experiences if for no other reason to realize we're not alone.
2. Holly Harding Member
 
 <inline-mention username="migraineur_n1lymx" user-id="3880873"/> You are SO right. It is the people who live with migraine who are the sources of the most wisdom and insight on the topic. What a salient point you made about the waiting period we are all made to suffer through by insurance companies which would never happen if those in charge had experienced one migraine in their lives. So very glad to have you, and your well-earned wisdom, compassion and willingness to share all of it - in our community! Please keep in touch! Warmly, Holly (migraine.com team).
RachelP Member

My insurance company changed their formulary and decided that my primary preventative would no longer be covered. I took the generic form for decades, living with the side effects, and a few years ago, my doctor submitted a letter of medical necessity for the name-brand, as I can take that without the side effects. They've approved the medication for years. They tried to deny it in 2023, but my doctor resubmitted the medical letter, and they approved it. At the beginning of the year, they denied it, denied his resubmission, and denied the appeal even after peer-to-peer review. I cannot function without it. I paid out of pocket for 5 pills while an additional appeal was underway, but then fully ran out of medication and lost a full week of work. I had to get my company's head of HR/Benefits involved. Thank God for her. I don't know who she had to brow beat, how she managed to get an exception, but she got that medication approved and got the approval for the second preventative I take (that insurance approved a year ago, but decided in January they wouldn't approve again and wouldn't tell me why). It takes both medications to change my migraines from chronic to episodic, but the combination has been a game changer and life saver.
1. RachelP Member
 
 <inline-mention username="Cody Leach" user-id="4536970"/> Yes! For this year, at least, I was able to get everything approved. I have to have my doctor resubmit for next year, but I'm really hoping it is just as a formality. I've been with this company for 16 years, and I think my boss told HR that if they couldn't get this fixed, I'd quit and they didn't want to have to replace me. LOL I take 100 mg Lamictal XR (and it has to be Lamictal, not the generic lamotrigine) daily, and Nurtec 75 mg every other day (the preventative dosage). This combination has given me my life back. (...and apologies for commenting on a 3 year old article. It was in the email I received today and I didn't even think to check the dates!)
2. Cody Leach Member
 
 <inline-mention username="RachelP" user-id="3911486"/> YAAY! So happy that you're now able to have your life back with both Lamictal XR and Nurtec. I can imagine it feels like an immense relief to know you're all set for the next year. Also, absolutely no worries on responding to an old article. Comments like yours help keep our community alive and flourishing. Considering <a href='https://migraine.com' target='_blank'>Migraine.com</a> has been around since 2010, we're bound to circle back to prior conversations to discuss them more. Wishing you well, and look forward to seeing you around! - Cody (Team Member)
Traderbeck Member

In regards to insurance companies rejecting migraine treatments: I’ve been denied for Botox shot and various medications but have been able to successfully appeal their initial decisions. Basically, you have to be willing to invoke a headache to get clearance. I think that’s their reasoning. The way to do it is through your doctor, as the <a href='https://migraine.com' target='_blank'>migraine.com</a> story says. Many doctors take no for an answer—it’s an arduous process to appeal and some won’t write a prescription if they know the insurance will reject it. Your job is to convince them that it is important to you to try the treatment and that you will do what you can to make the process easier for them. It’s important to know why it is being rejected and if they make exceptions. Sometimes they will if you’ve tried other treatments or your doctor is the only one who can treat in a certain radius. Can you fill out a copy of the appeal or provide answers and sent that back to the doctor’s office to help them understand the issue? Can you work with a staff member to fill it out? Often the doctors have to do it themselves. As mentioned, doctors have a number where they can streamline these requests with insurances. I think it’s always better to deal with a human—it’s harder for them to say no. They can expedite in some cases if it is an appeal. As always, try to be polite to everyone as this goes a long way. It’s so hard when you are in pain and dealing with bureaucracy, but most people want to help you even if their company doesn’t.
1. Tonya Henry Member
 
 <inline-mention username="Traderbeck" user-id="4179666"/> thank you for sharing! Like you, I am always nice. Yelling at someone will only get the phone hung up on you, or, no reply. I love a doctor who is willing to appeal and keep trying, until they reach a resolution. I have also reached out to the VA, to see why they did not approve a medication. They often do not have all the information. Again, thank you for sharing!! I hope that you are doing well, with your symptoms this week. (Tonya, team member).
timbanish Member

Having insurance deny prescription coverage is enough to bring on a migraine. A trip to the ER will cost much more than any medicine. Let insurance know that.
1. Rebecca C Member
 
 <inline-mention username="timbanish" user-id="3905326"/> I must agree with you. In this case, I have had this happen. Struggling to get approved for Vyepti - no go - it was denied 3 times. Each time, I got a migraine just from stress that lasted a few days. Vicious cycle ... Thanks for sharing. Wishing you no/low pain days ahead.
azurelle Member

I have worked for a prescription benefit management company for more than 20 years and I can tell from experience most people get denied because they aren't following the correct process. See my tips below for navigating coverage: ONE: you need to know your coverage on your plan, your doctor does not know your plan, they actually have no idea if a mediation is covered by your plan, when you are prescribed a new medication you must call your plan and check coverage before trying to fill the order, you should also be checking your coverage every Jan as that's when most plans update and things change, remember, you have prescription insurance to help get you the best cost and to offset retail pricing, these things are updated regularly TWO: some medications require what's called a prior authorization to be covered, you will be given this info when you call to check your coverage, typically someone in the doctor's office has to call and answer 4-6 clinical question about your situation to get meds covered, most plans prefer the generic alts to brand names so check on that coverage as well, also most plans will not cover new medications immediately, plans update on a schedule, not when new meds are released to the market -- for example, you become aware of a new med in June but it's not covered, this is typically because plans tend to update in Jan/Feb and Aug/Sept you may have to wait for a new med to be covered and when it's added for coverage you made need to do a prior authorization NOTE: prior authorizations typically are valid for one year, it is YOUR responsibility to know the information about your authorization and keep it update or renewed, after all, this is your medication and your treatment plan THREE: acute migraine meds like imitex having dispensing limits, usually 9 pills or one pack every 30 days, this follows FDA guidelines for safety but most plans also offer what's called a patient level prior authorization, this allows you request more based on your personal medical issues, your doctor's office much call in and provide the clinical reasons for the higher dose NOTE: this is not personal, in reality no one at the insurance knows a thing about you and they don't really care, the questions for and about coverage must be answered by a medical professional, you may not provide any information and this is often done as a safety net for you, I did prior authorizations for five years, I have horror stories about authorizations that came across my desk with doctors prescribing lethal doses, wrong meds for the diagnosis, and so on -- again, none of this is personal, it's clinical and it's set up to try and protect you One example I will share of an imitrex denial I did, the general doctor, not a headache specialist or neurologist, prescribed 100mg three times a day as a preventative medication, we all have migraines, we all know imitex is an acute medication, not a standard preventative and so on, the authorization was denied for clinical reasons -- but I didn't make the decision, I entered the information provided into the computer and it gave a denial based on the information from the doctor, it's all very straight forward and it all depends 100% on the information from your doctor, again, none of this is personal although it feels like it is, it's fact based and the fact is if your doctor doesn't provide the correct information in a timely manner you're going to have problems FOUR: you must follow the process in place, usually you have to do an authorization first, appeal it if it's denied for some reason (and honestly most denials I see to this day are because the 4-6 clinical questions are answered wrong by the doctor's office) and then do a benefits appeal after that if needed, you can't jump around and try to do a benefits appeal first, you MUST follow the process steps in place FIVE: if you're getting injections at the doctor's office check and see if it's covered under medical -- as a general rule treatments you give yourself are covered under prescription plans, treatments given to you in the office are covered under medical plan SIX; and I can't stress this enough -- BE NICE -- I'm just doing my job inputting the information provided by your doctor into the system which then computes an answer -- BE NICE WHEN YOU CALL IN -- representatives are much more likely to "go to bat for you" and try to guide you through the process when you're nice, you get nasty with the person on the phone and they're going to tell you something like "follow the directions on the back of page one" rather than trying to walk you through the process and maybe give you insider information like I'm doing right now And finally, always hunt for coupons and manufacturer programs to help offset the cost of medications, Google is your friend 
1. Cody Leach Member
 
 <inline-mention username="azurelle" user-id="3921241"/> Thank you so much for taking the time to share such a detailed recount of what navigating this process is like. I have no doubt many, many people will benefit from your comment! Wishing you well, - Cody (Team Member)
2. Rebecca C Member
 
 <inline-mention username="azurelle" user-id="3921241"/> AMAZING TIPS! Thank you for taking the time to help us in the community with medications and prior authorizations. It is an in-depth process that can be confusing to a majority of those here in the community. I also have experience with prior authorizations - sending them in. It can be a nightmare. I also have experience with an inexperienced physician. I have been wracking my brain around the way this specialist has been prescribing medication for my migraines and daily headaches. I say inexperienced bc he should know that one should be on a medication for a certain amount of time for it to be effective - right? He has had me jumping from one medication to another every month. Now he wants me to get the infusion - which was denied. I try to tell him this information, but it seems my observations are not getting through to him. I wonder, how do you manage a physician who doesn't understand the process? I am going in circles ... Your post is so very helpful, <inline-mention username="azurelle" user-id="3921241"/> - thank you. Rebecca (team member)
azurelle Member

INEXPERIENCED DOCTOR TIPS ONE: fill out all the paperwork yourself, you can have FMLA paperwork sent to you, fill it all out yourself and take in for your doctor to review and sign TWO: ask the office personnel (not the doctor, the staff) for a copy of prior auth or other paperwork you had sent to them, it should be in you file, take a copy of it, fill it out yourself, and take back in for your doctor to review and sign -- I know I said before clinical info must be provided by your doctor, but, I don't know who filling out what, I only know what the doctor's office is sending in, it's a bit of loop hole but you MUST NOT SAY YOU FILLED IT OUT when speaking to your insurance, everything has to be from the doctor THREE: do your research first -- for example, infusions are covered by medical, not prescription, prescription will deny it -- call your insurance, BE NICE, and ask for details about coverage, if you don't trust the answer given (we've all had that happen) just call back and start over and and again BE NICE, I will be more willing to answer all your questions and give you random tips if you're nice to me FOUR: talk to a pharmacist about dosing and medication changing, in my unprofessional/non-pharmacist opinion most therapies take about two weeks to even get to therapeutic levels in your system, then it takes another 2-4 weeks to know if it's really working, if not, it usually takes about 2 weeks to get out of your system, check with your pharmacists for details about starting and stopping meds -- your doctor (hopefully) knows diseases, your pharmacist knows medications, go to your office visit fully informed about how the medication is working -- and read the medication inserts you get in the bag with every fill NOTE: be your own advocate, I once had a doctor prescribe avonex instead of the amerge I requested, utterly the wrong medication for something I don't even have -- that was the last time I went to that doctor, mistakes like that are unacceptable and should not be tolerated, what if I had taken that medication? FIVE: start the appointment by saying "I called my insurance" or "I talked to my pharmacist" or "I was researching"-- and provide the doctor with the info you have at the start of the appointment, your doctor should accept the info you have and be willing to discuss it with you as part of the appointment -- my doctor laughs at/with me when I start with "so I was on the internet again, do you know anything about...." SIX: fire you doctor -- you are paying a doctor for a service, if you aren't getting good service fire your doctor and hire a different one -- you have plenty of options out there, don't put up with poor service, if you took your car in for an oil change and when you went to pick it up they said "no, we didn't change the oil but we rotated the tires" you would never go there again, same should apply to a doctor
1. Tonya Henry Member
 
 <inline-mention username="azurelle" user-id="3921241"/> thank you so much for sharing all of this information. You bring up lots of good tips. Being our best and most important advocate, is so true. I do hear some say they do not know how to speak up, but, it is important. We have to start somewhere. If we don't, I believe it is hard to get things done. You seem like you have had lots of experience with this. Besides here, have you ever written it in a post of your own on the site? If not, you could make a post and tell your story: tips of what has helped you and how you got to this point. <a href='https://migraine.com/stories/new' target='_blank'>https://migraine.com/stories/new</a>. If you do not want to, that is fine as well. I thank you for being part of the discussion and the site. (Tonya, team member). 
2. Rebecca C Member
 
 <inline-mention username="azurelle" user-id="3921241"/> Thank you so much for your tips. I believe advocating for oneself is the most important action to take. When a physician does not understand the proper process or fails to provide the correct prescribing treatment with your specific plan, it's time to say goodbye. As this continues, I have been considering this. I hate jumping from physician to physician, though this seems urgent. I am telling him how to treat me, and it seems faulty and negligent. As much as I want to work with a knowledgeable migraine specialist, this is where I draw the line. I appreciate you acknowledging my issue and thanks for your detailed response. Wishing you the best of health, Rebecca (team member)
CommunityMember4bf046 Member

My pain Management doctor, neuro, oncologist, PCM, therapist, and surgeon are all in the know when it comes to my Healthcare. I've had migraines since a car accident with a TBI in 1986. I believe I have gone through the gauntlet of medications. I have my preventative, my abortives, and of course my nausea and pain meds. I have tried Botox (never again). I actually loved the Imitrex injection, but I was allergic to it. I also have breast cancer, fybromyalgia, PTSD, high anxiety disorder, degenerative back disease, and bulging disc's in my neck. I put my body through hell to hell people who couldn't help themselves. 
1. Holly Harding Member
 
 <inline-mention username="CommunityMember4bf046" user-id="6932299"/> My goodness you have been through so much. You are a warrior, my friend! I'm guessing you have earned so much wisdom along the way. I hope you'll share that wisdom and those lessons learned with the rest of us. We are so glad you are a part of our community. Warmly - Holly (team member)