The letter you have
Prior authorization rejected. Step therapy required first. A drug left off the formulary. Your doctor prescribed it. The plan said no.
At stake: $200 – $30,000+/mo
Health & Medical
You found the right place.
Your Prior Authorization Was Denied. Here's How to Appeal.
What we do with it
We read the letter. We explain it in plain English. In about 30 seconds you’ll know where you stand — and what to do next.
No account needed · Results in about 30 seconds · Free to start
Prior Authorization Denials Have Tight Appeal Windows — Don't Wait
Pre-service prior authorization appeals must be decided within 30 days standard or 72 hours for urgent care. If you are currently without a medication you need, request an expedited appeal immediately. The faster you file, the faster the insurer is required to respond.
What Does a High Viability Score Mean?
A score above 70 means you have a solid case worth pursuing. A score of 90 or higher — which we see frequently when a step therapy exception applies or when the insurer's clinical criteria conflict with FDA-approved indications — means the denial has a real error a reviewer must address.
90–100Clear clinical or legal error — fighting back is very likely to work
70–89Solid case — strong grounds for formal appeal
50–69Possible — depends on documentation and state law
Three Common Drug Denials — and Why They Are Overturnable
These are the situations we see most often. Every one has clear legal and clinical grounds to challenge.
Prior Authorization Denied
85
Viability
Your insurer denied prior authorization for a medication your doctor prescribed — often within days of the request.
"Your request for prior authorization for [medication] has been denied. The requested drug does not meet our clinical criteria for coverage at this time."
Why it overturns: Prior authorization denials are frequently based on automated clinical criteria that never account for your specific medical history. Your physician prescribed this medication for documented reasons — the appeal forces the insurer to consider those reasons with a physician reviewer. A medical necessity letter from your prescribing physician that directly addresses the clinical criteria cited in the denial is the most effective single piece of evidence in a PA appeal. For specialty medications, the manufacturer's patient assistance program can also provide clinical support documentation.
Step Therapy Requirement
82
Viability
Your insurer says you must first try and fail a cheaper medication before they will cover what your doctor actually prescribed.
"Coverage for this medication requires completion of step therapy. You must first try [alternative drug] for a minimum of 30 days before this request will be considered."
Why it overturns: Most states now have step therapy exception laws. These laws require insurers to grant an exception when you have previously tried the required medication and it failed, when the required drug is contraindicated due to your other medications or conditions, when you are currently stable on the prescribed medication and a switch would risk your health, or when the required drug is clinically inappropriate for your condition. If any of these apply — and your physician documents it — the insurer is required by law to grant the exception.
Non-Formulary Rejection
78
Viability
Your medication is not on your plan's covered drug list — the formulary — and the insurer refuses to cover it.
"The requested medication is not included on your plan's formulary. Please contact your physician to request an alternative covered drug."
Why it overturns: Every health plan is required to have a formulary exception process. If no formulary alternative is therapeutically equivalent for your specific condition, if you have tried formulary alternatives and they were ineffective or caused adverse effects, or if the formulary alternative is clinically contraindicated for you — your physician can file a formulary exception request. A well-documented exception request citing failed alternatives and the clinical necessity of the specific drug is approved regularly, particularly for complex chronic conditions.
Here's How It Works — Three Simple Steps
From denial letter to appeal-ready in about 3 minutes. Act fast — prior auth deadlines are strict.
1
Upload Whatever You Received
Take a photo or upload a PDF — that's really all it takes.
2
We Read It and Explain It
Within seconds — your denial decoded, your rights identified.
3
Your Complete Appeal Letter Is Ready
Formally written, clinically cited, ready to send — for $39.
How to appeal a prior authorization denial — start free
Read the prior authorization appeal guide or upload the notice. In under a minute, you'll know exactly where you stand — and whether your state's step therapy exception law is on your side.
Start My Free Analysis →Free to analyze · $39 complete appeal · No subscription · All escalation levels included
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