Denied a medication? Start with the category it belongs to.

Plain guides to the drug categories plans deny most often: why the denial happened, what the letter means, and what an appeal has to show. General information, not medical or legal advice.

Usually denied as medical necessity

How medical necessity denials work →

Compounded medications denied: what plans cover and what they do notCompounded drugs sit outside the usual formulary rules, and most denials are about the compound itself rather than your clinical case. Here is what the criteria ask for and when an appeal has something to work with.compounded semaglutidecompounded tirzepatidecompounded topical pain creamsRead the guide →Dupixent and skin biologics denied: eczema, psoriasis and asthmaDenials of Dupixent, Skyrizi and the other dermatology and respiratory biologics usually rest on how severity was documented. Here is what the criteria ask for and how an appeal answers them.DupixentSkyriziTremfyaRead the guide →Off-label prescriptions denied: when a plan says the use is not approvedOff-label prescribing is legal and common, and coverage policies usually point to specific compendia and guidelines. Here is how an appeal identifies the support a plan's own policy recognises.off-label oncology regimensoff-label psychiatric prescribingoff-label pediatric dosingRead the guide →Oral cancer drugs denied: targeted therapies and oral chemotherapyOral oncology denials often turn on biomarker documentation, line of therapy, or a use the plan reads as off-label. Here is what an appeal has to show, and how urgency is put on the record.IbranceVerzenioImbruvicaRead the guide →

Usually denied as prior authorization

How prior authorization denials work →

ADHD stimulants denied: Adderall, Vyvanse and ConcertaStimulant denials mix prior authorization criteria, age rules and quantity limits, and sometimes a shortage is mistaken for a denial. Here is how to tell them apart and what an appeal has to show.Adderall XRVyvanseConcertaRead the guide →GLP-1 medications denied: Ozempic, Wegovy, Mounjaro and ZepboundGLP-1 denials usually turn on prior authorization criteria or on whether your plan covers weight-management drugs at all. Here is how to tell which one you are facing, and what an appeal has to show.OzempicWegovyMounjaroRead the guide →Hepatitis C antivirals denied: Mavyret, Epclusa and HarvoniHepatitis C treatment is usually gated behind prior authorization, and denials often rest on restrictions that many payers have since removed. Here is what the criteria ask for and how an appeal answers them.MavyretEpclusaHarvoniRead the guide →

Usually denied as step therapy

How step therapy denials work →

Biologics denied: Humira, Enbrel and the TNF inhibitorsTNF inhibitor denials usually come from a step therapy rule that asks you to fail a cheaper drug first. Here is what the rule requires, what an exception has to show, and what to gather before you appeal.HumiraEnbrelRemicadeRead the guide →CGRP migraine injections denied: Aimovig, Emgality and AjovyPreventive migraine injectables are usually denied because a plan wants older preventives tried first, or because the headache diary the criteria ask for was never submitted. Here is how that appeal works.AimovigEmgalityAjovyRead the guide →JAK inhibitors denied: Rinvoq, Xeljanz and OlumiantJAK inhibitors usually sit behind a step requirement that asks for a biologic first, plus safety documentation. Here is what the criteria ask for and how an override request answers them.RinvoqXeljanzOlumiantRead the guide →Sleep medications denied: Belsomra, Quviviq and DayvigoInsomnia drugs are commonly gated behind older generics, sleep-study documentation or quantity limits. Here is what the criteria ask for and how an appeal answers them.BelsomraQuviviqDayvigoRead the guide →

Usually denied as formulary exception

How formulary exception denials work →

Insulin and CGM denied: analogs, pumps and continuous glucose monitorsInsulin denials are usually about which brand your plan prefers; CGM denials are usually about which benefit pays and what the criteria ask you to document. Here is how each is appealed.LantusBasaglarSemgleeRead the guide →Migraine gepants denied: Nurtec, Ubrelvy and QuliptaOral gepants are frequently off-formulary or capped at a low monthly quantity. Here is what a formulary or tiering exception has to show, and what to gather before you file it.Nurtec ODTUbrelvyQuliptaRead the guide →PrEP and HIV medications denied: Descovy, Biktarvy and ApretudePrEP is subject to preventive-services rules that most other drugs are not, and HIV treatment denials usually come from formulary preference. Here is how each denial is read and answered.TruvadaDescovyApretudeRead the guide →Weight management medications denied: Contrave, Qsymia and phentermineNon-GLP-1 weight management drugs are often excluded from the pharmacy benefit entirely rather than denied on clinical grounds. Here is how to tell an exclusion from a criteria denial, and what each one needs.ContraveQsymiaphentermineRead the guide →

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Cove Health provides advocacy services. Information on this site is general information, not legal or medical advice. Cove Health is not a law firm and does not provide legal representation, and submission of records does not guarantee a particular outcome.