Procedure
Your plan said no. What now?
A denial is not the end of it. Commercial and employer plans have two levels you can use: an internal appeal to the plan, and an external review by an independent body the plan does not control.
The deadlines are the part people lose on. Start with the date on your denial letter.
The steps, in order
Get the denial in writing, with the reason
You need the exact reason stated. A denial for lack of documentation and a denial for medical necessity are different appeals with different evidence.
File the internal appeal within 180 days
You have 180 days from receiving the denial notice to file. That is the outer limit; file sooner because the plan's clock to respond starts when you file.
Know how long the plan has to answer
For care you have not received yet, 30 days. For care already received, 60 days. For urgent cases, 72 hours. If your plan requires two internal levels, those first two deadlines are halved.
If the internal appeal fails, request external review within four months
An independent review organization decides, and its decision binds the plan. Standard review takes up to 45 days; expedited review takes 72 hours. Where a fee is charged at all it is capped at $25, and many plans and the federally administered process charge nothing.
Ask for expedited review if waiting would harm you
Both the internal appeal and the external review have urgent tracks. Your prescriber saying delay would seriously jeopardize your health is what triggers them.
What to say on the phone
I am appealing the denial dated [date] for [drug name]. Please tell me the exact reason for the denial, confirm the deadline for my internal appeal, and send me the plan's prior authorization criteria for this drug. Is my plan subject to one or two levels of internal appeal?
Write down who you spoke to and when. If they say a document does not exist, ask them to say that in writing.
What each deadline rests on
Every number above comes from one of these. If a deadline here decides something for you, read the source, not our summary of it.
You have 180 days from receiving a denial to file an internal appeal with a commercial plan.
HealthCare.gov · source
You have four months from the final internal denial to request an external review, and the independent reviewer's decision binds your plan.
HealthCare.gov · source
Plan decision deadlines are 30 days for care not yet received, 60 days for care already received, and 72 hours for urgent cases. Where a plan requires two mandatory internal levels, the first two are halved.
29 CFR §2560.503-1 · source
External review standards, including the 45-day standard and 72-hour expedited decision windows, are set federally.
45 CFR §147.136 · source
Where this comes from
- HealthCare.gov — www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
- HealthCare.gov — www.healthcare.gov/appeal-insurance-company-decision/external-review/
- 29 CFR §2560.503-1 — www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-L/part-2
- 45 CFR §147.136 — www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-1
If the appeal fails, or you cannot wait
Cash-pay telehealth is the fallback, not the bargain: you pay the whole cost yourself, and a covered prescription is almost always cheaper than any of these. Use this route when coverage has actually been exhausted, or when you need to start while an appeal runs.
These companies pay us a commission if you start care through the links below. That is how this site is funded, and it does not change what is written above. How we pay for this.
| Company | What we found on its own site |
|---|---|
| PartnerMEDGmCheck availability | GLP-1 injections from $179 and tablets from $249. Brand options are a membership plus the drug's own cost: $99 for Zepbound or Wegovy, $171 for Ozempic. It discloses AI content and actor imagery. |
| PartnerBodybuilding Health+Check availability | Compounded tirzepatide at $174.67 to $209 a month, lower the more months you buy at once; semaglutide is tiered the same way. Operated by Dynamo Group LLC. |
| PartnerStrut HealthCheck availability | A telehealth storefront where weight loss is one of six categories. No GLP-1 price is published on the page our link opens. |
| PartnerRxSpan MDCheck availability | Multi-category telehealth that promises transparent pricing, then publishes no GLP-1 price on the page our link opens. |
| PartnerSnagRxCheck availability | Compounded semaglutide at $69 a month and tirzepatide at $119, the same at every dose, with no membership. Both are countdown sale prices, marked down from $299 and $399. Not available in Louisiana. |
| PartnerSkinnyRxCheck availability | Compounded semaglutide and tirzepatide injections at $99 for the first month, tablets at $149 and $199. No second-month price is printed for any of them. |
| PartneryourEraCheck availability | Compounded semaglutide at $79.20 a month and tirzepatide at $159.20. Both are six-month-plan prices, and the plan carries a six-month commitment. |
| PartnerbmiMDCheck availability | Compounded semaglutide from $119 a month and tirzepatide from $179. Both are limited-time sale prices, marked down from $228.60 and $349.20. |
| PartnerCollectiveCheck availability | Compounded semaglutide at $59 a month and tirzepatide at $69 at every dose, plus a required $199 yearly membership. It's free for 21 days, then billed for the full year at once, and it isn't refundable. |
| PartnerSprout HealthCheck availability | Compounded semaglutide from $149 a month and tirzepatide from $199, on plans that renew automatically. Also lists brand Wegovy and Zepbound. |
| PartnerWillowCheck availability | Compounded semaglutide at $299 a month (weekly injection or daily tablet) and tirzepatide injections at $399. HSA and FSA accepted; a full refund applies only if you cancel before the prescription reaches the pharmacy. |
| PartnerHumeCare+Check availability | A self-pay membership with no price shown before checkout, renewing automatically. The home page promises your money back if you don't lose 10 percent in six months; the terms limit that to 90 days, first-time users and no measurable loss. |
| PartnerEnhance MDCheck availability | Offers compounded semaglutide and tirzepatide with provider consultations and follow-up. Compounded drugs are not FDA-approved; ask which pharmacy will dispense your prescription and what continuing care includes. |
| PartnerCoreAge RxCheck availability | Compounded semaglutide advertised at $99 a month at every dose. The page our link opens has shown $149 instead, and a consultation fee can be added that may not be refundable. |
| PartnerOakCheck availability | One flat price at every dose, with shipping and supplies included free. |
| PartnerGala HealthCheck availability | One price at every dose. The advertised rate needs a yearly subscription. |
| PartnerDirect MedsCheck availability | One price at every dose from $147, with no monthly membership. The page states its discount two ways ($150 off in the banner, up to $200 off on the tiles), so check the total at checkout. |
| PartnerFoundCheck availability | Bills clinician visits to your insurance where it's in network, with the drug charged separately. Its Medicare offer, brand GLP-1s from $50 a month, doesn't count toward your Part D deductible or out-of-pocket maximum, and Extra Help doesn't apply. |
| PartnerEdenCheck availability | Semaglutide at $99 a month at every dose, with no membership on the page our link opens. Eden's own site pairs the same $99 with a required membership ($39 the first month, then $99), so check which one you're signing up for. |
| PartnerShedRxCheck availability | Injections plus needle-free drops and lozenges. You see a price only after the questionnaire, and the oral forms aren't sold in sixteen states. |
| PartnerHealthRXCheck availability | Compounded semaglutide at $133 a month on a three-month plan ($99 on twelve), tirzepatide from $209 ($179 on twelve). Its member reviews are labeled illustrative composites, not real patients. |
Prices in those notes were read from each company's own site in September 2026, October 2026 and August 2026, and they change often. Check the current number before you buy.
Other procedures are listed on the procedures page, and the coverage matrix shows where your state stands.