Procedure
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.
You need the exact reason stated. A denial for lack of documentation and a denial for medical necessity are different appeals with different evidence.
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.
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.
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.
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.
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 · read August 2026
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 · read August 2026
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 · read August 2026
External review standards, including the 45-day standard and 72-hour expedited decision windows, are set federally.
45 CFR §147.136 · source · read August 2026
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.
Prices in those notes were read from each company's own site in August 2026 and 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.