How to Advocate for Yourself When Your Medication Requires a Prior Authorization (or is denied)

When your doctor prescribes a medication, it’s often because they believe it’s the best course of treatment for your condition. But sometimes, the next hurdle isn’t medical - it’s

insurance-related.

One of the most frustrating challenges patients face is prior authorization (PA): when your insurance company requires extra approval before covering a medication. And worse? Sometimes the PA request is denied. If you’ve found yourself in this situation, you’re not alone—and you have options. The most important thing you can do? Advocate for yourself. No one knows your health journey better than you, and that makes you the most powerful voice in fighting for your care.

What Is a Prior Authorization?

A prior authorization is when your insurance company wants confirmation that a specific

medication is medically necessary before they agree to pay for it. Your provider usually submits documentation on your behalf, but that doesn’t always guarantee approval.

If the PA is approved, great! You can proceed to the pharmacy.

If the PA is denied, don’t panic - you can take action.

Take Matters Into Your Own Hands

Yes, your doctor’s office can (and should) help with this process—but you can contact your

insurance company directly and request a peer-to-peer review, a patient appeal, or even a

reconsideration of the denial.

When you call:

● Ask to speak with a pharmacy benefit representative or appeals specialist.

● Get your denial letter or explanation of benefits ready.

● Write down the name and ID number of the rep you speak with.

● Be calm, clear, and ready to share your personal story.

Share Your Medical Journey

This is where your voice matters most. You are the expert on what you’ve been through, and

how this medication could change your life.

When speaking with the insurance rep or submitting a written appeal:

● Explain why this medication is critical for you.

● Share past treatments you've tried, including side effects or lack of effectiveness.

● Mention any diagnostic tests, lab work, or imaging you’ve had that support the

diagnosis or treatment need.

● Offer to submit supporting documents: medical records, lab results, or letters from

your healthcare provider.

Let them know you’re willing to help them understand your full health picture—not just what’s in a claim form.

Be Specific About Benefits

Paint a clear picture of how the denied medication could improve your daily life, such as:

● Reducing flare-ups or hospital visits

● Improving ability to work or care for your family

● Alleviating specific symptoms that impact quality of life

● Reducing long-term costs with preventive care

Insurance companies often look at both clinical benefit and cost-effectiveness—so make it

clear how this treatment does both.

Request a Reversal or Appeal

Ask the insurance representative:

● Can this decision be reversed?

● What is the formal appeals process?

● Can I submit a patient statement?

● Is there a form for supporting documentation?

Often, a well-organized and heartfelt appeal, backed with medical facts, can make a difference.

Final Thoughts: You Are Your Best Advocate

Your doctor can submit the forms, and your pharmacist can guide you—but you bring the most powerful story to the table. If you’ve lived through years of symptoms, failed medications, side effects, or hospitalizations—you deserve to be heard.

Stand up for yourself. Share your story. Push back.

Sometimes, the difference between a denial and a life-changing approval is the voice of the

person who needs it most - yours.