Denied? Stay Persistent!!

PBM denial responses change frequently — often daily — with new or vague reasons being introduced. It’s not unusual to receive more denials than approvals, and it can feel discouraging. But don’t give up. Stay at it!

A denial is not the end of the road.

What to Do If Your Appeal Is Denied

• Read the denial reason carefully.

• If the reason involves the claim being paid at a benchmark (such as AWP, NADAC, FUL, etc.):

  • Verify the cost of the medication.

  • If the reimbursement is below your actual acquisition cost (ACQ), you have grounds to file an EXTERNAL appeal.

PBMs often rely on denials to deter follow-up your persistence matters.