Psychiatric Medication, Practically

What to Say When You Call About a Denied Medication

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Calling about a denied medication goes better with a short list ready: the criteria document, a case number, and a specific request for expedited review when urgency applies. This walks through exactly what to say, in what order, and how to log the call so it strengthens a written appeal later.

Last updated: July 2026

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What should you have ready before you dial?

Before you call, gather the denial letter, your insurance ID and group number, the medication name, and the pharmacy's rejection code if you have it. The denial letter should state the specific reason for the denial and the clinical criteria the plan used to reach it 1 -- read that reason back to the representative rather than describing the denial from memory, since a vague description ("it got denied") slows the call down. Have a pen ready to write down the case number, the representative's name or ID, and the date and time the moment they're given, not afterward. If your prescriber is willing to join a three-way call or complete a peer-to-peer review, keep their direct line on hand too, since requests that come from the clinician's office directly can move faster 2.

What exactly do you ask for on the call?

State plainly that you're calling to appeal a denied medication, and ask for four things in order: the exact criteria document the plan used, a case or reference number for this call, confirmation of your internal appeal deadline, and whether expedited review applies. Ask directly, "Can you send me the criteria document you used to deny this, in writing?" Plans are expected to provide the reason for a coverage denial, and getting it in writing creates a paper trail your prescriber can respond to directly 1. If the representative can't answer something, ask who can and get that person's name and callback number before you hang up. Don't accept a vague "it doesn't meet criteria" as a final answer -- ask specifically which criterion wasn't met, since that detail often determines what your prescriber submits next.

Should you ask for an expedited review?

Ask for an expedited review whenever waiting for the standard decision could jeopardize your health, function, or ability to keep working or attending school -- a psychiatric medication interruption often qualifies, especially where a lapse carries real clinical risk. Say the words "I'm requesting an expedited review" directly, rather than describing urgency and hoping the representative offers it, since an expedited request typically must be explicitly invoked to start its own faster clock. Ask what the expedited timeline is for your plan and have that number read back to you. Note who is authorized to approve an expedited request, since front-line representatives sometimes can't grant one and need to route you to a clinical reviewer. If your prescriber's office can submit supporting documentation for urgency directly, get the fax number or portal address before you hang up 3.

Logging the call for your appeal record

Write a brief call log the same day: the date and time, the representative's name and ID, the case number, the stated reason for denial, and any commitment made -- a callback date, a document to be sent, or a timeline given. This matters because a written internal appeal can reference the call directly, and any gap between what you were told and what the plan later claims is easier to catch with a same-day note. If you're unsure who files the prior authorization versus who files the appeal, ask that on the same call, since the answer determines whether your prescriber's office or you personally submits the next document. Keep the log even if the issue resolves quickly -- a resolved call can still matter if the same medication is denied again at the next refill.

If the call doesn't resolve it

A single phone call sometimes fixes a coding error or a documentation gap, but a denial rooted in plan criteria usually still needs a formal written appeal, and how many appeal levels you get depends on your specific plan design. Ask on the call whether external review is available once the internal appeal is decided, since external review after a denied appeal is an independent step outside the plan itself 4. If your prescriber hasn't already requested a peer-to-peer review, ask whether one is available before you file a longer written appeal, since it can resolve a denial in days rather than weeks. None of this has to happen alone -- your prescriber's office has likely done this before, and asking directly what they need from you is a reasonable next call.

Common questions

Ask for one directly, and if they say there isn't one, ask for the call reference number their system generates automatically, since most call-center software logs one even when it isn't offered upfront. If neither is available, note the exact date, time, and phone number you called, plus the representative's name, so the call can still be traced later.

Call whichever side gave you the denial notice, since that's the party whose records you actually need. If the pharmacy said "denied," it's relaying an answer from the insurance company's system, so the insurance company is usually who can explain the clinical reason behind it and take a formal appeal request from you.

Recording laws vary by state, and many require all parties to consent, so ask the representative directly whether the call is already being recorded on their end -- most insurer calls are -- and request a copy of that recording for your records instead of recording the call yourself without asking.

One call rarely finishes an appeal; treat it as the fact-finding step that tells you which document to send next. Ask for a supervisor only if the representative can't answer a specific procedural question, since escalating too early can restart the conversation from scratch instead of building on what you already learned.

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If the medication issue turns into a health emergency

  • —Thoughts of suicide or self-harm while waiting on a medication decision
  • —Withdrawal or destabilization symptoms after an unplanned gap in a psychiatric medication
  • —A crisis that can't wait on a phone call or appeal timeline

Call procedures and hold times vary by insurer; this describes a general approach, not guaranteed language for your specific plan. This is general information, not legal or clinical advice, and if you are in crisis, call or text 988 (Suicide & Crisis Lifeline), free and available 24/7.

References

  1. 1.U.S. Centers for Medicare & Medicaid Services / HealthCare.gov (2025). How to Appeal an Insurance Company Decision. HealthCare.gov. link ✓appeal-denied-claiminternal-appealexternal-reviewcoverage-denial
  2. 2.American Medical Association (2025). Prior authorization research & reports. American Medical Association (AMA). link ✓prior-authorizationtreatment-delayphysician-survey
  3. 3.Centers for Medicare & Medicaid Services (2024). Medicare and Medicaid Programs; Patient Protection and Affordable Care Act; Advancing Interoperability and Improving Prior Authorization Processes (CMS-0057-F). Federal Register. link ✓prior-authorizationstep-therapypayer-policy
  4. 4.U.S. Centers for Medicare & Medicaid Services / HealthCare.gov (2025). External Review of a Health Plan Decision. HealthCare.gov. link ✓external-reviewappeal-denied-claimindependent-reviewparity-enforcement

4 sources, numbered by first appearance. General health information, not medical advice. AI-assisted editorial content — every citation independently verified. Editorial policy

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