Gather the current plan information
Find the formulary, Summary of Benefits and Coverage, pharmacy network and any current medication-specific coverage criteria. An employer plan can exclude a benefit even when the medication appears elsewhere on an insurer’s website. Ask about your exact plan and prescribed indication.
Let the prescriber handle clinical documentation
Keep a list of the documents your care team requests. The clinician must determine which clinical information supports the request. This organizer is a preparation checklist; checking every item does not establish eligibility or predict approval.
If you receive a denial
Locate the written reason, appeal or exceptions process, filing deadline and instructions for your plan. Record actual deadlines in your own calendar. Internal appeal and external review are different processes; availability and procedures depend on the plan and decision.
Keep private documents in your own storage
Use the checklist to mark what you have located without entering diagnoses, member IDs or medical records here. Checkmarks are held only in this tab and reset on reload. Nothing is uploaded or sent to Analytics. Print a copy to take to the next conversation.
Use the evidence alongside the tool
Read the related guide, prepare provider questions, and compare researched services.
See how these questions appear in real offers
Use the plan terms in these reviews alongside your own written quote.
Coverage resources
HealthCare.gov: prescription coverage and exceptions · Appealing a health plan decision. Follow the documents and instructions for your own plan.