Specialty drug classes
Drug-class-specific appeal guides. Each shows what the class does, the major drugs, common denial patterns, and the clinical guidelines that win appeals.
Antifibrotic agents
Pirfenidone (Esbriet), nintedanib (Ofev) for idiopathic pulmonary fibrosis (IPF) and progressive pulmonary fibrosis (PPF). High-cost specialty drugs with frequent step-therapy and lab-monitoring requirements.
Biologic drugs (mAbs and biosimilars)
Monoclonal antibodies and other biologics targeting specific immune or growth pathways. Used in rheumatology, dermatology, gastroenterology, oncology, ophthalmology, and beyond. Specialty-tier with frequent prior-auth + step-therapy requirements.
Biosimilars
FDA-approved highly-similar versions of reference biologics. Plans frequently require biosimilar use first — patient may appeal when continuing on reference biologic is medically necessary.
Direct oral anticoagulants (DOACs)
Apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), edoxaban (Savaysa). Replaced warfarin as first-line for AF and VTE — but plans commonly require warfarin trial first.
GLP-1 receptor agonists
Semaglutide (Ozempic, Wegovy, Rybelsus), tirzepatide (Mounjaro, Zepbound), liraglutide (Victoza, Saxenda). The most-denied drug class in US insurance — and one of the most commonly reversed on appeal.
Immune checkpoint inhibitors
Pembrolizumab (Keytruda), nivolumab (Opdivo), atezolizumab (Tecentriq) and others. PD-1/PD-L1/CTLA-4 inhibitors transformed oncology — and frequently face appeals for off-label use, combination therapy, and adjuvant settings.
Medications for Opioid Use Disorder (MOUD)
Buprenorphine (Suboxone, Sublocade), methadone, naltrexone (Vivitrol). Federally protected access — but commonly denied for residential SUD, long-acting injectables, and dual-diagnosis treatment.
Non-GLP-1 diabetes medications
SGLT2 inhibitors, DPP-4 inhibitors, insulins, sulfonylureas, metformin, dual-action agents. Denials commonly involve step therapy and brand-vs-generic.
Opioids and controlled-substance pain medications
Long-acting opioids, IR opioids, ER formulations. Federal CDC guidelines and state laws have tightened access — denials commonly involve daily MME limits and forced tapers.
Psychiatric medications
Antidepressants, antipsychotics, mood stabilizers, anti-anxiety agents. Denials commonly violate MHPAEA — stricter prior auth, step therapy, or quantity limits than for comparable medical drugs.
Specialty pharmacy drugs
High-cost, complex-to-administer, or special-handling drugs requiring specialty pharmacy distribution. Includes biologics, oncology orals, hep C antivirals, hemophilia clotting factors, and PrEP.
Stimulants for ADHD
Methylphenidate, amphetamine-derivative, and non-stimulant ADHD treatments. Frequent appeals for combination therapy, formulation switches during shortage, and pediatric dosing.
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