HealthRX.com · Printable appeal checklist
Mounjaro denial and payment-route record
Note the prescription and the plan, sort the denial by its stated reason, and log every submission with its case number and deadline. Federal appeal clocks for private plans and the 2026 Extra Help limits are printed for reference, with questions for the pharmacist, the plan and any clinic that offers help.
Prescription and plan
Mounjaro strength, quantity and days supplied
Coverage typecommercial, Medicare, Medicaid or none
Plan name and member ID
Prescriber and office contact
What the denial letter says
- Approval missing: has the insurer received a complete request, and what is its case number?
- Earlier medicine required: does the prescriber have the history, or a documented reason it was unsuitable?
- Drug excluded: is an exception or appeal available under this plan?
- Covered but costly: is it the deductible, coinsurance, supply length or pharmacy network?
- Employer exclusion: what is the process for asking for a benefit change?
Submissions and calls
| Date | Sent or called | Case number | Person or department | Answer due |
|---|---|---|---|---|
Federal clocks for private plans (HealthCare.gov)
- A denied prior authorization must be explained in writing within 15 days.[1]
- File the internal appeal within 180 days (6 months) of the denial notice.[1]
- Request external review in writing within 4 months of the final denial.[2]
- A standard external review is decided no later than 45 days after the request.[2]
- External review under the HHS-administered federal process costs nothing.[2]
If you have Medicare: Extra Help in 2026 (Medicare.gov)
- Income limits: $23,940 for an individual, $32,460 for a married couple.[3]
- Resource limits: $18,090 for an individual, $36,100 for a married couple.[3]
- If you do not qualify now, you can reapply whenever your income or resources change.[3]
Questions to ask
- Pharmacist: was the insurance claim or the savings card rejected, and with what message?
- Plan: is a formulary or tier exception available for Mounjaro, and what form starts it?
- Plan: what is the deadline for the internal appeal, and where do I send it?
- Clinic or nonprofit: do you fund this medicine now, and do you serve my location?
- Pharmacy: does a payment outside insurance count toward my deductible?
Sources for the facts on this sheet
- HealthCare.gov, Centers for Medicare & Medicaid Services. Internal appeals | HealthCare.gov. Accessed 2026-10-18. https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/
- HealthCare.gov, Centers for Medicare & Medicaid Services. External Review | HealthCare.gov. Accessed 2026-10-18. https://www.healthcare.gov/appeal-insurance-company-decision/external-review/
- Centers for Medicare & Medicaid Services, Medicare.gov. Help with drug costs | Medicare. Accessed 2026-10-18. https://www.medicare.gov/basics/costs/help/drug-costs
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.