We understand that navigating prescription coverage can sometimes feel overwhelming, especially when a medication you or a loved one needs has been denied. Please know that a denial is not necessarily the final answer. You and your doctor have the right to ask for a review, and we are here to help guide you through every step of the appeals process.
What Happens if My Prior Authorization is Denied?
If a prior authorization request is not approved, it simply means we need more information or that there may be a safer, lower-cost alternative available under your plan. If you receive a denial, you have several supportive paths forward:
- Explore Alternatives: Your provider can prescribe an alternative medication that is fully covered by your pharmacy benefit plan.
- Peer-to-Peer Review: Before filing a formal appeal, your provider can request a conversation with a SmithRx Clinical Review Pharmacist to share additional medical reasoning that might overturn the decision.
- File a Formal Appeal: You or your doctor can formally request that we re-evaluate the decision.
How You Will Be Notified: We will send a detailed explanation of the denial to your provider via fax. We will also reach out to you via email, text, and postal mail with the specific reason for the decision and clear instructions on how to file your appeal.
How to File an Appeal
If you and your doctor decide to move forward with an appeal, your provider can submit the request on your behalf. They can initiate this by:
- Phone: Calling our Member Support line at (844) 454-5201.
- Online: Submitting an e-appeal via CoverMyMeds.
- Fax: Sending the completed appeal form to (866) 642-5620.
What is a Letter of Medical Necessity (LMN)?
During the appeal process, your doctor may submit a Letter of Medical Necessity. This is a document that explains to our clinical team exactly why a specific, non-covered medication is essential for your health condition and why other alternatives may not work for you.
Expected Timelines
We know that waiting for health answers is hard, so our clinical teams work as efficiently as possible to review your case.
The timeline for a decision depends on the urgency of your medical needs:
| Request Type | Formal Appeal Turnaround Time | Letter of Medical Necessity (LMN) Turnaround Time |
| Urgent Requests | Up to 72 hours | Up to 72 hours |
| Standard (Non-Urgent) | Up to 30 calendar days | Up to 15 calendar days |
Note: These timelines begin once we receive all necessary documentation from your provider. If our team needs to reach out to your doctor for additional information, the process may take a bit longer. Your provider has 180 days from the original denial date to submit an appeal.
How to Track Your Appeal Status
We want to keep you informed every step of the way. You will automatically receive updates via text or email when your case is created, if we need more details from your doctor, and the moment a final decision is reached.
You can also check your status at any time by:
- The Member Portal: Log in at smithrx.com/portal and check your notifications dashboard. (Please ensure your phone number and email are updated in your profile).
- Live Chat: Visit www.smithrx.com.
- Email: Reach out to us at help@smithrx.com.
- Phone: Call Member Support at (844) 454-5201.
We are committed to helping you access the care you need. Please don't hesitate to reach out if you have any questions about these steps.