Health plan denied medication · SPD Advocacia
Did the plan deny the medication? Oral chemotherapy and biologics may be required
Oral cancer drugs, biologics, medication during hospitalization and off-label drugs. See when the health plan must cover them.
Straight answer
Is the health plan required to provide medication?
The plan must cover medications used during hospitalization and in covered outpatient treatments, such as chemotherapy. The law also requires coverage of oral anticancer drugs taken at home for cancer treatment. Biologics and other drugs may be claimed according to the ANS list and the criteria of Law 14,454/2022. Denials because the use is off-label or the drug is not on the list can be challenged, based on the medical prescription.
What the law says
Patient rights
Medicines used during hospitalization are covered.
Chemotherapy, including oral cancer drugs for home use.
Covered according to the ANS list and guidelines, with a review of the case.
They can be required under the criteria of Law 14,454/2022.
Source: Law 9,656/1998, arts. 10, § 13, and 12, with Laws 14,307/2022 and 14,454/2022.
What is your case?
Situations the firm handles
Take-home cancer drug
Mandatory coverage for cancer treatment.
Law 9,656/1998, art. 12Autoimmune diseases
Medicines for arthritis, psoriasis, Crohn's and others.
ANS listOff-label use
A well-grounded prescription can justify coverage.
Case reviewMedicine denied at the hospital
Mandatory coverage during hospitalization.
Law 9,656/1998Through the SUS
See the page on high-cost medication.
STF, Theme 6I bought the medication
Request for reimbursement of what was paid.
Case reviewStep by step
How the firm works
- Quick review. We check the medical indication, the denial and the contract or the SUS rule.
- Documents. We guide the medical report and organize the denial, tests and protocol numbers.
- Request. Complaint, notice or lawsuit with a request for an injunction, depending on the urgency.
- Follow-up. Enforcement of the decision, renewal of prescriptions and new denials.
Case review
Let's review your case
Answer the questions, one at a time. At the end you can attach documents, which go straight to a folder in the firm's Drive, and send the summary via WhatsApp. Everything is protected by attorney-client confidentiality.
Common questions
Frequently asked questions
Does the plan cover pharmacy medication?
As a rule, no, except for the cases provided for, such as oral cancer drugs and others on the list.
What if the medicine is expensive and urgent?
The request can be made with an injunction.
Can I get reimbursed for what I bought?
Yes, if the coverage is owed. Keep the receipts.
Is a report needed?
Yes. A report with the diagnosis, treatment and justification for the drug.
Do you serve clients outside Anápolis?
Yes. Service is provided at the firm's office in Anápolis, or online for all of Goiás and other states.
How much does it cost?
After the analysis, the firm sends a written fee proposal before any engagement.