[Discussion] formulary is doing more work than we give it credit for
formulary is doing more work than we give it credit for. Change my mind, genuinely — I have no stake in being right about this. External review, which is the most underused mechanism discussed on this board. Internal appeals are decided by the plan. External review sends the determination to an independent body.…
step therapy is a documentation problem, not an argument
Have you asked for the clinical policy bulletin by number?
A denial letter is required to state a reason and to reference the criterion applied. That reference is the handle: request the clinical policy document by its identifier and answer it point by point.
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Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
What has been documented as tried, and for how long?
the formulary is published, read it before you appeal
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Is this a prior authorisation denial or a formulary exclusion?
Is this a prior authorisation denial or a formulary exclusion?
janoshik_junkie is right that this is documentation rather than persuasion. It took me a year to accept that.
employer plans and individual plans are different fights