[Discussion] the formulary advice in here is 3 years out of date
the formulary advice in here is 3 years out of date. Making the case below, and I expect to lose some of it in the comments.
Figures up front so nobody has to dig: 3 years.
Step therapy requires documented trial of preferred alternatives. It is not an argument to be won on merits; it is a record to be produced, and the record is what the appeal must contain.
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.
Happy to answer the boring questions. Those are usually the ones worth asking.
best — the order this archive was captured in
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Internal appeals are decided by the plan. External review is decided by an independent body and, where it applies, its determination is binding. They are separate mechanisms and the second is chronically underused.
Left up. It carries dates, a criterion and an outcome, which is what makes these threads useful.
What is the appeal deadline on the letter?
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
prior authorisation criteria change every plan year
the second-level appeal is where things actually turn
the second-level appeal is where things actually turn
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
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Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
I would not skip the peer-to-peer.
Agreed — and request the bulletin by number. They have to give it to you.
a peer-to-peer call is often faster than a written appeal
What exactly does the denial letter give as the reason?
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Has a peer-to-peer been offered or requested?
- 1Internal appeals are decided by the plan. External review is decided by an…7 comments in this branch · started by u/bence_zielinski