[Discussion] the formulary advice in here is 3 years out of date
the formulary advice in here is 3 years out of date.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…
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.