unpopular opinion: most of what gets said here about formulary is guesswork
unpopular opinion: most of what gets said here about formulary is guesswork. Not a hot take, just something I have not seen said plainly here. 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…
Appeal deadlines run from the date on the determination letter. They are strict, they are short, and a missed deadline usually forfeits that level entirely.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
Correcting myself upthread: the deadline was 11 days, not the figure I gave.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
a peer-to-peer call is often faster than a written appeal