[Win] approved after i sent them their own policy criteria back
Quick one. Canada here.
appeal works very differently where I live than in the threads that dominate the front page, and I keep seeing people confidently given advice that simply does not apply outside the US.
Specifics: the route I used took 21 weeks and cost roughly what I expected. The admin was worse than the cost. The thing that would have saved me the most time was knowing which document to ask for at the start.
Happy to answer questions from anyone in the same jurisdiction.
best — the order this archive was captured in
Flair changed to match the content. Read the sidebar before posting next time and we are square.
You have restated the marketing copy. What is the actual substance here.
Denied for prior auth, resubmitted with step therapy documentation, approved on appeal. The criteria exist, you just have to meet them.
do not suggest misrepresenting a diagnosis, that is fraud
appeal letter templates are in the wiki
New Zealand plan: step therapy required 5 medications first. Did them all, got approval. The order matters.
Which plan type? formulary is different.
Strongly agree. Step therapy is predictable if you have the criteria.
step therapy documentation is the weapon, use it
Respectfully this is a sample of one presented as a finding.
the carve-out clause varies by employer
Copay was step therapy for the copay then another 7% of the total. Read the actual plan document.
External review overturned the denial. Took 22 weeks but the process exists.
formulary exclusions are negotiable sometimes
resubmission after denial requires new documentation
Not convinced. The evidence does not support that reading.
- 1Flair changed to match the content. Read the sidebar before posting next…12 comments in this branch · started by u/appeal_letter_al
- 2the carve-out clause varies by employer5 comments in this branch · started by u/amylin_amy