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c/insurancefights·posted 11 months ago by u/wholesome_lurker

copay — 3 things I got wrong before I got it right

Discussion The Quiet One ×2

I have had 8 orders now and I keep a table, so here is the honest summary rather than a vibe.

Material has been consistent. Communication has not. Shipping has varied by about 24 days on nominally the same lane, which matters more in summer than in February.

The independent number came back 98.4% against a claimed 97.2%, which I read as agreement rather than a discrepancy — inter-lab variance on this assay is a point or two either way and treating one lab as ground truth is how people end up in pointless arguments with vendors.

Batch number is in the comments. Ask if you want the method.

790 up / 189 down81% upvoted31 commentsid 1dykw03 Sep 2025

31 comments

23 in this archive, depth 4

best — the order this archive was captured in

u/liv_vukovic70 points·10 months ago

Strongly agree. Step therapy is predictable if you have the criteria.

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u/plain_titration17 points·10 months ago

Strongly agree.

Disagree on that part. 95.1% and 98.7% on the same vial is normal.

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u/hugo_pires5 points·10 months ago

appeal letter templates are in the wiki

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u/teodor_duarte6 points·10 months ago

Strongly agree.

Adding to this: formulary is doing more work than the comment implies.

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u/hassan_chowdhury36 points·10 months ago

prior auth criteria are state-specific, step therapy differs

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u/neha_rahimi-35 points·10 months ago

redact member ids and group numbers from every screenshot

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u/formulary_fighterMOD53 points·10 months ago

This is an urgent-care question wearing a forum question's clothes. Please contact a clinician rather than waiting for replies.

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u/wholesome_lurkerOP31 points·10 months ago

The confident tone is doing a lot of work that the evidence is not.

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[removed]40 points·10 months ago

[removed by moderator]

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u/valeria_grimaldi49 points·10 months ago

Yeah, the denial code matters, it tells you what to fight.

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u/step_therapy_s33 points·10 months ago

Copay was prior authorization for the copay then another 8% of the total. Read the actual plan document.

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u/arne_amankwah19 points·10 months ago

This is correct. Appeal letters work.

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u/wholesome_lurkerOP14 points·10 months ago

Edit to your parent would help — the concentration you quoted assumes one scenario and you have written another above it.

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u/milos_vestergaard10 points·10 months ago

Not convinced. The evidence does not support that reading.

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u/prior_auth_painappeals10 points·10 months ago

do not suggest misrepresenting a diagnosis, that is fraud

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u/cardio_endpoint_c3 points·10 months ago·edited

do not suggest misrepresenting a diagnosis, that is fraud

Yes, exactly this, and it is the bit that took me 24 weeks to accept.

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u/elin_lindqvist13 points·10 months ago·edited

Yeah, the denial code matters, it tells you what to fight.

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u/marisol_moreau11 points·10 months ago

What was the denial code?

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u/jarno_adeyemi5 points·10 months ago

resubmission after denial requires new documentation

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u/line_petrov9 points·10 months ago

Mechanistically the bit that matters is formulary. It explains most of the early profile and a decent chunk of the outcome.

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u/hugo_pires5 points·10 months ago

The practical rule people converge on is 28 days at fridge temperature after first puncture, and that comes from the preservative, not the peptide.

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u/hedda_aguirre3 points·10 months ago

Yeah, the denial code matters, it tells you what to fight.

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u/vikram_mbeki2 points·10 months ago

appeal letter templates are in the wiki

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About c/insurancefights

The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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