reading formulary threads from 2024 and half of it aged badly
reading formulary threads from 2024 and half of it aged badly. Making the case below, and I expect to lose some of it in the comments.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level denial.
Prior authorisation criteria are republished each plan year. A criterion that blocked you in one year may not exist in the next, so a denial is worth retesting after the turnover.
Happy to answer the boring questions. Those are usually the ones worth asking.
best — the order this archive was captured in
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.
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the second-level appeal is where things actually turn
Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.
Cosigning on external review. It is a real mechanism, it is underused, and the deadlines are strict.
External review, which is the most underused mechanism discussed on this board.
Internal appeals are decided by the plan. External review sends the determination to an independent body. Where it applies its decision binds the plan, and the deadlines to request it are short and strictly enforced.
The two things that trip people up: not knowing it exists, and exhausting the internal levels so slowly that the external window closes. Ask on the first denial what the external route is and what the deadline will be. Availability and rules vary by jurisdiction and plan type, so say where you are when you ask here.
The process that has actually worked for people on this board, in order.
Get the denial in writing and find the criterion it names. Request the clinical policy bulletin by its number. Write the appeal against that document, criterion by criterion, attaching what has been tried and for how long. Note the deadline from the letter date and diarise it.
If the first level fails, go to the second. If the second fails, ask about external review, which is independent and, where it applies, binding. Keep every date, department and reference number as you go.
It is administrative rather than rhetorical, and the people who win are the ones who treat it that way.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
employer plans and individual plans are different fights
Left up. It carries dates, a criterion and an outcome, which is what makes these threads useful.
A peer-to-peer conversation puts the prescribing clinician in front of a reviewing clinician. It bypasses the correspondence cycle entirely and is often the fastest available route.
That criterion is from the previous plan year. The current bulletin has different wording.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
Small fix — external review is independent of the plan. The second-level internal appeal is not.
Yes. Written, always, even when they tell you a phone call is sufficient.
What has been documented as tried, and for how long?
- 1The process that has actually worked for people on this board, in order. Get…11 comments in this branch · started by u/ferritin_low