help me understand formulary, I have read the wiki twice
Question in the title, detail here: help me understand formulary, I have read the wiki twice.
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.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Not medical advice, obviously, and nothing here is approved for human use. One person with a spreadsheet.
best — the order this archive was captured in
Member and policy numbers redacted from the screenshot above. Everything else left as posted.
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.
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
appeal in writing even when they say a call is enough
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
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.
A denial letter is required to state a reason and to reference the criterion applied. That reference is the handle: request the clinical policy document by its identifier and answer it point by point.
step therapy is a documentation problem, not an argument
keep every date, every reference number, every name of a department
keep every date, every reference number, every name of a department
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
prior authorisation criteria change every plan year
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.
Cosigning on external review. It is a real mechanism, it is underused, and the deadlines are strict.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
Small fix — external review is independent of the plan. The second-level internal appeal is not.
- 1Internal appeals are decided by the plan. External review is decided by an…7 comments in this branch · started by u/plain_titration_2024