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c/insurancefights·submitted 5 months ago by u/idris_iyer

[PSA] formulary is not what most of this community thinks it is

Winbranch of 8 comments

Something I noticed reading old threads that I have not seen said out loud. The advice on copay in this community changed substantially around the start of last year, and nobody went back and updated the older posts. So depending on which thread the search engine hands you, you get two contradictory answers with the…

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8 comments, started 5 months ago
u/muscle_cramp_mo11 points·5 months ago

redact member ids and group numbers from every screenshot

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u/arne_amankwah5 points·5 months ago

Sceptical. If this were true we would see it reflected in the data and we do not.

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u/muscle_cramp_mo3 points·5 months ago

formulary exclusions are negotiable sometimes

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u/whois_wanda2 points·5 months ago

This is correct. Appeal letters work.

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u/kian_balogun5 points·5 months ago

That is net peptide content, not purity. Different number, different meaning.

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u/ahmed_abubakar6 points·5 months ago

step therapy documentation is the weapon, use it

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u/idris_iyer7 points·5 months ago

the carve-out clause varies by employer

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u/ines_krastev5 points·5 months ago

say which country and which plan type

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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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