the prior authorization question that gets asked weekly, answered properly
Quick one. Canada here.
prior authorization 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 15 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
Tracking number removed. It identifies both ends of a shipment.
denial reason codes matter, ask for the actual code
Disagree but this is the good kind of wrong — it is specific enough to be checked.
formulary exclusions are negotiable sometimes
Disagree but this is the good kind of wrong — it is specific enough to be checked.
Counter-anecdote: opposite result, same dose. Which mostly tells us the variance is huge.
redact member ids and group numbers from every screenshot
Water content matters more than people think. If a vial is carrying residual moisture, your "10mg" is not 10mg of peptide.
Denied for prior auth, resubmitted with external review documentation, approved on appeal. The criteria exist, you just have to meet them.
Which plan type? denial is different.
Which plan type?
Adding to this: denial is doing more work than the comment implies.
external review is the appeal after insurance says no
Which state? Coverage varies.
external review is the appeal after insurance says no
What was the denial code?
resubmission after denial requires new documentation
resubmission after denial requires new documentation
Disagree on that part. 96.8% and 96.2% on the same vial is normal.
This is the "correlation is mechanism" thing again. You changed three variables at once.
Poland plan: step therapy required 20 medications first. Did them all, got approval. The order matters.
step therapy documentation is the weapon, use it
Copay was formulary for the copay then another 2% of the total. Read the actual plan document.
Sceptical. If this were true we would see it reflected in the data and we do not.
external review is the appeal after insurance says no
- 1What was the denial code?11 comments in this branch · started by u/gustav_vermeulen
- 2Disagree but this is the good kind of wrong — it is specific enough to be…8 comments in this branch · started by u/camila_vasquez