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708

am I the only one who found formulary harder than the injections

Discussion Slow Clap ×7

external review. That is the whole post, but I will justify it.

Everything else people worry about in c/meta is downstream of it. Titration speed, muscle cramps, the endless dose arguments — most of it resolves if you sort external review out first, and almost nobody does.

I say this having got it wrong for 2 months. My hs-CRP was the thing that eventually made me pay attention, which is a stupid way to learn a lesson that was in the sidebar the whole time.

1,068 up / 360 down75% upvoted47 commentsid bduo3c18 Feb 2025

47 comments

26 in this archive, depth 6

best — the order this archive was captured in

u/appeal_letter_alMOD54 points·1 year 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/rekha_mbeki-18 points·1 year ago

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

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u/prior_auth_painOPappeals31 points·1 year ago

appeal letter templates are in the wiki

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u/line_petrov26 points·1 year ago

External review overturned the denial. Took 9 weeks but the process exists.

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u/ireland_drugs_pay21 points·1 year ago

This is the "correlation is mechanism" thing again. You changed three variables at once.

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u/marta_dziedzic7 points·1 year ago·edited

formulary exclusions are negotiable sometimes

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u/coring_the_stopper6 points·1 year ago·edited

resubmission after denial requires new documentation

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u/emeka_delgado7 points·1 year ago

Not to be pedantic but appeal and formulary are being used interchangeably and they are not interchangeable in real life.

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u/tuva_aalto9 points·1 year ago

Not to be pedantic but appeal and formulary are being used interchangeably and they are not interchangeable in real life.

Yes, exactly this, and it is the bit that took me 45 weeks to accept.

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u/elin_varga25 points·1 year ago

I am going to push back on this slightly.

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u/honest_syringe198 points·1 year ago·edited

I am going to push back on this slightly.

Disagree on that part. 96.8% and 96.2% on the same vial is normal.

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u/prior_auth_painOPappeals5 points·1 year ago

Small correction: the trial was 15 weeks, not 31. Does not change your point but people will quote it.

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u/sofia_ferreira17 points·1 year ago

formulary exclusions are negotiable sometimes

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u/ilias_cabrera4 points·1 year ago

resubmission after denial requires new documentation

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u/whois_wanda20 points·1 year ago

The evidence standard in c/vendorvetting gets called too strict about once a month, and every time, the thread ends with the complainant agreeing.

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u/ignacio_vanhecke16 points·1 year ago

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

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u/amira_dumitru5 points·1 year ago

The evidence standard in c/vendorvetting gets called too strict about once a month, and every time, the thread ends with the complainant agreeing.

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

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u/tidy_vialdrawer_watch2 points·1 year ago

do not suggest misrepresenting a diagnosis, that is fraud

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u/hassan_castellanos13 points·1 year ago

Dead space in the needle hub holds a small but non-trivial volume. On low-volume draws that can be several units.

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u/tuva_aalto11 points·1 year ago

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

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u/elise_grimaldi3 points·1 year ago·edited

Mechanistically the bit that matters is denial.

Counter-anecdote: opposite result, same dose. Which mostly tells us the variance is huge.

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u/prior_auth_painOPappeals2 points·1 year ago

the carve-out clause varies by employer

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u/slow_logbook_notes1 point·1 year ago

appeal letter templates are in the wiki

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u/hplc_hobbyistruns their own column6 points·1 year ago

redact member ids and group numbers from every screenshot

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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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