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c/insurancefights·submitted 1 year ago by u/prior_auth_pain

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

Discussionbranch of 9 comments

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.…

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9 comments, started 1 year ago
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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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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