prior authorization — 9 things I got wrong before I got it right
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 9 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
Strongly agree. Step therapy is predictable if you have the criteria.
Not to be pedantic but step therapy and copay are being used interchangeably and they are not interchangeable in real life.
denial reason codes matter, ask for the actual code
Disagree. What you are describing is consistent with formulary, not with what you concluded.
Yeah, the denial code matters, it tells you what to fight.
resubmission after denial requires new documentation
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.
This is correct. Appeal letters work.
prior auth criteria are state-specific, appeal differs
Which state? Coverage varies.
formulary exclusions are negotiable sometimes
Copay was formulary for the copay then another 20% of the total. Read the actual plan document.
denial reason codes matter, ask for the actual code
- 1Which state? Coverage varies.5 comments in this branch · started by u/valeria_grimaldi
- 2this deserves more than 20 upvotes4 comments in this branch · started by u/pavel_nkemelu