This is a continuation of a long topic, addressed by post number rather than by page. Start at post 1 · go to the accepted answer.
Reimbursement changes: a compound covered one year might not be the next. A formulary decision in January can change by April. Checking again before refilling saves frustration.
Nothing here is legal or medical advice, and appeal processes differ enough by jurisdiction and payer that specifics do not transfer.
I have kept the units in throughout, for the obvious reason.
Everything in post #60 holds. The case it does not cover is the one I have.
Formulary changes happen on a published schedule, so a denial now may be answering criteria that change shortly.
Where an exception process exists separately from an appeal, they are different routes with different criteria and using the wrong one loses time.
An update on my earlier Prior authorisation post: the pattern held for another six weeks and then stopped, which I did not predict and cannot explain.
This settles it for me, at least until somebody posts a reason it should not.
Where I part company with post #68, and it is a narrow parting.
A clinician's supporting letter that addresses the criteria explicitly is worth considerably more than one that describes the patient generally.
This has been discussed before and I could not find the thread, so, again.
Date every account in this subcategory. Payer criteria change frequently and the archive keeps posts permanently.
On post #68 — agreed on the reasoning, with one qualification.
Whatever the answer on Prior authorisation turns out to be, the method for getting there is the same: state the assumption, do the arithmetic in public, invite the correction.
Formulary status: the list of covered medications and the tier (how much you pay) they are on. Checking the current formulary before going to a clinic appointment saves surprise at the pharmacy.
Written in the hope of being told what I have missed.
Post #74 is right about the mechanism and I think understates the practical bit.
Practical experience of Prior authorisation, offered as one case with the conditions stated, not as a general finding. Conditions first, because they are what make it interpretable.
I would be cautious about generalising from the Prior authorisation example above. It is a good example. It is one example.
Taking post #78 at face value and following it one step further.
Prior authorisation: pre-approval requirements and how to satisfy them. Most denials cite specific criteria. Understanding the criterion is the first step in satisfying it.
The short answer was in the first line; everything after is the working.
The single most useful preparation is obtaining the actual criteria document rather than working from what somebody was told on the phone.
I have seen it go both ways, which is why I hedge.
Keep every document with dates in one place. An appeal months later is assembled from whatever you kept.
A guess, clearly labelled as one.
Tier placement and step therapy: some formularies place a medication on a higher tier or require you to fail cheaper alternatives before approving the one you want. Understanding the requirements before treatment starts matters.
Where I part company with post #81, and it is a narrow parting.
I would put moderate confidence on the mainstream reading of Prior authorisation and no more. That is not scepticism for its own sake; it is where the sourcing actually stops.
Post #81 is the version of this I will quote in future. One addition.
The question underneath Prior authorisation is usually "how would I tell?" rather than "what is true?", and that one has a method attached to it.
Write down what you would expect to see under each hypothesis before you collect anything. If they predict the same observation, collecting it will not help.
A clinician's supporting letter that addresses the criteria explicitly is worth considerably more than one that describes the patient generally.
Two sources, same conclusion, and I could not rule out that one copied the other.
Adding a note of thanks rather than an opinion. I did not know most of that.
My experience of Prior authorisation contradicts the reply above. I am posting it as a data point rather than as a refutation, because one person's experience is exactly that.
Confirming post #85 from a second method, which matters more than confirming it from a second person.
Nobody has said the unglamorous part of Prior authorisation yet, so: most of the variation is explained by things that are boring to write about and easy to check.
Everything in post #85 holds. The case it does not cover is the one I have.
Prior authorisation criteria are usually published by the payer, and reading them before the appointment changes the outcome more than anything else does.
I would call that likely rather than established.
Narrowing post #89, because the general version has more than one answer.
Prior authorisation is one of those subjects where the general answer and the answer for a specific case diverge, and the thread will go in circles until someone says which one is being asked for.