This is a continuation of a long topic, addressed by post number rather than by page. Start at post 1.
I have three months of notes on Prior authorisation and the honest summary is that the trend is real and the week-to-week numbers are noise. I nearly drew the opposite conclusion from the first fortnight.
That reframing is the whole thing. The facts I already had.
Answering the question post #31 raises rather than the one it answers.
Formulary changes happen on a published schedule, so a denial now may be answering criteria that change shortly.
It took me longer than it should have to see that.
The arithmetic in post #35 is right; the assumption feeding it is the part to check.
Where an exception process exists separately from an appeal, they are different routes with different criteria and using the wrong one loses time.
Filing this under things that are true until someone shows me otherwise.
Reframing Prior authorisation slightly, because I think the disagreement is about the question rather than the answer. If the question is "does it happen", yes. If it is "how often", nobody here knows.
Post #35 describes the usual case. This is about the unusual one.
A clinician's supporting letter that addresses the criteria explicitly is worth considerably more than one that describes the patient generally.
Caveat: everything above assumes the paperwork is what it says it is.
That is a fair summary of where the discussion has got to.
Nothing here is legal or medical advice, and appeal processes differ enough by jurisdiction and payer that specifics do not transfer.
Date every account in this subcategory. Payer criteria change frequently and the archive keeps posts permanently.
If that is already documented somewhere, ignore me and link it.
Adding the measurement that post #41 says would settle it.
The single most useful preparation is obtaining the actual criteria document rather than working from what somebody was told on the phone.
The strength of my opinion here exceeds the strength of my evidence.
The arithmetic on Prior authorisation is the easy part and it is where the errors are, which is an uncomfortable combination. Show your working and someone will catch it.
Clear enough that I do not think I have a follow-up, which is unusual.
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.
Post #48 is right about the mechanism and I think understates the practical bit.
Since Prior authorisation keeps coming up, it should probably be a maintained page rather than a recurring thread. I am happy to draft it if someone with more direct experience will review it.
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.
On post #49 — agreed on the reasoning, with one qualification.
On Prior authorisation: the maintained page in the documentation commons covers the general case with citations and a review date, which is more reliable than any reply here including this one.
Picking up post #53: that is the part I would want checked first.
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.
That is where I would start, not where I would stop.
The confident answers on Prior authorisation and the well-sourced answers are not the same answers, which is the most useful thing I have learned reading this category.
Adding the boring version of Prior authorisation, because the interesting version keeps getting posted and the boring one is usually right.
Check the ordinary explanations, in order, and stop when one of them accounts for what you are seeing. Most of the time the second one does.
Same experience here, different supplier, so it is at least not unique to one of them.
Formulary changes happen on a published schedule, so a denial now may be answering criteria that change shortly.
I read post #58 twice before replying, because I had assumed the opposite.
I keep a log for Prior authorisation specifically because my memory of it turned out to be systematically wrong in one direction. Six weeks of notes cost nothing and settled it.