how much of what we believe about step therapy actually comes from prior authorization threads
Question in the title, detail here: how much of what we believe about step therapy actually comes from prior authorization threads.
Prior authorisation criteria are republished each plan year. A criterion that blocked you in one year may not exist in the next, so a denial is worth retesting after the turnover.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
If somebody has the same thing measured a different way, post it next to mine and we will see whether they agree.
best — the order this archive was captured in
Why step therapy denials feel unfair and are nonetheless beatable.
The requirement is that documented trials of preferred alternatives exist. It is a record-keeping standard, not a clinical judgement about you, which is why arguing the clinical merits rarely moves it and producing dates and durations often does.
What to assemble: what was tried, at what dose, for how long, and what the documented outcome was. A one-page table with dates beats three pages of prose every time. Where a trial is contraindicated rather than simply unsuccessful, that needs to be stated explicitly by the prescriber in those terms.
None of this is legal or medical advice — it is what the threads here have found works.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Agreed — and request the bulletin by number. They have to give it to you.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.