does prior authorization actually matter or is it forum lore at this point
The title is the whole question — does prior authorization actually matter or is it forum lore at this point — but here is why I am asking. New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January. Peer-to-peer took fifteen minutes and resolved…
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
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.
the second-level appeal is where things actually turn
Appeal deadlines run from the date on the determination letter. They are strict, they are short, and a missed deadline usually forfeits that level entirely.
That criterion is from the previous plan year. The current bulletin has different wording.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.