the step therapy question that gets asked weekly, answered properly
the step therapy question that gets asked weekly, answered properly, and I am aware this is a minority view on this board.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Tell me where this is wrong. That is the useful part of posting it.
best — the order this archive was captured in
Step therapy requires documented trial of preferred alternatives. It is not an argument to be won on merits; it is a record to be produced, and the record is what the appeal must contain.
External review, which is the most underused mechanism discussed on this board.
Internal appeals are decided by the plan. External review sends the determination to an independent body. Where it applies its decision binds the plan, and the deadlines to request it are short and strictly enforced.
The two things that trip people up: not knowing it exists, and exhausting the internal levels so slowly that the external window closes. Ask on the first denial what the external route is and what the deadline will be. Availability and rules vary by jurisdiction and plan type, so say where you are when you ask here.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
document what has been tried and for how long, that is the whole case
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
Member and policy numbers redacted from the screenshot above. Everything else left as posted.
External review was the thing that finally worked. I did not know it existed until a thread on this board.
prior authorisation criteria change every plan year
step therapy is a documentation problem, not an argument
A peer-to-peer conversation puts the prescribing clinician in front of a reviewing clinician. It bypasses the correspondence cycle entirely and is often the fastest available route.
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
a template letter that quotes their own criteria back is the strongest one
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Not convinced. That is a formulary exclusion rather than a prior authorisation denial, and the route to challenge it is different.
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.
ask for the denial reason in writing, always
Agreed. The denial letter tells you which criterion failed, and answering that specific criterion is the entire job.
Agreed.
This is the whole method. Answer the criterion they named, not the decision in general.
the formulary is published, read it before you appeal
Has a peer-to-peer been offered or requested?
Internal appeals are decided by the plan. External review is decided by an independent body and, where it applies, its determination is binding. They are separate mechanisms and the second is chronically underused.
What is the appeal deadline on the letter?
Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level denial.
- 1Agreed. The denial letter tells you which criterion failed, and answering…7 comments in this branch · started by u/marta_vanhecke