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c/insurancefights·submitted 1 months ago by u/RetaAndRegret2

the prior authorization question that gets asked weekly, answered properly

Templatebranch of 8 comments

Quick one. Canada here. prior authorization works very differently where I live than in the threads that dominate the front page, and I keep seeing people confidently given advice that simply does not apply outside the US. Specifics: the route I used took 15 weeks and cost roughly what I expected. The admin was worse…

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8 comments, started 1 months ago
u/camila_vasquez178 points·1 months ago·edited

Disagree but this is the good kind of wrong — it is specific enough to be checked.

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u/milan_wikstrom59 points·1 months ago·edited

formulary exclusions are negotiable sometimes

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u/milos_vestergaard53 points·1 months ago

Disagree but this is the good kind of wrong — it is specific enough to be checked.

Counter-anecdote: opposite result, same dose. Which mostly tells us the variance is huge.

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u/blunt_coldbox_notes33 points·1 months ago

redact member ids and group numbers from every screenshot

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u/neha_erdogan13 points·1 months ago

This is correct. Appeal letters work.

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u/tomas_lehtinen0 points·1 months ago

Water content matters more than people think. If a vial is carrying residual moisture, your "10mg" is not 10mg of peptide.

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u/line_petrov1 point·1 months ago

copay is separate from coverage

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u/karim_restrepo83 points·1 months ago

Denied for prior auth, resubmitted with external review documentation, approved on appeal. The criteria exist, you just have to meet them.

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About c/insurancefights

The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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