Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the talking.
Long enough now to say something useful rather than something enthusiastic.
Coverage criteria are plan-specific rather than insurer-specific. Two people with the same insurer and different employers have different rules, which is why "my insurer covers it" is not transferable information.
What I am after is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. Not looking for reassurance. Looking for the part I have got wrong.
TomTeleRx said:Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the…
My insurance denied my PA related to cost and coverage. Has anyone successfully appealed? I'm considering going compounded instead.
TomTeleRx said:Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the…
This is where I part company with the consensus forming above. The affordability discussion here usually stops at individual tactics. At list price this class is out of reach for most of the people who would benefit, and no amount of appeal strategy changes that — it is a pricing problem wearing a paperwork costume.
Correct me if the detail matters more than I have assumed.
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View ResultsDr.NateNeph said:The affordability discussion here usually stops at individual tactics.
Dr.NateNeph said:...compounded vs brand cost and coverage...
This debate comes up weekly and I think both sides have valid points:
Pro-brand: FDA-approved, manufacturing standards guaranteed, clinical trial data directly applicable
Pro-compounded: 10x cost savings, same active molecule, independent testing available, accessibility
My position: if you can afford brand or have insurance coverage, that's the gold standard. If not, properly tested compounded from a 503B pharmacy is a reasonable alternative. Neither side should shame the other.
Dr.LipidDallas said:My insurance denied my PA related to cost and coverage.
Mine went the same way, slower.