PharmacoVig_BOS said:

Denials are usually procedural rather than clinical, and the order that works reflects that.

Agreed, and 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.

jennifer_SEA said:

Worth adding the genuine exception, because it is real and narrow: a change made for an identified patient where the prescriber determines it produces…

Genuinely useful, thank you. I had the facts and not the framework.

PharmacoVig_BOS said:

Denials are usually procedural rather than clinical, and the order that works reflects that.

Pushing back on PharmacoVig_BOS here. 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.

If somebody has the primary source to hand I would rather cite it than paraphrase it.

Dr.SleepRoch said:

Two pharmacies quoted me last year, one describing itself as 503A and one as 503B, and I assumed 503B just meant bigger until both stopped within…

Vendor communication red flags for compounded supply:

• Won't provide COA before purchase — walk away
• Claims "100% pure" without analytical data — unrealistic
• No physical address or phone number — accountability matters
• Pushes you to buy more than you need — pressure tactics
• Won't answer questions about their compounding process — transparency is key
• Payment only via crypto or wire transfer — legitimate pharmacies accept cards

A legitimate compounding pharmacy operates like a healthcare business, not a gray market dealer.

Moderator note: leaving this open. It is being argued well and the disagreement is the useful part.