[Private Plan] my plan added a lifetime maximum halfway through my year
my plan added a lifetime maximum halfway through my year, and I am aware this is a minority view on this board.
The three separate questions people ask here as though they were one.
Is it approved for sale — a national regulatory question with one answer. Is it covered — a provincial or private-plan question with many answers. Can I actually get this quantity dispensed — a quantity-limit question that is separate from coverage and stops as many people.
Say which of the three you are asking and name your province and plan type. Threads that do this get answered in two replies; threads that do not generate a page of people talking past each other, all of them correct about somewhere else.
How to write a special authorization request that gets approved.
Get the published criteria for your province. Answer them explicitly, in their own terms, in the same order. Attach what has been documented — what was tried, at what dose, for how long, with what outcome — as dates rather than narrative. Where a criterion cannot be met, have the prescriber say why in the criterion’s own language rather than around it.
Members here who have done this describe a much better hit rate than those who submitted a clinical letter that did not engage with the form. It is an administrative exercise, and treating it as one is the whole trick. None of which is advice — it is what the threads report.
Cash pricing, which people skip because they assume coverage is the only route.
Prices at the counter vary between pharmacies, sometimes substantially, in the same city. Members here have found spreads worth a real amount per month by ringing four places and asking for the cash price of a specific presentation.
That does not make coverage unimportant. It does mean that while an authorization is in process — which can take weeks — knowing the actual cash spread is worth half an hour of phone calls. Post what you find with the province and the month; the comparison threads here work for exactly the same reason the UK pricing tracker does.
That is everything I have. The rest is opinion and I have tried to keep it out.
best — the order this archive was captured in
the exception drug status route exists in several provinces
a rejected claim is not the same as a denied authorization
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary.
rania_diallo is right that a rejected claim and a denied authorization are different animals.
Plan and policy numbers redacted from the screenshot above.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Have you asked the pharmacist to check?
Formulary criteria are revised, and plan renewal is a natural point at which a previously refused request may succeed without anything about the applicant changing.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
- 1Employer-sponsored plans have their own criteria and appeal processes,…6 comments in this branch · started by u/rania_diallo