help me understand special authorization, I have read the wiki twice
help me understand special authorization, I have read the wiki twice. I am not trying to be the "source?" guy. I would just like a source.
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.
Tell me where this is wrong. That is the useful part of posting it.
best — the order this archive was captured in
National regulatory approval establishes that a product may be sold. Whether any plan pays for it is a separate decision, and public drug plans are administered provincially.
National regulatory approval establishes that a product may be sold.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
Push back: approval by the national regulator says nothing about whether any plan will pay.
Careful, that criterion was updated at renewal and the version you are quoting is superseded.
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.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Province added to the title. Coverage is provincial and the thread could not be answered without it.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
A rejected claim at the pharmacy counter and a denied authorization are different events with different remedies. The first can be an administrative or quantity issue; the second is a determination you can appeal.
A rejected claim at the pharmacy counter and a denied authorization are different events with different remedies.
Adding the fastest step — ask the pharmacist. They can usually check in minutes.
Kept every form and reference number. When they had no record of a submission, I did.
a rejected claim is not the same as a denied authorization
the pharmacist is often the fastest route to a definite answer
- 1National regulatory approval establishes that a product may be sold. Whether…6 comments in this branch · started by u/oskar_kaufmann