Canada: Canada, and what it actually costs here
The title is the argument: Canada: Canada, and what it actually costs here. Here is the rest of it. Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more. Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected. The…
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
formulary decisions are provincial, so the province is the first fact
formulary decisions are provincial, so the province is the first fact
Disagreeing with this line: that is an employer plan process and the provincial one differs.
compare cash prices before assuming coverage is the only path
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.
This. The special authorization form is published and reading it before applying changes the outcome.
employer plans have their own criteria and their own appeals
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.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Special authorization is a documented exception process with published criteria. Applications that answer those criteria explicitly, point by point, fare better than general clinical narratives.