genuine question about private plan that I am slightly embarrassed to ask
genuine question about private plan that I am slightly embarrassed to ask. If this has been answered properly somewhere, link me and I will delete.
Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
Tell me where this is wrong. That is the useful part of posting it.
best — the order this archive was captured in
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.
[deleted]
Provincial plan, employer plan, or paying cash?
Small fix — that formulary position is another province’s and does not apply here.
Have you asked the pharmacist to check?
Correcting myself: it was a quantity limit rather than a denial, which changes the whole process.
Health Canada approval is not coverage
What did the denial actually say?
What did the denial actually say?
Agreed — write the application against the published criteria rather than around them.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.
Was this a denied authorization or a rejected claim?
Was this a denied authorization or a rejected claim?
sequence_checker is right that a rejected claim and a denied authorization are different animals.
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.
Is there a quantity limit involved rather than a coverage refusal?
Is there a quantity limit involved rather than a coverage refusal?
Adding the fastest step — ask the pharmacist. They can usually check in minutes.
Adding the fastest step — ask the pharmacist.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
This is why every thread here needs a province in it.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
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.
private plans and provincial plans are different fights entirely
- 1Special authorization is a documented exception process with published…7 comments in this branch · started by u/anya_antonsen