the Netherlands: private plan, and what it actually costs here
the Netherlands: private plan, and what it actually costs here. It is the sort of thing everyone half-believes and nobody writes down.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
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.
If two or three other people have done the same thing we might actually learn something. Alone it is an anecdote.
best — the order this archive was captured in
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.
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
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.
formulary decisions are provincial, so the province is the first fact
special authorization forms are published, read them before applying
Provincial plan, employer plan, or paying cash?
Have you asked the pharmacist to check?
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.
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quantity limits are as common a barrier as coverage itself
Plan and policy numbers redacted from the screenshot above.
Plan and policy numbers redacted from the screenshot above.
Agreed — write the application against the published criteria rather than around them.
Was this a denied authorization or a rejected claim?
the exception drug status route exists in several provinces
Have you seen the special authorization criteria for your province?
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Small fix — that formulary position is another province’s and does not apply here.
Quantity limits restrict how much may be dispensed in a period even where coverage exists. They are a distinct barrier and require a distinct request.
Quantity limits restrict how much may be dispensed in a period even where coverage exists.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
say the province or the answers will be wrong
employer plans have their own criteria and their own appeals
employer plans have their own criteria and their own appeals
noor_ivaturi is right that a rejected claim and a denied authorization are different animals.
Disagree — that is your province’s formulary position and it does not carry to another.
Push back: approval by the national regulator says nothing about whether any plan will pay.
- 1Provincial plan, employer plan, or paying cash?8 comments in this branch · started by u/omar_eriksen