[Discussion] Canada is doing more work than we give it credit for
The title is the argument: Canada is doing more work than we give it credit for. 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 pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
If somebody has the same thing measured a different way, post it next to mine and we will see whether they agree.
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.
Small fix — that formulary position is another province’s and does not apply here.
Disagree — that is your province’s formulary position and it does not carry to another.
Is there a quantity limit involved rather than a coverage refusal?
Push back: approval by the national regulator says nothing about whether any plan will pay.
Correcting myself: it was a quantity limit rather than a denial, which changes the whole process.
formulary decisions are provincial, so the province is the first fact
Careful, that criterion was updated at renewal and the version you are quoting is superseded.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
a denial letter names a criterion, that is your handle
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
Same view — private and provincial plans are genuinely different processes with different appeal routes.
Yes. Cash prices vary and comparing them before assuming coverage is the only route is worth doing.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
private plans and provincial plans are different fights entirely
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.
the pharmacist is often the fastest route to a definite answer
That is an employer plan process, and the provincial route is different in both form and timeline.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
Agreed on keeping every form and date. When something goes wrong the paper trail is the whole case.
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.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
- 1Is there a quantity limit involved rather than a coverage refusal?10 comments in this branch · started by u/first_pen_fear