someone explain special authorization to me like I have not read a paper in years
someone explain special authorization to me like I have not read a paper in years, and I want the answer with the reasoning attached rather than just the conclusion.
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.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Kept every form and reference number. When they had no record of a submission, I did.
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.
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.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
private plans and provincial plans are different fights entirely
Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected.
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Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Have you asked the pharmacist to check?
Small fix — that formulary position is another province’s and does not apply here.
Same view — private and provincial plans are genuinely different processes with different appeal routes.
ask the pharmacy what the cash price is, it varies
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Pharmacy staff name removed. The pharmacy can stay in a pricing post.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
say the province or the answers will be wrong
Careful, that criterion was updated at renewal and the version you are quoting is superseded.
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
Have you seen the special authorization criteria for your province?
a rejected claim is not the same as a denied authorization
Is there a quantity limit involved rather than a coverage refusal?
special authorization forms are published, read them before applying
Nothing here is medical or legal advice. The pharmacist and the prescriber are the people who can act, and both are faster than a forum.
formulary decisions are provincial, so the province is the first fact
Nothing here is medical or legal advice.
cagrilintide_enthusiast is right that a rejected claim and a denied authorization are different animals.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.
the exception drug status route exists in several provinces
a denial letter names a criterion, that is your handle
Provincial plan, employer plan, or paying cash?
the pharmacist is often the fastest route to a definite answer
- 1Pharmacy staff name removed. The pharmacy can stay in a pricing post.9 comments in this branch · started by u/lane_watcher
- 2Formulary criteria are revised, and plan renewal is a natural point at which…8 comments in this branch · started by u/pavel_kravchenko