[Meta] the Canada rule is doing its job and people should stop complaining
Proposal, not a decision: the Canada rule is doing its job and people should stop complaining.
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.
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.
How to write a special authorization request that gets approved.
Get the published criteria for your province. Answer them explicitly, in their own terms, in the same order. Attach what has been documented — what was tried, at what dose, for how long, with what outcome — as dates rather than narrative. Where a criterion cannot be met, have the prescriber say why in the criterion’s own language rather than around it.
Members here who have done this describe a much better hit rate than those who submitted a clinical letter that did not engage with the form. It is an administrative exercise, and treating it as one is the whole trick. None of which is advice — it is what the threads report.
Screenshot none of this. Read the whole thread, including the parts where I am told I am wrong.
best — the order this archive was captured in
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.
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.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Agreed — write the application against the published criteria rather than around them.
a denial letter names a criterion, that is your handle
a denial letter names a criterion, that is your handle
This is why every thread here needs a province in it.
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ask the pharmacy what the cash price is, it varies
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
Small fix — that formulary position is another province’s and does not apply here.
say the province or the answers will be wrong
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.
laila_wojcik is right that a rejected claim and a denied authorization are different animals.
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.
employer plans have their own criteria and their own appeals
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Was this a denied authorization or a rejected claim?
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.
Nothing here is medical or legal advice.
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
Correcting myself: it was a quantity limit rather than a denial, which changes the whole process.
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
Cosigning on quantity limits. They stop as many people as outright denials do and get discussed far less.
Provincial plan, employer plan, or paying cash?
- 1Criteria changed at plan renewal and the denial that had been immovable…13 comments in this branch · started by u/niels_norgaard
- 2Was this a denied authorization or a rejected claim?6 comments in this branch · started by u/laila_wojcik