does private plan actually matter or is it forum lore at this point
does private plan actually matter or is it forum lore at this point — that is what I am asking, and I have already read the wiki twice.
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.
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.
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.
Sceptical readings welcome. The confident ones are the ones I distrust.
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.
Left up. It distinguishes a rejected claim from a denied authorization, which most posts here do not.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
employer plans have their own criteria and their own appeals
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
Was this a denied authorization or a rejected claim?
Disagree — that is your province’s formulary position and it does not carry to another.
Yes. Cash prices vary and comparing them before assuming coverage is the only route is worth doing.
the same product can be covered in one province and not the next
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
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.
Adding the fastest step — ask the pharmacist. They can usually check in minutes.
a rejected claim is not the same as a denied authorization
This. The special authorization form is published and reading it before applying changes the outcome.
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.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
This is why every thread here needs a province in it.
Agreed on keeping every form and date. When something goes wrong the paper trail is the whole case.
Agreed on keeping every form and date.
Agreed — write the application against the published criteria rather than around them.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
the pharmacist is often the fastest route to a definite answer
- 1Disagree — that is your province’s formulary position and it does not carry…12 comments in this branch · started by u/pavel_kravchenko