Canada is the most under-discussed thing on this board
Canada is the most under-discussed thing on this board — a position I have arrived at slowly and would like tested.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
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.
Would rather be corrected in public than confident in private.
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.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
Left up. It distinguishes a rejected claim from a denied authorization, which most posts here do not.
compare cash prices before assuming coverage is the only path
keep every form, every date, every reference number
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
That is an employer plan process, and the provincial route is different in both form and timeline.
Is there a quantity limit involved rather than a coverage refusal?
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.
the exception drug status route exists in several provinces
special authorization forms are published, read them before applying
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.
the pharmacist is often the fastest route to a definite answer
What did the denial actually say?
Agreed. Province first — coverage is a provincial decision and national answers are wrong somewhere by construction.
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.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Adding the fastest step — ask the pharmacist. They can usually check in minutes.
- 1The pharmacist sorted in five minutes what the phone line had not managed in…10 comments in this branch · started by u/santiago_szabo