how much of what we believe about private plan actually comes from Canada threads
Question in the title, detail here: how much of what we believe about private plan actually comes from Canada threads.
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.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
Not medical advice, obviously, and nothing here is approved for human use. One person with a spreadsheet.
best — the order this archive was captured in
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.
A rejected claim at the pharmacy counter and a denied authorization are different events with different remedies.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
That is an employer plan process, and the provincial route is different in both form and timeline.
That is an employer plan process, and the provincial route is different in both form and timeline.
bence_zamora is right that a rejected claim and a denied authorization are different animals.
the pharmacist is often the fastest route to a definite answer
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.
the same product can be covered in one province and not the next
Push back: approval by the national regulator says nothing about whether any plan will pay.
employer plans have their own criteria and their own appeals
keep every form, every date, every reference number
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.
Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected.
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formulary decisions are provincial, so the province is the first fact
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.
Plan and policy numbers redacted from the screenshot above.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
a rejected claim is not the same as a denied authorization
a rejected claim is not the same as a denied authorization
This is why every thread here needs a province in it.
say the province or the answers will be wrong
Agreed. Province first — coverage is a provincial decision and national answers are wrong somewhere by construction.
private plans and provincial plans are different fights entirely
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
Disagree — that is your province’s formulary position and it does not carry to another.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
ask the pharmacy what the cash price is, it varies
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.
- 1Employer-sponsored plans have their own criteria and appeal processes,…6 comments in this branch · started by u/isabela_guerrero