the province question that gets asked weekly, answered properly
the province question that gets asked weekly, answered properly. It is the sort of thing everyone half-believes and nobody writes down.
Kept every form and reference number. When they had no record of a submission, I did.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
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.
Tell me where this is wrong. That is the useful part of posting it.
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.
Agreed on keeping every form and date. When something goes wrong the paper trail is the whole case.
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
Small fix — that formulary position is another province’s and does not apply here.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.
Plan and policy numbers redacted from the screenshot above.
Disagree — that is your province’s formulary position and it does not carry to another.
a denial letter names a criterion, that is your handle
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
Same view — private and provincial plans are genuinely different processes with different appeal routes.
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.
a rejected claim is not the same as a denied authorization
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
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.
employer plans have their own criteria and their own appeals
ask the pharmacy what the cash price is, it varies
Those criteria were revised at renewal, so the version quoted upthread is out of date.