[PSA] special authorization is not what most of this community thinks it is
special authorization is not what most of this community thinks it is. That is the post. The justification is underneath.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
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.
Corrections welcome, especially the pedantic ones. Pedantry is how this board earns its reputation.
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.
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.
Province added to the title. Coverage is provincial and the thread could not be answered without it.
employer plans have their own criteria and their own appeals
Push back: approval by the national regulator says nothing about whether any plan will pay.
Push back: approval by the national regulator says nothing about whether any plan will pay.
This is why every thread here needs a province in it.
the exception drug status route exists in several provinces
say the province or the answers will be wrong
keep every form, every date, every reference number
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.