three years of special authorization threads, summarised so you do not have to read them
three years of special authorization threads, summarised so you do not have to read them — a position I have arrived at slowly and would like tested.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
Kept every form and reference number. When they had no record of a submission, I did.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Happy to answer the boring questions. Those are usually the ones worth asking.
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.
quantity limits are as common a barrier as coverage itself
a denial letter names a criterion, that is your handle
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Have you seen the special authorization criteria for your province?
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Disagree — that is your province’s formulary position and it does not carry to another.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Provincial plan, employer plan, or paying cash?
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-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Cosigning on quantity limits. They stop as many people as outright denials do and get discussed far less.
the exception drug status route exists in several provinces
I would not read one pharmacy’s cash price as the going rate. The spread is real.
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.
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