unpopular opinion: most of what gets said here about Canada is guesswork
Thinking out loud about this: unpopular opinion: most of what gets said here about Canada is guesswork.
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.
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.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Tell me where this is wrong. That is the useful part of posting it.
best — the order this archive was captured in
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.
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.
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.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
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.
Yes. Cash prices vary and comparing them before assuming coverage is the only route is worth doing.
ask the pharmacy what the cash price is, it varies
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
the exception drug status route exists in several provinces
Small fix — that formulary position is another province’s and does not apply here.
formulary decisions are provincial, so the province is the first fact
a denial letter names a criterion, that is your handle
Province added to the title. Coverage is provincial and the thread could not be answered without it.
quantity limits are as common a barrier as coverage itself
quantity limits are as common a barrier as coverage itself
milos_vestergaard is right that a rejected claim and a denied authorization are different animals.
private plans and provincial plans are different fights entirely
say the province or the answers will be wrong
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
Disagree — that is your province’s formulary position and it does not carry to another.
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