the formulary question that gets asked weekly, answered properly
the formulary question that gets asked weekly, answered properly. Change my mind, genuinely — I have no stake in being right about this.
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.
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.
Research-use-only material is not approved for human use and nothing here should be read as a recommendation to use it.
best — the order this archive was captured in
Left up. It distinguishes a rejected claim from a denied authorization, which most posts here do not.
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.
Have you asked the pharmacist to check?
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.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
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.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
- 1Left up. It distinguishes a rejected claim from a denied authorization,…6 comments in this branch · started by u/lane_watcher