formulary — 11 things I got wrong before I got it right
formulary — 11 things I got wrong before I got it right. Not a hot take, just something I have not seen said plainly here.
Special authorization is a documented exception process with published criteria. Applications that answer those criteria explicitly, point by point, fare better than general clinical narratives.
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.
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.
Sceptical readings welcome. The confident ones are the ones I distrust.
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.
Disagree — that is your province’s formulary position and it does not carry to another.
What did the denial actually say?
Small fix — that formulary position is another province’s and does not apply here.
Correcting myself: it was a quantity limit rather than a denial, which changes the whole process.
ask the pharmacy what the cash price is, it varies
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
Push back: approval by the national regulator says nothing about whether any plan will pay.
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
Have you seen the special authorization criteria for your province?
Same view — private and provincial plans are genuinely different processes with different appeal routes.
employer plans have their own criteria and their own appeals
keep every form, every date, every reference number
formulary decisions are provincial, so the province is the first fact
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
say the province or the answers will be wrong
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.
- 1Push back: approval by the national regulator says nothing about whether any…9 comments in this branch · started by u/samir_falk