the province thing finally clicked for me and I want to write it down
Posting this as a discussion rather than a claim: the province thing finally clicked for me and I want to write it down.
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.
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.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
Happy to answer the boring questions. Those are usually the ones worth asking.
best — the order this archive was captured in
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.
Provincial plan, employer plan, or paying cash?
Push back: approval by the national regulator says nothing about whether any plan will pay.
Careful, that criterion was updated at renewal and the version you are quoting is superseded.
That is an employer plan process, and the provincial route is different in both form and timeline.
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
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.
keep every form, every date, every reference number
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.
Was this a denied authorization or a rejected claim?
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
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.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.