[Discussion] special authorization is doing more work than we give it credit for
Thinking out loud about this: special authorization is doing more work than we give it credit for.
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.
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.
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.
That is everything I have. The rest is opinion and I have tried to keep it out.
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.
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?
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.
a denial letter names a criterion, that is your handle
Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Province added to the title. Coverage is provincial and the thread could not be answered without it.
ask the pharmacy what the cash price is, it varies
Kept every form and reference number. When they had no record of a submission, I did.
Was this a denied authorization or a rejected claim?
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Correction: that is regulatory approval, not coverage.
Agreed — write the application against the published criteria rather than around them.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Which province?
That is an employer plan process, and the provincial route is different in both form and timeline.
formulary decisions are provincial, so the province is the first fact
the criteria change at plan renewal and nobody announces it
compare cash prices before assuming coverage is the only path
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.
What did the denial actually say?
Same view — private and provincial plans are genuinely different processes with different appeal routes.
the exception drug status route exists in several provinces
the pharmacist is often the fastest route to a definite answer
Yes. Cash prices vary and comparing them before assuming coverage is the only route is worth doing.
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