unpopular opinion: most of what gets said here about province is guesswork
Something I keep coming back to: unpopular opinion: most of what gets said here about province is guesswork.
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.
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.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Would rather be corrected in public than confident in private.
best — the order this archive was captured in
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.
Pharmacy staff name removed. The pharmacy can stay in a pricing post.
[removed by moderator]
Have you seen the special authorization criteria for your province?
Was this a denied authorization or a rejected claim?
Same view — private and provincial plans are genuinely different processes with different appeal routes.
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.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Push back: approval by the national regulator says nothing about whether any plan will pay.
Agreed on keeping every form and date. When something goes wrong the paper trail is the whole case.
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.
Cash pricing, which people skip because they assume coverage is the only route.
This is why every thread here needs a province in it.
the exception drug status route exists in several provinces
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.