[Question] special authorization — what am I missing here
Asking properly rather than in a comment on somebody else’s thread: special authorization — what am I missing here.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
Kept every form and reference number. When they had no record of a submission, I did.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Not medical advice, obviously, and nothing here is approved for human use. One person with a spreadsheet.
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.
Quantity limits restrict how much may be dispensed in a period even where coverage exists.
karim_restrepo is right that a rejected claim and a denied authorization are different animals.
employer plans have their own criteria and their own appeals
a rejected claim is not the same as a denied authorization
Provincial plan, employer plan, or paying cash?
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Compared cash prices across four pharmacies before pursuing coverage and the spread was larger than I expected.
the criteria change at plan renewal and nobody announces it
Small fix — that formulary position is another province’s and does not apply here.
Push back: approval by the national regulator says nothing about whether any plan will pay.
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.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
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.
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.
That is an employer plan process, and the provincial route is different in both form and timeline.
Have you asked the pharmacist to check?
Was this a denied authorization or a rejected claim?
keep every form, every date, every reference number
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
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.
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.
Nothing here is medical or legal advice.
Adding the fastest step — ask the pharmacist. They can usually check in minutes.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
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