someone explain Canada to me like I have not read a paper in years
Slightly embarrassed to be asking this, but: someone explain Canada to me like I have not read a paper in years.
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
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.
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.
Happy to answer the boring questions. Those are usually the ones worth asking.
best — the order this archive was captured in
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.
The three separate questions people ask here as though they were one.
Agreed — write the application against the published criteria rather than around them.
Small fix — that formulary position is another province’s and does not apply here.
Small fix — that formulary position is another province’s and does not apply here.
diego_almeida is right that a rejected claim and a denied authorization are different animals.
special authorization forms are published, read them before applying
That is an employer plan process, and the provincial route is different in both form and timeline.
Push back: approval by the national regulator says nothing about whether any plan will pay.
Have you seen the special authorization criteria for your province?
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.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Correction: that is regulatory approval, not coverage.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
I would not read one pharmacy’s cash price as the going rate. The spread is real.
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Same view — private and provincial plans are genuinely different processes with different appeal routes.
compare cash prices before assuming coverage is the only path
- 1The three separate questions people ask here as though they were one. Is it…8 comments in this branch · started by u/constipation_club
- 2Nothing here is medical or legal advice. The pharmacist and the prescriber…7 comments in this branch · started by u/declared_value_dv