special authorization is the most under-discussed thing on this board
special authorization is the most under-discussed thing on this board. I have gone back and forth on this for months.
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.
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.
Sceptical readings welcome. The confident ones are the ones I distrust.
best — the order this archive was captured in
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.
Careful, that criterion was updated at renewal and the version you are quoting is superseded.
Health Canada approval is not coverage
private plans and provincial plans are different fights entirely
Health Canada approval is not coverage
elin_varga is right that a rejected claim and a denied authorization are different animals.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
Is there a quantity limit involved rather than a coverage refusal?
Small fix — that formulary position is another province’s and does not apply here.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
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.
Kept every form and reference number. When they had no record of a submission, I did.
the same product can be covered in one province and not the next
A rejected claim at the pharmacy counter and a denied authorization are different events with different remedies.
Disagreeing with this line: that is an employer plan process and the provincial one differs.
Plan and policy numbers redacted from the screenshot above.
Plan and policy numbers redacted from the screenshot above.
Adding the fastest step — ask the pharmacist. They can usually check in minutes.
Which province?
I would not read one pharmacy’s cash price as the going rate. The spread is real.
Which province?
This is why every thread here needs a province in it.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
Right, and the pharmacist can usually give a definite answer faster than a week of forum speculation.
- 1Plan and policy numbers redacted from the screenshot above.9 comments in this branch · started by u/canada_coverage
- 2Formulary criteria are revised, and plan renewal is a natural point at which…7 comments in this branch · started by u/formulary_fighter