private plan — 18 things I got wrong before I got it right
private plan — 18 things I got wrong before I got it right, which sounds obvious until you try to state the evidence for it.
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.
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.
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.
Happy to answer the boring questions. Those are usually the ones worth asking.
best — the order this archive was captured in
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
employer plans have their own criteria and their own appeals
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
ask the pharmacy what the cash price is, it varies
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.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
solene_eriksen is right that a rejected claim and a denied authorization are different animals.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Correcting myself: it was a quantity limit rather than a denial, which changes the whole process.
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.
Formulary criteria are revised, and plan renewal is a natural point at which a previously refused request may succeed without anything about the appli
This is why every thread here needs a province in it.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
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.
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