[Discussion] can we stop arguing about formulary until somebody posts a number
The title is the whole question — can we stop arguing about formulary until somebody posts a number — but here is why I am asking.
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.
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.
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
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.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Health Canada approval is not coverage
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
ask the pharmacy what the cash price is, it varies
Same view — private and provincial plans are genuinely different processes with different appeal routes.
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.
incretin_ivy is right that a rejected claim and a denied authorization are different animals.
Careful, that criterion was updated at renewal and the version you are quoting is superseded.
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.
Provincial plan, employer plan, or paying cash?
I would not read one pharmacy’s cash price as the going rate. The spread is real.
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.
Have you seen the special authorization criteria for your province?
the pharmacist is often the fastest route to a definite answer
quantity limits are as common a barrier as coverage itself
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.