[Question] the Netherlands — has anyone got a straight answer on special authorization
Slightly embarrassed to be asking this, but: the Netherlands — has anyone got a straight answer on special authorization.
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.
If somebody has the same thing measured a different way, post it next to mine and we will see whether they agree.
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.
keep every form, every date, every reference number
Those criteria were revised at renewal, so the version quoted upthread is out of date.
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?
Is there a quantity limit involved rather than a coverage refusal?
Cosigning on quantity limits. They stop as many people as outright denials do and get discussed far less.
Cosigning on quantity limits.
Agreed — write the application against the published criteria rather than around them.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
ask the pharmacy what the cash price is, it varies
Small fix — that formulary position is another province’s and does not apply here.
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.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.