why does nobody talk about province
Question in the title, detail here: why does nobody talk about 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.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
Moved provinces and the coverage position changed completely. Same person, same history, different formulary.
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.
Push back: approval by the national regulator says nothing about whether any plan will pay.
Pharmacy staff name removed. The pharmacy can stay in a pricing post.
Yes. Approval and coverage are separate, and this board conflates them in about half its threads.
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.
Those criteria were revised at renewal, so the version quoted upthread is out of date.
the criteria change at plan renewal and nobody announces it
Cosigning on quantity limits. They stop as many people as outright denials do and get discussed far less.
Special authorization is a documented exception process with published criteria.
Agreed — write the application against the published criteria rather than around them.
Have you asked the pharmacist to check?
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.
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