[Question] does anyone have the special authorisation criteria in writing
does anyone have the special authorisation criteria in writing. Searched first, found three threads that contradict each other, hence the post.
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.
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.
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.
Please do not ask me what dose you should be on. I genuinely do not know and neither does anyone else here.
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.
Correction: that is regulatory approval, not coverage. They are separate decisions by separate bodies.
Criteria changed at plan renewal and the denial that had been immovable simply did not apply any more.
Was this a denied authorization or a rejected claim?
Confused a rejected claim with a denied authorization for a month and pursued entirely the wrong process.
That is an employer plan process, and the provincial route is different in both form and timeline.
Is there a quantity limit involved rather than a coverage refusal?
keep every form, every date, every reference number
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Not convinced. A rejected claim at the counter is not a denied authorization and the next step differs.
the exception drug status route exists in several provinces
- 1Formulary criteria are revised, and plan renewal is a natural point at which…6 comments in this branch · started by u/matias_salgado