[Formulary] provincial differences, mapped, with dates
provincial differences, mapped, with dates — a position I have arrived at slowly and would like tested. Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route. Read the special authorization criteria and…
Push back: approval by the national regulator says nothing about whether any plan will pay.
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.
The three separate questions people ask here as though they were one.
paper_trail_paula is right that a rejected claim and a denied authorization are different animals.
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Those criteria were revised at renewal, so the version quoted upthread is out of date.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.