three years of special authorization threads, summarised so you do not have to read them
three years of special authorization threads, summarised so you do not have to read them. Not a hot take, just something I have not seen said plainly here.
Read the special authorization criteria and wrote the application against them line by line. Approved first time after a previous refusal.
Employer-sponsored plans have their own criteria and appeal processes, independent of the provincial formulary. Which one applies determines everything about the route.
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.
I will update this if the picture changes rather than quietly leaving it up.
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.
Provincial plan, employer plan, or paying cash?
Kept every form and reference number. When they had no record of a submission, I did.
Agreed on keeping every form and date. When something goes wrong the paper trail is the whole case.
Spent three weeks on what turned out to be a quantity limit rather than a coverage question.
Same view — private and provincial plans are genuinely different processes with different appeal routes.
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.
The pharmacist sorted in five minutes what the phone line had not managed in a fortnight.
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.
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.
quantity limits are as common a barrier as coverage itself