Government of Ontario: Ministry of Health and Long–Term Care

Nutrition Products

Nutrition Product (NP) claims to be reimbursed by the Ontario Drug Benefit (ODB) program must be prescribed in accordance with patient eligibility criteria and supported by a valid, fully completed NP form. For easy reference to a complete list of NPs eligible for ODB reimbursement and the patient eligibility criteria, refer to Part IX of the Formulary. NP patient eligibility criteria also appear at the back of this form. An NP form is valid for one year following the date completed by the prescriber. NP forms will be audited to ensure that ODB eligible recipients meet the patient eligibility criteria for NPs.

The information collected on this form is collected for the purpose of payment under the Ministry of Health and Long–Term Care Act and for Drug Utilization Review. It is collected under the authority of section 6 of the Ministry of Health and Long–Term Care Act. For information contact the Ontario Drug Programs Help Desk at 1 800 668–6641.

Section 1 – Prescriber

(To be completed by Prescriber before the claim can be processed. The completed Nutrition Products form should be given to the patient with the prescription for a Nutrition Product. Pharmacists must have a fully completed Nutrition Products form before submitting an ODB claim.)

Patient last name

First name

Nutrition Product (Name / strength)

Diagnosis

Patient eligibility criteria chosen

Patient using product as sole source of nutrition and meets one of the following: oropharyngeal or gastrointestinal disorders resulting in esophageal dysfunction or dysphagia; e.g. head and neck surgery, neuromuscular disorder, or cerebral vascular disease where dysphagia prevents eating
maldigestion or malabsorption disorder and / or significant gut failure where food is not tolerated; e.g. pancreatic insufficiency, biliary obstruction, short bowel syndrome
for patients requiring the use of a chemically defined diet as a primary treatment of a disease where the therapeutic benefit has been demonstrated; i.e. Crohn’s Disease

Nutrition Product is the patient’s sole source of nutrition yes
no

Prescriber’s last name

First name

CPSO number

Prescriber’s signature

Date YYYY MM DD

Section 2 – Pharmacist

Any form that is not fully completed, or that leaves doubt as to whether patient eligibility criteria have been appropriately applied will result in a recovery of funds from the pharmacy.

Patient Health/ODB eligibility number
Nutrition Product form is complete and text indicated on form meets patient eligibility criteria:
yes
no
PIN:

Pharmacist’s signature

ON no.

Date of initial dispensing YYYY MM DD

Patient Eligibility Criteria for Coverage of Nutrition Products

The following patient eligibility criteria will determine a recipient’s eligibility for coverage of Nutrition Products (NPs) under the Ontario Drug Benefit (ODB) program.

Nutrition Products will be reimbursed for ODB eligible persons when prescribed by a physician as the patient’s sole source of nutrition and meet one of the following:

oropharyngeal or gastrointestinal disorders resulting in esophageal dysfunction or dysphagia; e.g. head and neck surgery, neuromuscular disorder, or cerebral vascular disease where dysphagia prevents eating;
maldigestion or malabsorption disorder and / or significant gut failure where
food is not tolerated; e.g. pancreatic insufficiency, biliary obstruction, short
bowel syndrome;
for patients requiring the use of a chemically defined diet as a primary
treatment of a disease where the therapeutic benefit has been demonstrated;
i.e. Crohn’s Disease

Each claim for reimbursement must be supported by a valid, fully completed Nutrition Product form.

Pharmacists are required to retain a copy of the Nutrition Product form on file for a period of two years.

Exclusions:
A nutrition product will not be reimbursed under the ODB program if it is intended for one of the following uses:

prescribed weight loss in the treatment of obesity
food allergies
body building
voluntary meal replacement
nutritional supplement
convenience
used as a replacement for breast feeding for infants with normal gastrointestinal absorptive function

Patients tolerating some solid foods and requiring only supplementation in addition to food are not eligible for coverage.

A Guide to Completing the Nutrition Products Form
(refer to Part IX of ODB Formulary for more details)

For the Prescriber

Complete All of Section 1 of the Nutrition Product (NP) form.
Give completed form to patient together with the NP prescription, or fax the completed NP form directly to the patient’s pharmacist.
Prescribers should not assume that pharmacists will complete missing sections. Pharmacists cannot complete Section 1 information on behalf of the prescriber.
Prescribers should not complete an NP form if the patient does not meet the patient eligibility criteria.

For the Pharmacist

Ensure Section 1 is complete, and the patient eligibility criteria indicated meets the patient eligibility criteria for NPs before the prescription is filled.
Return forms with information missing from Section 1 to prescriber for completion, or have the prescriber fax you a revised NP form.
Complete all of Section 2.
Process the claim through the Health Network, completing all steps for validation. If the Network rejects the claim, check to ensure the patient meets the patient eligibility criteria for the appropriate use of the NP.
Do not complete / amend Section 1 information. This must be completed by the prescriber.
Do not process NP claims for patients which in your professional judgement do not meet the patient eligibility criteria for NPs.
The ministry routinely conducts pharmacy audits for post-payment verification of claims paid by the ODB program. Any NP form that is not fully completed, or that leaves doubt as to whether the patient eligibility criteria for NPs have been appropriately applied will result in recovery of funds from the pharmacy.

The Pharmacist must have a fully completed NP form before submitting an ODB claim.

To obtain additional copies of NP forms, physicians and pharmacists call (613) 548–6586, or 1 888 310–9008.

3057–87 (03/03)