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 eligibility criteria chosen

Patient using product as sole source of nutrition and meets one of the following:

Nutrition Product is the patient’s sole source of nutrition





Prescriber’s signature



Date    

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.

  1.  
  2. Nutrition Product form is complete and text indicated on form meets patient eligibility criteria:


  3.  

Pharmacist’s signature



 

Date of initial dispensing    

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:

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:

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

For the Pharmacist

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)