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

Ontario Public Drug Programs (OPDP)
Drug Programs Delivery Branch
5700 Yonge St., 3rd floor
Toronto ON  M2M 4K5

Request for Zavesca® –
Niemann Pick Type C (NPC)

Please fax completed form and/or any additional relevant information to 416 327–7526 or toll-free 1 866 811–9908; or send to the Exceptional Access Program (EAP), 5700 Yonge Street, 3rd floor, Toronto ON  M2M 4K5.
For copies of this and other EAP forms, please visit

The Executive Officer (EO) of Ontario Public Drug Programs considers requests for coverage of drug products not listed in the Ontario Drug Benefit Formulary under the Exceptional Access Program (EAP). This form is intended to facilitate requests for drugs considered under the EAP. The EO may request additional documentation to support the request. Please ensure that all appropriate information for each section is provided to avoid delays.

Section 1 – Prescriber Information

Type of Prescriber

Mailing address

Section 2 – Patient Information




Section 3 – Drug, Dosage and Regimen

Section 4 – Clinical Information – New Request

Provide NPC 1 and 2 mutation analysis report.

If less than 2 disease associated/pathogenic mutation are identified in the NPC 2 genes, please also provide lysosomal filipin staining report OR fibroblast cholesterol esterification report.

Provide the NPC functional disability scoring report.

Section 5 – Clinical Information – Renewal Request

Provide the NPC functional disability scoring report.

Section 6 – Current Medication Use and Co-Morbid Conditions

The information on this form is collected under the authority of the Personal Health Information Protection Act, 2004, S.O. 2004, c.3, Sched. A (PHIPA) and Section 13 of the Ontario Drug Benefit Act, R.S.O. 1990c.O.10 and will be used in accordance with PHIPA, as set out in the Ministry of Health and Long-Term Care “Statement of Information Practices”, which may be accessed at If you have any questions about the collection or use of this information, call Ontario Public Drug Programs at 1 866 811–9893 or contact the Director, Drug Programs Delivery Branch, 5700 Yonge St., 3rd Floor, Toronto ON  M2M 4K5.