Ontario Public Drug Programs (OPDP) Drug Programs Delivery Branch 5700 Yonge St., 3rd floor Toronto ON M2M 4K5
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 http://www.health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx
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.
First name Initial Last name
Treatment Centre Fax no. Telephone no.
First name Initial Last name Ontario Health Insurance Number
Male Female
Body Weight (kg) Date of Birth (yyyy/mm/dd)
New request Renewal of existing EAP Approval (specify EAP #)
Zavesca® (miglustat) 100 mg capsule Regimen and Dosage
Confirmed Diagnosis of Niemann Pick Type C (NPC) 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. Age at Diagnosis
Niemann Pick Type C (NPC) Functional Disability Rating Score: Wraith J. et al. Molecular Genetics and Metabolism 98 (2009) 152–165
Provide the NPC functional disability scoring report.
List of current medication use and document serious co-morbid conditions, if any
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 www.health.gov.on.ca. 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.
Authorized prescriber (print name) Authorized prescriber signature (mandatory) Registration number Date (yyyy/mm/dd)