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

Drug Programs Delivery Branch
5700 Yonge St. 3rd floor
Toronto ON M2M 4K5

Request for an Unlisted Drug Product
Exceptional Access Program (EAP)

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

The Ministry of Health and Long-Term Care (the “ministry”) considers requests for coverage of drug products not listed in the Ontario Drug Benefit Formulary under section 16 of the Ontario Drug Benefit Act. This form is intended to facilitate requests for drugs under the Exceptional Access Program. The ministry 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

Fax No.
Telephone No.

Section 2 - Patient Information



Section 3 - Drug Requested

Section 4 -Diagnosis and Reason for Use

Section 5 – Current and / or Previous Medications
  1. Please provide details of alternatives (listed drugs and/or non-drug therapy) tried for this condition:








Section 6 – Clinical Information

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. 1990 c.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 the Ontario Drug Benefit (ODB) Help Desk at 1 800 668–6641 or contact the Director, Drug Programs Delivery Branch (DPDB), Ministry of Health and Long-Term Care, 3rd floor, 5700 Yonge St., Toronto ON  M2M 4K5.