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
http://www.health.gov.on.ca/en/public/forms/odb_fm.aspx

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

First Name Initial
Last Name

Type of Prescriber
Physician
Nurse practitioner
Other (specify)

Mailing Address
Street no. Street Name
City Postal code

Fax No.
( )

Telephone No.
( )

Section 2 - Patient Information

First Name Initial
Last Name
Health Number
Date of birth (yyyy/mm/dd)

New request
Renewal of existing EAP approval (specify EAP# ) - Enter next Individual Clinical Review number

Section 3 - Drug Requested

Requested drug product
DIN
Strength / Dosage form
Frequency of administration
Expected start date
Duration of therapy

Section 4 -Diagnosis and Reason for Use

Diagnosis for which the drug is requested:

Reason for use over formulary alternatives:

If the patient is currently taking the requested product, please provide start date & objective evidence of its efficacy:

Section 5 – Current and / or Previous Medications

Please provide details of alternatives (listed drugs and/or non-drug therapy) tried for this condition:
1. Name of drug(indicate if currently or previously taken)
Name of drug(indicate if current or previously taken) current       previous

Dosage    Approximate timeframe of therapy
Reason(s) why fomulary alternatives are not appropriate

2. Name of drug(indicate if currently or previously taken)
Name of drug(indicate if current or previously taken) current       previous

Dosage    Approximate timeframe of therapy
Reason(s) why fomulary alternatives are not appropriate

3. Name of drug(indicate if currently or previously taken)
Name of drug(indicate if current or previously taken) current       previous

Dosage    Approximate timeframe of therapy
Reason(s) why fomulary alternatives are not appropriate

4. Name of drug(indicate if currently or previously taken)
Name of drug(indicate if current or previously taken) current       previous

Dosage    Approximate timeframe of therapy
Reason(s) why fomulary alternatives are not appropriate
Provide patient’s concomitant drug therapies for other conditions:

Section 6 – Clinical Information Please provide relevant medical data (e.g. culture and sensitivity reports, serum drug levels, laboratory results):

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 www.health.gov.on.ca. 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, 3^rd floor, 5700 Yonge St., Toronto ON M2M 4K5.

Authorized prescriber (Print Name)
Authorized prescriber signature (mandatory)

Registration number
Date (yyyy/mm/dd)

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

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

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