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
Enter the first four digits - Enter the next three digits - Enter the next three digits
Male Female
Body Weight (kg) Date of Birth (yyyy/mm/dd)
New request Renewal of existing EAP Approval (specify EAP #)
Elaprase® (idursulfase) 2 mg/ml Regimen and Dosage
Confirmed Diagnosis of Hunter’s Disease (MPS II)
Please provide enzymology testing report AND mutation analysis report
Ambulatory Ambulatory with assistance Wheelchair outside the home Wheelchair inside the home Bedbound
and results of orthopedic assessment, if available
Provide Spirometry Report and / or sleep study (to determine respiratory function)
Ventilator Status (if patient on ventilator, please confirm if patient is on ventilator due to complications of MPS II)
Provide Chest Radiograph, ECG, and Echocardiogram Reports (to determine cardiac function)
Neurocognitive Status, performed by a clinical psychologist (Require consult report) and audiometry results, if available for assessment of neuro-sensoral hearing loss
Provide details of Quality of Life using age-appropriate measure (e.g. SF–36 for adults, CHQ PF–28 for children)
Neurocognitive Status, performed by a clinical psychologist (Every 3–5 years; Require consult report) and audiometry results, if available
Details of Sentinel Events (e.g. hospitalizations, surgical procedures etc.)
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 the Ontario Drug Programs Help Desk at 1 800 668–6641 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)