Applying to the Exceptional Access Program
Get help paying for drugs not covered on the Ontario Drug Benefit Formulary.
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Exceptional Access Program
You may need a drug that’s not currently covered on the Ontario Drug Benefit (ODB) Formulary.
In this case, you may get help paying for selected drugs when you make a request for case-by-case consideration through the Exceptional Access Program (EAP).
As a first step to getting this help, you and your doctor or nurse practitioner can do a search to make sure the drug you need is covered through the Exceptional Access Program.
How to qualify
To qualify for the funding of selected drugs through the Exceptional Access Program, including applications through the Compassionate Review Policy, you must:
- be enrolled in one of the Ontario Drug Benefit Program’s funding programs based on your age, income, facility where you live, or through one of the Ministry’s social assistance programs.
- be prescribed the drug by an Ontario doctor licensed through the College of Physicians and Surgeons of Ontario or an Ontario nurse practitioner licensed through the College of Nurses of Ontario
- a Quebec or Manitoba doctor or nurse may prescribe the drug if you live on the border with either of these provinces
- get the prescription filled at a pharmacy in Ontario that has an agreement with the Ministry to dispense drugs under the ODB
- doctors specially licensed as dispensing physicians may also fill prescriptions in their office
How to apply
Your doctor or nurse practitioner fills out and submits the application for you. Only a doctor or nurse practitioner can apply for coverage through the Exceptional Access Program.
We consider each application according to:
- the drug that is needed
- the medical condition for which it is being used
- the approved criteria for funding
Review the funding criteria
Approved funding criteria for drugs listed in EAP are posted on the Ministry website and your doctor and nurse practitioner can do a search and review the funding criteria:
- to avoid delays from submitting incomplete requests
- to ensure the drug that is not funded on the regular ODB formulary by a prescription can be funded on a case-by-case basis for the condition requested
- to ensure if the request requires a specialist to submit the application
Submit the request
Your Ontario doctor or nurse practitioner can submit the request to the Exceptional Access Program in a number of ways:
- by using the Special Authorization Digital Information Exchange web portal
- by fax using one of the numbers below:
1-866-811-9908(toll-free) 416-327-7526(Toronto area)
Your Manitoba or Quebec doctor or nurse can submit the request by fax to the following toll-free number.
Who reviews the application
Pharmacists who specialize in the Exceptional Access Program carefully consider each application. In some cases, applications are sent out for medical expert review. These pharmacists generally base their review on the approved funding criteria for the requested drug. The criteria for funding have been developed through an established process that involves Canadian and provincial expert committees, medical experts, patients, drug manufacturers, advocacy groups, and provincial drug programs from across Canada.
The Executive Officer of the Ontario Public Drug Programs makes the final decision about the funding criteria that are reviewed through the EAP.
Timing for decisions on applications
Applications to the Exceptional Access Program are reviewed as quickly as possible and a decision on your application will be sent to the requesting doctor or nurse practitioner in 3 days to 6 weeks (starting on the business day your complete application is received).
The response time depends on:
- the drug and the condition that it is being used to treat.
- if the application is complete
- the wait may be longer if the application is missing information or required supporting documents
- if a request requires external review
- if documents are requested through the SADIE webportal, by fax, or by mail
If you decide to fill your prescription in advance of the funding decision and the request is not approved, you will not receive any coverage of your out-of-pocket costs. We can only help you pay for a drug once your application has been approved.
The turnaround time in EAP is updated on a weekly basis on the Ministry website.
Length and amount of coverage
We realize you may have to start taking the drug before your doctor or nurse practitioner can submit an application to the Exceptional Access Program.
But once an application is submitted, and if it’s approved, the cost of the drug may sometimes be covered for up to 30 working days prior to the date we received the application.
Coverage durations will vary depending on the drug and the condition and are determined by the funding criteria that have been approved for the drug.
Requests for drugs that are not listed in the EAP program for rare life-, limb-, or organ-threatening conditions
The Ministry does not fund every drug available in Canada. Some drugs are not funded on the Ontario drug benefit formulary and are also not listed in the EAP list with approved provincial funding criteria. For some drugs, your doctor or nurse practitioner can make a request for coverage to be considered for funding through the Ministry’s Compassionate Review Policy on a case-by-case basis.
Your doctor or nurse practitioner can review this policy to determine if your situation can meet the Compassionate Review Policy. The Compassionate Review Policy cannot be used to apply for drugs for its Health Canada marketed conditions.
How to apply for drugs through the Compassionate Review Policy
The doctor or nurse practitioner can use a special form that the drug programs has provided to collect the information needed for this type of request application.
If you’re applying for a drug that is not available in Canada through the Compassionate review policy, you must first apply to Health Canada’s Special Access Program for approval for the drug to be imported. The approval must be granted by Health Canada before CRP can be considered. However, approval to receive an imported drug through Health Canada does not guarantee funding by the province. The request must still meet the compassionate review policy for being a rare, life-, limb-, or organ-threatening condition and all appropriate funded alternatives must be tried or considered.
The Executive Officer of the Ontario Public Drug Programs makes the final decision on whether to approve or deny an application.
Drugs used for cancer treatment
You can get help paying for drugs used to treat cancer.
If you need an oral cancer drug, your doctor or nurse practitioner can submit your application to the Exceptional Access Program on your behalf.
For most injectable cancer drugs, your oncologist – a doctor specializing in cancer can submit a request for coverage on your behalf through one of Ontario’s cancer hospitals.
Ontario Health - Cancer Care Ontario oversees the funding for injectable cancer drugs. Learn more about the New Drug Funding Program.
Injectable cancer drugs that are administered in the hospitals are generally not charged to the patient.
Oral or injectable cancer drugs used when you are admitted to the hospital are not charged to the patient.
For many new oral cancer drugs taken at home, you may need an approval through the Exceptional Access Program to have the drug covered. The same eligibility apply to cancer drugs as to other drugs funded through the Exceptional Access Program. Coverage is not provided for every oral cancer drug in Canada. Only those cancer drugs that are approved for provincial funding through the established national and provincial processes are considered for provincial funding through the Ontario drug benefit program which includes the Exceptional Access Program.
At the pharmacy
Once you’ve been approved for coverage through the Exceptional Access Program, including applications made through the Compassionate Review Policy, make sure to:
- show the pharmacist your valid Ontario health card
- tell the pharmacist which funding program you are enrolled in to qualify you to receive drugs funded under the Ontario drug benefit program which includes drugs that are not on the formulary that have been pre-authorized for coverage through the Exceptional Access Program. If you are not a senior over 65 years of age, and not 24 years of age or younger without a private plan, and not receiving benefits through a special home or long-term care or through a social assistance program, you may apply to be enrolled in the Trillium Drug Program to qualify for help with coverage of costly prescriptions based on your household income.