Exceptional Access Program, Ministry of Health and Long- Term Care. Telephone Request Service Reimbursement Criteria Exceptional Access Program, Ministry of Health and Long- Term Care. Disclaimer: The information in this document is updated on a regular basis. Although we strive to ensure that all information is accurate at the time of posting, please be aware that some items may be subject to change from time- to- time. The information provided in this document and website is intended for information purposes only and does not provide any medical diagnosis, symptom assessment, health counseling or medical opinion for individual users. This information also does not constitute medical advice for physicians or patients. For more detailed information on prescription drugs, please consult a qualified healthcare professional. Last updated August, 2. Table of contents TELEPHONE REQUEST SERVICE REIMBURSEMENT CRITERIA.. Exceptional Access Program, Ministry of Health and Long- Term Care.. TABLE OF CONTENTS.. Ciprofloxacin HCl and Dexamethasone (Ciprodex ).. Daptomycin (Cubicin ).. Fidaxomicin (Dificid ).. CHRONIC RENAL FAILURE DRUGS.. Calcium Carbonate.. Lanthanum Carbonate.. Sevelamer hydrochloride.. Vitamin B Complex with Vitamin C.. LOW MOLECULAR WEIGHT HEPARIN (LMWH).. Dalteparin sodium.. Enoxaparin sodium.. Tinzaparin sodium.. ORAL HYPOGLYCEMIC AGENTS.. PALLIATIVE CARE MEDICATIONS.. Diazepam 5 mg/ml injection.. Dimenhydrinate 5. Furosemide 1. 0 mg/ml injection.. Glycopyrrolate 0. Hyoscine 2. 0 mg/ml injection and 1. Lorazepam 4 mg/ml.. Methadone 1mg, 5 mg, 1. Metoclopramide 1. Midazolam 5 mg/ml injection.. Morphine 2 mg/ml, 1. Oxycodone 5 mg, 1. Oxycodone HCl Extended Release 1. Phenobarbital 1. 20 mg/ml injection.. This document supplements the Leniency Program. Leniency Program: Frequently Asked. Exceptional Access Program. Ministry of Health & Long Term Care: EAP Reimbursement Criteria for Frequently Requested Drugs (PDF) Ocular Inflammatory Disease/Uveitis. Reimbursement criteria for frequently requested drugs and. Narcotics, Benzodiazepines, Stimulants, and Gabapentin. Ethical dilemmas arise with regularity, indeed daily, in the practice of rheumatology. As such, the practitioner must have the sensitivity and capacity to recognize. Eculizumab chemo billing. EAP Reimbursement Criteria for Frequently Requested Drugs. Exceptional Access Program (EAP). Phenytoin 5. 0 mg/ml injection.. Scopolamine 0. 4 mg/ml, 0. POST- TRANSPLANT DRUGS.. Mycophenolate mofetil.. HIV DRUGS RENEWAL ONLY.. MULTIPLE SCLEROSIS DRUGS RENEWAL ONLY.. Dimethyl Fumarate.. Glatiramer acetate.. Interferon beta- 1a.. Interferon beta- 1b.. INTRODUCTION The Ontario Public Drug Programs has developed these reimbursement criteria to provide physicians with information about selected drug products that may be considered for funding through the Exceptional Access Program s (EAP) Telephone Request Service (TRS).
The TRS offers physicians another way to submit EAP requests for a group of selected drugs. This document provides a list of the drugs and their funding criteria that are considered through the TRS. In most cases, the request, the request will be assessed in real time with a one business day turnaround. Physicians (or their delegates) are encouraged to review the reimbursement criteria for the drug being requested before calling the service to ensure that all of the necessary information is available during the call. Callers who wish to submit a request for drug products and indications not currently available through TRS will be asked to fax the request to EAP. If your request is approved, the physician will receive a faxes response letter notifying him/her of the funding decision. The EAP response letter will list the specific drug, drug identification number (DIN) or product identification number (PIN), strength and dosage form that is considered for funding and physicians and pharmacists are responsible to ensure that funded products are provided to avoid unnecessary out- of- pocket costs to the patient. Note that not all generic brands are funded or interchangeable (on- formulary or off- formulary). You can refer to the formulary for a list of interchangeable drugs products. The Ministry reserves the right to change the list of drug products at its sole discretion. If you have any questions or concerns regarding the TRS, please contact us at: Exceptional Access Program Telephone Request Service 3rd Floor, 5. Yonge St. North York, ON M2. M 4. K5 Phone: 1- 8. Fax: 1- 8. 66- 8. E- mail: EAPFeedback. Line@ontario. ca 6. ANTIBIOTICS Cefazolin Dosage Form: 1 g/vial injection For treatment of infections susceptible to cefazolin. Standard Approval Duration: As requested up to 5 years Ciprofloxacin HCl and Dexamethasone (Ciprodex ) Dosage Form: ciprofloxacin (3 mg/ml) and dexamethasone (1 mg/ml) otic solution For the treatment of otitis externa where: The patient has perforated tympanic membrane, ventilation tubes, or documented pre- existing hearing impairment; or Chronic therapy with Ciprodex (i. Aminoglycoside therapy has failed (and physician provides details pertaining to aminoglycoside use and concerns about a resistant pathogen). NOTE: Ciprodex reimbursement is not considered for any other indications (e. Standard Approval Duration: 1 month 7. Dapsone Dosage Form: 1. For the treatment of: Pneumocystis jiroveci pneumonia (PJP) prophylaxis in immunocompromised patients (e. Standard Approval Duration: Lifetime 8. Daptomycin (Cubicin ) Dosage Form: 5. For the treatment of patients with one or more of the following condition(s): i) Osteomyelitis caused by methicillin- resistant staphylococcus aureus (MRSA); ii) Device- related osteoarticular or prosthetic joint infections caused by methicillinresistant staphylococcus aureus (MRSA); iii) Diabetic foot infections caused by methicillin- resistant staphylococcus aureus (MRSA); AND/OR iv) Staphyloccoccus aureus bloodstream (SAB) infection including right- sided Staphylococcus aureus infective endocarditis (SARIE) infection caused by methicillin- resistant Staphylococcus aureus (MRSA) Additionally, the patient must have failed to adequately respond to, be intolerant* to, or have a contraindication to vancomycin. Standard Approval Duration: Up to maximum of 5. Exclusion Criteria: Daptomycin is not funded for patients with: i) MRSA- related pneumonia; ii) skin/skin structure infections other than diabetic foot infections caused by MRSA. Fidaxomicin (Dificid ) Dosage Form: 2. For the treatment of Clostridium difficile infection (CDI) in patients who meet the EAP criteria for vancomycin use, but where the patient: has experienced a third or subsequent episode within 6 months of treatment with vancomycin for prior episodes, with no previous trial of fidaxomicin; OR has experienced treatment failure* with oral vancomycin for the current CDI episode; OR has had a documented allergy (immune mediated reaction) to oral vancomycin; OR has experienced a severe adverse reaction or intolerance** to oral vancomycin treatment that resulted in the discontinuation of vancomycin therapy. Re treatment criteria: Re treatment with fidaxomicin will only be considered for an early relapse occurring within 3. Relapse/ recurrence occurring beyond 3. Note: Fecal biotherapy ( stool transplantation ), if available, should be encouraged for this patient population. Approved Dose and Standard Approval Duration: 2. Gentamycin Dosage Form: 4. For treatment of infections susceptible to gentamycin. Standard Approval Duration: As requested up to 5 years Posaconazole Dosage Form: 4. Suspension, 1. 00mg tablets For the prophylaxis of Aspergillus and Candida infections in patients who have recently (within the past 3 months) undergone an allogeneic bone marrow (stem cell) transplant. Standard Approval Duration: Limited to 4 months For the prophylaxis of invasive fungal infections in patients who have previously (3 months or longer) undergone an allogeneic stem cell transplant and are experiencing moderate to severe graft- versus- host- disease (GVHD) will be considered on a case- bycase basis. Standard Approval Duration: Limited to 4 months Renewals will be considered on a case- by- case basis for patients who continue to experience ongoing symptoms of moderate to severe GVHD. Please provide information regarding infections that were experienced while on therapy (as applicable) including the names of medications and treatments being used to manage GVHD. Standard Approval Duration: Case- by- case 1. Posaconazole Dosage Form: 4. For the treatment of invasive aspergillosis* in patients who are refractory or intolerant to voriconazole OR who have documented contraindication to voriconazole. Note: Requests without a positive fungal culture must be accompanied by a consultation note from an infectious disease expert with details of how the diagnosis was made and will be considered on a case- by- case basis. Standard Approval Duration: 3 months Renewals will be considered on a case- by- case basis. For the treatment of mucormycosis** in patients who have failed, have a contraindication to, or experienced intolerance to amphotericin B; OR For the step- down treatment of mucormycosis** in patients who have been initially treated with amphotericin B but cannot tolerate long- term therapy with this agent. Note: Requests without a positive fungal culture but where the diagnosis of mucormycosis is documented by an infectious diseases consult and other tools (e. Standard Approval Duration: 3 months Renewals will be considered for patients who are responding to therapy but who have not experienced clinical resolution of their condition. Note that requests for renewal must be accompanied by supporting clinical information (Infectious disease consultation/radiology report). First renewal: 3 months Subsequent renewals: Case- by- case duration 1. Vancomycin Dosage Form: 1. Note that not all manufactured brands are reimbursed. Please refer to the EAP approval letter to confirm funded brands.) For patients with Clostridium difficile- associated diarrhea (CDAD) confirmed by toxin assay or typical endoscopic appearance, or histologic pattern on biopsy. If toxin results are pending, clinical suspicion is required. The following information is also required: For the first episode, patient must have failed an adequate trial of metronidazole or have an intolerance or contraindication to metronidazole, if there are no indicators of severe CDAD. For subsequent episodes, physician must provide detailed history of previous CDAD infection, including dates, duration and dose of treatment used, and patient s response to treatment.
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