The Exceptional Access Program (EAP)

What does the program cover?

In special cases, the Exceptional Access Program (EAP) covers most of the cost of various prescription drug products that are not on the approved Ontario Drug Benefit (ODB) list.  This includes cases where drugs on the ODB list have been tried and do not work; or, where an alternative drug is not available through ODB.

Who can qualify to get an EAP drug?

To qualify for coverage of a drug through EAP, you must first qualify for the ODB program.

How do I get coverage for a drug through the EAP, and how does the program work?

Talk to your doctor. Only an Ontario, Manitoba or Quebec doctor may request coverage of a drug through the EAP. The request must be made in writing or by telephone and include information about:

Your doctor will receive a letter back from the ministry which will let you know if coverage has been approved through the EAP.

Are all requests made to the EAP approved?

No, not all requests are approved. Each request is reviewed according to clinical criteria (known as EAP criteria) which are developed and recommended by the ministry’s expert advisory committee and approved by the Executive Officer of the Ontario Public Drug Programs. An external medical consultant may also review your request.

Reviews are prioritized based on:

EAP criteria must always be met before coverage can begin. This includes:

What costs will I pay?

The program covers most of the cost of drugs approved through the your EAP. Remember that under the rules of ODB, you may be asked to pay a small yearly fee and a fee to have your prescriptions filled. Learn more >>

What if treatment is required and I pay for my drug before my doctor has submitted an EAP request or before the EAP request is approved?

You should ask your doctor to submit an EAP coverage request on your behalf as soon as possible. Patients are responsible for out-of-pocket costs for prescriptions purchased prior to a funding decision by the EAP.

However, for some drugs that are eventually approved, the EAP may consider reimbursement of out-of-pocket costs up to a maximum of 30 business days before the date the EAP request was received from your doctor. You must submit your original receipts for this consideration. Any reimbursement of out-of-pocket costs only applies to ODB-eligible costs (i.e., credit card charges, bank charges, pharmacy charges in excess of ODB fees are not reimbursed.)

Important: As coverage is not guaranteed, you may not be able to fully or partially recover out-of-pocket costs that you incur prior to your request being submitted by your doctor. If your request is not approved for funding, you are responsible for the out-of-pocket costs resulting from your decision to initiate treatment in advance of a funding decision.

 

For More Information

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