Prior approval from the Ministry of Health and Long-Term Care is required in order for patients to receive funding for OHIP insured hospital and medical services out of country (OOC). Written approval must be received from the ministry before OOC health services are rendered.

Important : Processing an Application for OOC Prior Approval may take several weeks. To reduce processing delays, please ensure that all relevant sections of the application form are completed, the treatment being requested is clearly specified, and supporting documentation (if any) has been provided.

• Out of Country Prior Approval Process
• Specialist Confirmation
• CritiCall and Emergency Referrals
• Eligibility
• Approval
• Services Not Eligible for Out of Country Funding
• Workplace Safety and Insurance Board (WSIB)
• Positron Emission Tomography (PET) Studies/Programs
• ConnexOntario
• OOC Erbitux Treatment
• Pine River Institute

Physicians seeking out of country hospital or medical treatment on behalf of their patients must complete and submit a Prior Approval Application to the ministry before out of country treatment is rendered.

The following new Out-of-Country Prior Approval application forms are now available.

• Prior Approval Application for Full Payment of Insured Out-of-Country (OOC)
  Health Services (Form 4520-84)
• Prior Approval Application for Full Payment of Insured Out-of-Country (OOC)
  Health Services - Request for Diagnostic Laboratory Testing (Form 4521-84)
• Application for Approval of Full Payment of Insured Out-of-Country (OOC)
  Health Services – Emergency/911/CritiCall Transfers (Form 4524-84)

These new forms are specific to the type of out-of-country service being requested and are intended to replace the existing form.  When applying for funding for out-of-country health services on your patient’s behalf, please complete the application form that is appropriate for the out-of-country service being requested.

Completed application forms may be mailed to the ministry at the address provided at the top of the form, or sent by fax to: 1-866-221-3536 or 613-536-3181.

Please note that the ministry will continue to accept out-of-country prior approval applications submitted using the old form until October 31, 2010.  After that time, the old forms will be considered obsolete and you will be contacted to resubmit an application to the ministry using a new application form. 

For more information about the out-of-country prior approval process, please refer to Bulletin 4512

Note : As the referring Ontario physician, it is your responsibility to clearly describe your patient's condition, recommended treatment, availability of services in Ontario, and also arrange for your patient's follow up care in Ontario.

Additional information relating to the Out of Country Prior Approval process and instructions for completing the Prior Approval Application form can be found in :

• OHIP Bulletin 4525
• OHIP Bulletin 4512
• OHIP Bulletin 4494
• OHIP Bulletin 4493
• OHIP Bulletin 4490
• OHIP Bulletin 4469
• OHIP Bulletin 4459

Effective April 1, 2011, requests for prior approval for funding of out of country health services require written confirmation from an Ontario physician who is a specialist in the type of service for which funding is requested. The specialist must confirm that the service is:

• generally accepted by the medical profession in Ontario as appropriate for a person in the same medical circumstances as the insured person, and
• medically necessary, and
• either
  • an identical or equivalent service is not performed in Ontario, or
  • an identical or equivalent service is performed in Ontario, but it is necessary for the insured person to travel out of Canada to avoid death or medically significant irreversible tissue damage.

General practitioners (GPs) may submit applications that include confirmation from a specialist.

GPs may also submit applications for CritiCall transfers and services that are within their scope of practice if they provide proper confirmation. Out of country services that are sometimes requested by GPs include specialist consultations and diagnostic imaging.

In exceptional emergency circumstances, it may not be possible for an attending emergency room physician to provide necessary medical care in Ontario. When acute or life-threatening circumstances require immediate services that are not available in the Ontario treating hospital, the referring emergency room physician must contact CritiCall at 1-800-668-4357 to determine if there is a suitable treatment bed at another Ontario hospital. If CritiCall is not able to transfer the patient within Ontario, CritiCall has the authority to arrange a transfer to an OOC facility. The referring emergency room physician is still required to submit a prior approval application (within 24 hours) to the ministry on behalf of the patient.

Contact or learn more about the CritiCall program.

• Criticall – What’s New

CritiCall Ontario : Help Sheets

• Guidelines when calling CritiCall Ontario
• When CritiCall Ontario Transfers Patients to the USA

Eligibility for full funding will be determined in accordance with the requirements described in the Health Insurance Act (HIA). The HIA provides that the Ontario Health Insurance Plan (OHIP) make payment for OOC services for insured Ontario residents in two distinct circumstances :

1. Prior Approved Services (services that are provided outside Canada under arrangements made by prior approval before the patient receives medical services). The requested OOC services are prescribed as insured services, if the "Prior Approval Application for Full Payment of Insured Out of Country Health Services" establishes that the services and treatment being requested are :
   • Performed at a hospital or licensed health facility; and
   • Not experimental or for research or for a survey; and
   • Generally accepted in Ontario as appropriate for a person in the same medical circumstances as the insured person; and
   • Not performed in Ontario by an identical or equivalent procedure; or
   • Performed in Ontario but the insured person must receive the services outside Canada to avoid a delay that would result in death or medically significant irreversible tissue damage.
2. Emergency Services (for insured Ontario residents travelling outside Canada). In this situation, OHIP covers only emergency health services at limited rates for medical circumstances that are acute and unexpected, arise outside Canada and require immediate treatment. Land/Air Ambulance services originating outside Ontario are not covered. It is always recommended that residents purchase travel insurance to cover costs.

When your patient's application for OOC Prior Approval has been processed by the ministry, a decision letter will be sent to you and a copy sent to your patient. The ministry's decision letter will clearly outline what service(s) have been approved, the facility where the service(s) are to be provided and the approved cost of the service(s).

The decision letter is based on the medical documentation that was provided with the application. If your patient's circumstances change, you may submit a new prior approval application to the ministry requesting new treatment and/or services as well as the proposed OOC physician/facility for consideration.

In the case of prior approvals, the ministry only covers costs for prior approved medical services. Expenses incurred for non-medical services such as travel, accommodation and meals (except where included as part of insured hospital services) are not insured services of OHIP.

Also excluded from an insured service is treatment that is generally accepted in Ontario as experimental, for research or a survey, including clinical and drug trials.

If your patient requires OOC hospital or medical services as the result of a work-related accident, the prior approval process is not applicable and a form should not be submitted to the ministry. Please contact the Workplace Safety and Insurance Board (WSIB) to discuss coverage as OHIP does not insure services to which a person is entitled under the Workplace Safety and Insurance Act (WSIA).

For more information contact :

Accountability Management Branch, Provider Payment Programs – Out of Country Program
Negotiations and Accountability Management Division
Ministry of Health and Long-Term Care
370 Select Drive, P.O. Box 168
Kingston, ON K7M 8T4
Tel: 1-888-359-8807
E-mail: OOCPriorApprovalInq.moh@ontario.ca
Fax: 1-866-221-3536 / 1-613-536-3184

As of May 17, 2010 all applications for PET studies are being handled by PET Scans Ontario. 

To obtain further information including copies of all necessary forms, please visit the PET Scans Ontario website: www.petscansontario.ca 

If you have any questions about PET services, please call the PET Information Line at:  1-877-4PET-411 (1-877-473-8411), or email PET Scans Ontario at: contactus@petscansontario.ca.

ConnexOntario Health Services Information collects and maintains information regarding those addictions, problem gambling, and mental health service organizations in Ontario that are funded by the Ministry of Health and Long-Term Care. This information aids both the public and professionals in efficiently accessing the most available and appropriate service in a given geographical area.

ConnexOntario provides this information via service-specific, toll-free phonelines and its public website : www.connexontario.ca. 

For a list of OHIP-Designated Initial Assessment Facilities, please visit the ConnexOntario website.

On November 12, 2008, the manufacturer of Erbitux made a submission to the Ontario Public Drug Programs (OPDP) for in-province funding under the New Drug Funding Program (NDFP), for the following two indications:

• in combination with irinotecan, for the treatment of EGFR-expressing metastatic colorectal carcinoma inpatients who are refractory to other irinotecan-based chemotherapy regimens; and
• as a single agent, for the treatment of EGFR-expression, metastatic colorectal carcinoma inpatients who are intolerant to irinotecan-based chemotherapy.

The submission of Erbitux is currently under review by Ontario’s Committee to Evaluate Drugs (CED).  Once the review has been completed, the CED will provide a recommendation to the Executive Officer of the OPDP, who will make a final funding decision.  It is anticipated this review will be completed in early 2009.

The CED reviewed Vectibix for the treatment of metastatic colorectal cancer in patients who have tested positive for non-mutated K-RAS oncogene and have failed chemotherapy containing fluoropyrimidine, oxaliplatin, and irinotecan.  The Executive Officer accepted the CED’s recommendation and approved funding for Vectibix; this product is now available under the New Drug Funding Program (NDPF) as of November 17, 2008.  As part of the CED’s review, there was no evidence comparing Vectibix to Erbitux in a randomized clinical trial.  Therefore, comparisons were not made with respect to efficacy and toxicity of these two products.  However, based on the clinical evidence for Vectibix, patients receiving this product were demonstrated to have superior progression-free survival when compared to those receiving placebo.  For this reason the Ministry strongly encourages physicians to consider Vectibix prior to exploring out-of-country treatment with Erbitux.

The following are web-links to the in-province eligibility criteria for Vectibix and availability of K-RAS testing:

www.cancercare.on.ca/english/home/toolbox/drugs/ndfp/eligforms/

www.mountsinaiservices.com/K-ras/default.htm

Effective immediately, in order to process an application for out-of-country treatment with Erbitux, the ministry requires that physicians outline the in-province treatment options that have been used and discuss whether the patient is suitable for the in-province treatments not yet tried.

In-province funded treatment options now include :

First-line treatment options :

• FOLFIRI regimen (regimen containing irinotecan and 5-FU)+/- Avastin (bevacizumab)
• FOLFOX regimen (regimen containing oxaliplatin and 5-FU)
• Tomudex (raltitrexed)
• 5-FU
• Xeloda (capecitabine)

Second-line treatment options:

• FOLFIRI regimen
• FOLFOX regimen
• Irinotecan as single agent

Third-line treatment options:

• Vectibix

Pine River Institute is a residential treatment centre and outdoor leadership experience for youth 13 to 19 years of age who are in crisis, largely as a result of addictive behaviours.

Contact or learn more about the Pine River Institute