What the form is for
Manitoba covers several oral diabetes drugs only through Exception Drug Status, which means the patient has to meet the criteria in the EDS listing before Pharmacare pays. This form covers five of them: canagliflozin, empagliflozin, linagliptin, saxagliptin, and sitagliptin. Approval is granted only when you show the patient meets those criteria, and Manitoba Health can ask for more documentation.
For combination products, such as empagliflozin with metformin or sitagliptin with metformin, use the general EDS request form instead. Other drugs have their own Manitoba EDS forms.
Who completes it
The prescriber completes and signs the whole form. There’s no patient section, and you confirm on the form that you’ve told the patient their information is going to Manitoba Health to obtain EDS coverage.
How to fill it in
Prescriber, patient, and medication
Enter your name, address, phone, fax, and licence number, not your billing number. Give the patient’s name, date of birth, PHIN, and Manitoba Health registration number (MHSC). Check the medication requested and enter the strength and regimen.
Diagnosis and indication
Mark type 2 diabetes, or for empagliflozin only, the cardiovascular indication: an adjunct to diet, exercise, and standard care to reduce cardiovascular death in type 2 diabetes. Use “other” only for an indication you can support from the criteria notice.
The three statements
Answer yes or no to all three: the patient had a trial of metformin that led to intolerance or inadequate control, had a trial of a sulfonylurea with the same result, and insulin isn’t an option. If you answer no to any of them, give your rationale in the space provided. For canagliflozin and the DPP-4 inhibitors, the criteria in the EDS notice rest on inadequate control on, or intolerance to, metformin and a sulfonylurea when insulin isn’t an option, so explain any no with the specific clinical reason.
Established cardiovascular disease, for empagliflozin
For the cardiovascular indication, check the condition that applies: previous MI, multi-vessel coronary artery disease, single-vessel disease with significant stenosis and a positive stress test or an unstable angina admission within 12 months, unstable angina more than 2 months ago with confirmed coronary disease, ischemic or hemorrhagic stroke, or occlusive peripheral artery disease. The criteria also need inadequate glycemic control despite an adequate trial of metformin.
Additional clinical information and signature
Add the A1C values, the doses and dates of the metformin and sulfonylurea trials, and the reason for any intolerance. Check the consent box, then date and sign.
Common reasons it’s delayed
- A “no” to the metformin, sulfonylurea, or insulin statements with no rationale.
- Empagliflozin requested for cardiovascular protection with no qualifying condition checked.
- A combination product requested on this form instead of the general one.
- A billing number entered in place of the licence number.
- No doses, dates, or A1C values to show the earlier trials failed.
Submitting and who pays
Fax the form to the EDS office at (204) 942-2030 or 1-877-208-3588, which are for health professionals only. Diabetes drugs are triaged as chronic requests, with a turnaround of 5 to 10 business days. Coverage starts from the date the request is received, and drugs bought before that aren’t covered, so send it before the patient fills the prescription. Once approved, Pharmacare pays after the patient’s deductible is met.