What the 4406-87 is for
The ministry considers coverage of drugs not listed on the Ontario Drug Benefit Formulary under section 16 of the Ontario Drug Benefit Act. Form 4406-87 is the general request that works for any EAP drug. The patient must be eligible for ODB, which includes people enrolled in the Trillium Drug Program. Many drugs have their own EAP criteria, and some can be requested by phone through the Telephone Request Service.
Who completes it
An authorized prescriber completes all six sections and signs. The patient has no part to fill in.
How to fill in sections 1 to 6
Section 1 and 2: prescriber and patient
Give your name, prescriber type, address, phone and fax, so the ministry can reach you with questions and its decision. For the patient, give the health number and date of birth, and tick new request or renewal with the existing EAP number.
Section 3: drug requested
Name the product, DIN, strength and dosage form, frequency, expected start date and duration of therapy.
Section 4: diagnosis and reason for use
State the diagnosis and why a formulary alternative won’t do. If the patient already takes the drug, give the start date and objective evidence that it works, such as lab values or scores.
Section 5: current and previous medications
List each alternative tried, with dose, approximate timeframe, whether current or previous, and why it failed or isn’t appropriate. Then list the patient’s other drugs for other conditions. Many drugs’ EAP criteria name the therapies that must be tried first, so match your list to them.
Section 6: clinical information
Attach or enter the medical data the criteria call for: cultures and sensitivities, serum drug levels, lab results, or disease activity measures.
Common reasons it’s delayed
- Prior therapies listed without dose, duration or the reason they failed.
- No objective evidence of efficacy for a patient already on the drug.
- A request for a drug whose criteria the patient doesn’t meet.
- Missing lab results or scores the drug’s criteria require.
- A renewal sent after the current approval expired.
- An unsigned form or a missing registration number.
Submitting and who pays
Submit through SADIE, or fax to the numbers printed on the form, or mail to the Drug Programs Delivery Branch. Turnaround starts on the business day the ministry receives a complete request. The ministry replies by letter with the coverage dates. Share a copy with the patient or pharmacy so there is no gap in treatment.