Non-Formulary Usage Form

Send completed forms to the pharmacy provider or as per protocol. If the anticipated cost of the medication exceeds $500 per day or $3000 for the full course of therapy, approval must first be obtained from the appropriate authority in accordance with the level of approval required under Shared Health Policy 600.105.109 Medication Non-Formulary Use.

Note: This form must be completed and submitted by the prescribing clinician (or delegate on behalf of the prescriber).

Non-Formulary Usage Form

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This field is for validation purposes and should be left unchanged.

Patient Information

Initials:(Required)

PHIN or Medical Record Number:(Required)

Date of Birth:(Required)

MM slash DD slash YYYY

mm/dd/yyyy

Location (Site and ward/department):(Required)

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Medication Requested

Generic and/or Brand Name:(Required)

Dosage Form:(Required)

Route of Administration:(Required)

Dose and Frequency:(Required)

Expected Duration of Therapy:(Required)

Cost/Day or Cost/Treatment Course(Required)

Cost/Day

Cost/Treatment Course

Estimated Cost(Required)

Please specify the urgency of the request (date required):(Required)

MM slash DD slash YYYY

mm/dd/yyyy

Diagnosis/ Indication:(Required)

e.g. summary about the diagnosis and severity of the illness for which this medication is being requested

Details of Alternatives Tried (if applicable):

Include names, doses, and duration of all formulary alternatives and why they were not appropriate or failed

Supporting Evidence:

Attach relevant medical data, current clinical guidelines, or supporting literature that justifies the use for this specific patient’s condition

Drop files here or Select files

Max. file size: 10 MB.

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Approval Confirmation

Please ensure approval has been granted prior to submission of this request. Refer to the policy here: 600.105.109-Medication-Non-Formulary-Use

Level of approval:

Approval Authority	Estimated Cost per Day	Estimated Total Treatment Course Cost (In Hospital)
Staff Pharmacist	Less than $500/day	Less than $3,000
Pharmacy Manager	$500 – $1,500/day	$3,000 – $20,000
Pharmacy Director (or designate) + Site Chief Medical Officer (or designate)	$1,500 – $5,000/day	$20,000 – $100,000
Chair, Provincial Pharmacy & Therapeutics Committee (PPTC) or designate	Greater than $5,000/day	Greater than $100,000

Note: Requests submitted deemed incomplete will be returned for completion.

Full name of the highest approving authority(Required)

First Last

Title of the approving authority(Required)

Approver Email(Required)

Include any relevant details regarding the approval process if applicable.

I acknowledge that this request is for a supply of a non‑formulary medication for the expected treatment duration specified before and does not constitute a formulary addition request.(Required)

Please sign

Date(Required)

MM slash DD slash YYYY

mm/dd/yyyy

Full name of the pharmacist you are working with:(Required)

First Last

Pharmacist Email:(Required)

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Prescriber Contact Information:

Name(Required)

First Last

Site and Department/Service:(Required)

Phone(Required)

Email(Required)

Is this form being filled out by someone other than the prescriber?(Required)

Yes

No

Delegate Name(Required)

First Last

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