Québec prescribers use this 3-page request to ask RAMQ to cover a drug that isn't on the Liste des médicaments, or an exception drug for an indication the List doesn't recognize. Coverage requires an eligible drug, a serious and chronic condition, a particular medical necessity and no other covered option. RAMQ assesses each request case by case, in order of receipt.
The authorized prescriber completes and signs the form. A first request needs every section except 8 and 9, a renewal needs sections 1 to 4, 8, 10 and 11, and outpatient end-of-life palliative care requests use sections 4, 7, 10 and 11.
Download the current version from the source each time; forms change without notice.
Demande d'autorisation de paiement – Mesure du patient d'exception
Request for Payment Authorization – Exceptional Patient Measure
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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No other drug on RAMQ's lists and no other insured treatment can be used, because of contraindications, significant intolerance or failure. Failure counts only if the patient took the alternative at an effective dose for long enough. Being more effective than another drug does not make a drug a last resort. Section 7 asks for this treatment history.
Section 6 rates functional limitation from 0 (none) to 4 (extreme) for physical activities, daily activities at home and outside the home, and social activities, based on the patient's state before the drug was started. It also asks about morbidity or mortality risk, psychological impairment, severity scales, and repeated consultations or hospitalizations.
No. Prescribers outside Québec who have not joined Québec's health insurance plan use form 4516, the out-of-Québec version of the same request, and send it through RAMQ's secure online form with supporting documents. RAMQ answers those requests by mail rather than through secure messaging.