When a Québec patient reacts badly to a generic and needs the brand-name (innovator) version, this 2-page request asks RAMQ to reimburse the innovator rather than only the lowest-priced equivalent. Approval requires a serious allergy or intolerance to a non-medicinal ingredient the innovator doesn't contain. Without approval, the public plan pays the lowest price and the patient pays the difference.
The prescriber completes the whole form: insured person, prescriber, the innovator drug requested, the questions about the reaction in section 4, and the signed certification in section 5 that the information is accurate.
Download the current version from the source each time; forms change without notice.
Demande de remboursement exceptionnel du coût d'un médicament innovateur
Request for Exceptional Reimbursement of the Cost of an Innovator Drug
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.
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Not on its own. The public plan reimburses the lowest-priced equivalent, and the patient pays the difference for the innovator. Only a short list of drugs is reimbursed with the Ne pas substituer mention, under specific conditions, without a form. In other cases the prescriber sends form 4596 showing a serious reaction to a generic's non-medicinal ingredient.
Section 4 asks for the generic brand responsible, whether the reaction was an allergy or an intolerance, its consequence, a detailed description and treatment, the date, the non-medicinal ingredient involved, whether that ingredient is in the innovator, whether a suitable generic exists in Canada, and any other molecule tried.
No. The form states that every requested item must be provided and that RAMQ will refuse an incomplete request. Answer all of section 4, including the questions about generics available in Canada, and send any supporting documents with the form through the secure upload page. Section 4 question 10 is the only optional item.