This 2-page request asks RAMQ to exempt Nexium (esomeprazole) or Prevacid FasTab (lansoprazole) from the maximum payable price for a patient who can only take a proton pump inhibitor in dissolved form. It applies to severe dysphagia or to a nasogastric or gastrojejunal tube. RAMQ no longer updates the form and points prescribers to its online service instead.
The authorized prescriber completes every section: patient and prescriber details, the drug with strength, dosage and planned duration, the clinical reason in section 4, then signs section 6 certifying the information is accurate.
Download the current version from the source each time; forms change without notice.
Demande d'exemption du prix maximum payable (PMP) – Nexium (Esoméprazole), Prevacid FasTab (Lansoprazole)
Request for Exemption from the Maximum Payable Price (MPP) – Nexium (esomeprazole), Prevacid FasTab (lansoprazole)
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RAMQ still lists form 8500 on its professional forms index, but the PDF states that RAMQ no longer updates it. Prescribers can make the same request through the online service Patient et médicaments d'exception. If you send the PDF version instead, expect additional processing time.
Patients who can take a proton pump inhibitor only in dissolved form and who have severe dysphagia, a nasogastric tube, or a gastrojejunal tube. Section 4 of the form records which situation applies, with the cause of the dysphagia or the type of tube, and section 5 leaves room for optional extra details.
RAMQ publishes form 8500 in French only, under the title Demande d'exemption du prix maximum payable (PMP). Before returning it, RAMQ asks prescribers to confirm that all required sections are completed and that the form is signed, since unsigned or partial forms slow the request.