Enrols a patient in end-stage terminal illness, living at home, in the Palliative Care Drug Program.
- Completed by
- Palliative care physician or nurse (authorizer)
- Issued by
- NS Pharmacare Programs (Health and Wellness)
- Format
- Language
- English
Nova Scotia Pharmacare Standard ESD Request Form
Nova Scotia Pharmacare uses this one-page form to request coverage of an exception status drug when no specialized form applies. Exception status drugs are covered only when the patient meets criteria set by the Atlantic or Canadian Expert Advisory Committees. The prescriber states the diagnosis, the drug and dosage requested, and why it is needed, then returns the form to Pharmacare Programs.
Who completes it
The prescriber completes the whole form: patient details including health card number, diagnosis or indication, the requested drug and dosage, the reason for the request, and their name, address, licence number and signature.
Submitting and payment
- How to submit it
- Mail or fax the form to Nova Scotia Pharmacare Programs using the details printed at the bottom, or submit online through Ocean if taking part in the Pharmacare ESD Pilot.
Good to know
- Tick one reason (contraindication, adverse event, therapeutic failure or other) and explain it; the form has one free-text box for the explanation and another for other comments.
- Check 'Criteria for coverage of exception status drugs: Pharmacare Programs' first, since coverage depends on the patient meeting the criteria listed for the requested drug.
- Nova Scotia offers 58 specialized forms; this standard request is for exception status drugs that none of them covers.
- The current version is dated 01/2024; Nova Scotia's exception status drugs page lists it under 'All standard requests', last updated 12 July 2024.
Get the official form
Download the current version from the source each time; forms change without notice.
Request for Coverage of Exception Status Drug
Fill it with Vero
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.
How this list is checked
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Frequently asked questions
When should I use Nova Scotia's standard exception status drug form?
Use it to request Pharmacare coverage of an exception status drug that has no specialized form. Nova Scotia publishes 58 specialized forms for drugs and conditions such as arthritis, ADHD, diabetes agents and asthma inhalers; for those, the specialized form applies instead.
What reasons can I give on the Nova Scotia standard exception status drug form?
The form offers four checkboxes: contraindication, adverse event, therapeutic failure or other, followed by an 'Explain' box. Use it to show how the patient meets the published exception status drug criteria for the requested drug, and add any other comments in the space provided.
Where do I send the Nova Scotia standard exception status drug request?
Return it to Nova Scotia Pharmacare Programs by mail or fax, using the address and fax number printed at the bottom of the form. Providers with an Ocean account can instead send the request online through Ocean as part of the Pharmacare ESD Pilot.