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WSIB Medication Exception Form (10880A)

Prescribers use this three-page WSIB form to ask for coverage of a medication outside the WSIB formulary for a work-related injury or illness. Part A covers non-opioid requests and Part B opioid requests; each asks for the rationale, previously trialed medications, goals of therapy and the patient's function, and Part B adds morphine equivalent dose, pain severity, risk screening and tapering. The current version is 10880A (04/26).

Who completes it

Only the medication prescriber, such as a physician or nurse practitioner, can complete the form; the form states that no one else, including the patient, may fill it out.

Submitting and payment

How to submit it
Submit the completed form and any supporting documents through wsib.ca/submit, signing by hand or ticking the electronic-signature box and entering your name and the date.
Who pays
The WSIB pays the prescriber under fee code M758 for Part A (non-opioid request) and M639 for Part B (opioid request), and you tick both boxes only when you complete both parts.

Good to know

  • The WSIB requires authorization for all opioids with a morphine equivalent dose greater than 90, and long-term opioid prescriptions need an opioid treatment agreement between patient and prescriber.
  • Part B asks whether the patient has had lost prescriptions, early renewals or unsanctioned dose escalation, and lists concurrent sedating drugs such as benzodiazepines, hypnotics and gabapentinoids.
  • For initial requests, list previously trialed medications, including those contraindicated or not tolerated; the WSIB considers medications outside its formulary case by case.
  • The WSIB requires one prescriber and one pharmacy for all opioid prescribing, and supports free naloxone kits for people on chronic opioids at risk of overdose.

Get the official form

Download the current version from the source each time; forms change without notice.

Medication exception form

Formulaire de demande d'exception pour un médicament

Official pagePDFVersion française

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.

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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.

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Frequently asked questions

Who can fill out the WSIB medication exception form?

Only medication prescribers. The form states that it cannot be filled out by anyone else, including the person with the injury or illness. The prescriber signs a declaration that the information is true and complete, enters their WSIB provider ID and invoice number, and ticks the fee code for each part completed.

What does Part B of the medication exception form ask about opioids?

Whether there is an opioid treatment agreement, whether a naloxone kit is recommended and the Opioid Risk Tool score, plus the rationale, previous trials, goals of therapy and whether the morphine equivalent dose has increased. It also rates pain and function over the past week and asks about sedating medications and any tapering or rotation plan.

Which fee codes apply to Form 10880A?

M758 for Part A, the non-opioid treatment request, and M639 for Part B, the opioid treatment request. Tick both only if you complete both parts. M639 is also the code the WSIB physician fee schedule lists for its opioid assessment form, which the WSIB requests when it needs information on opioid indications and benefit.