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Reimbursement Instructions – Case-by-Case Review Program

Intravenous Cancer Drugs

This process applies to any injectable cancer drug administered in an outpatient hospital clinic and approved by the Case-by-Case Review Program.

What You Need to Know Before Submitting a Claim

  • The patient must receive treatment at a hospital affiliated with Ontario Health (Cancer Care Ontario). The program will directly reimburse the hospital for doses administered. We do not reimburse for doses administered in private clinics.
  • To be reimbursed, the hospital must submit treatment claims for each patient monthly. Submit the CBCRP treatment data template by the 6th of the month following the treatment. (E.g., submit data by the 6th of February for all doses administered during January.)
  • The reimbursement rate will be based on the current Provincial Drug Reimbursement Programs price list. If the approved drug is not on this list, the reimbursement rate will be based on the hospital acquisition cost.
  • Where biosimilars are available on the Canadian market, CBCRP funding will be for the least expensive available product (reference biologic or biosimilar).
  • The cost of the treatment delivery related to this approval will be funded by the Systemic Treatment – Quality-Based Procedure (ST-QBP). 

How to submit a claim

You must have access to eClaims to submit a claim. If you do not have access, contact your site’s LRA (Local Registration Authority) to request an eClaims account for CBCRP submissions. Processing new accounts for eClaims may take 1 to 3 weeks. If your claim is urgent, please work with your site’s pharmacy department, which will be able to upload to eClaims on your behalf.

  1. Download and complete the Case-by-Case Review Program Treatment Data Template.
  2. Log in to eClaims.
  3. Under Communications, select “New” button.
  4. Fill in Subject Line with “Facility Name – Month of Treatment Claims.”
  5. Under Categories, select “Case-by-Case Review Program: 3 – Treatment Data.”
  6. Select “Attach a file” and browse to select file (e.g., treatment data excel file) to upload. Repeat for each additional file.
  7. Select “Send” button once you have completed browsing and selecting all files.

Please do not email any documents containing personal health information (PHI) to Ontario Health.

 

Submit a Claim

 

Take-Home Cancer Drugs

Take-home cancer drugs (e.g., oral chemotherapy) approved by the Case-by-Case Review Program are reimbursed by the Ontario Drug Benefit (ODB) program.

Oncologists: Give your patients a copy of the Case-by-Case Review Program approval letter to take to the pharmacy that will fill their prescription.

Pharmacies: Process this claim through the Health Network System as indicated in the applicable sections of the Ontario Drug Benefit Formulary and the Ontario Drug Benefit Act. If you have questions about submitting claims through the Health Network System, contact the ODB helpdesk for assistance.

Contact Information

Questions on program eligibility/application process?
Email the CBCRP at OH-CCO_cbcrp@ontariohealth.ca.
Please do not email any documents containing personal health information (PHI) to Ontario Health.

Issues related to eClaims?
Contact the Service Desk. Standard support hours are 8 a.m. to 8 p.m. EST, Monday to Friday. Call 1-866-729-9787, or email OH-CCO_ITSM-ITServiceDesk@ontariohealth.ca.