Last updated: December 7, 2023
Use Special Authority eForms to submit requests. eForms are easier to submit and return decisions quicker than faxing paper forms.
Special Authority requests must be completed by a licensed medical prescriber. See How to submit a Special Authority request. Incomplete forms will not be processed.
To request a status update, please call the toll-free Medical Practitioner Line at 1-866-905-4912. Do not send a request by fax as faxed requests will not be responded to. Patients may also access their own medication history, including Special Authority requests, through Health Gateway.
If you can't find the form you need below, search for the drug in the Special Authority drugs list.
Jump to CGM/FGM, insulin pumps and blood glucose test strips | Compounded medications
General Special Authority request (use only if there is no specific form below)
eForms are simpler and quicker than faxing. Enrol now.
5328 |
Atopic dermatitis
5852 |
Alzheimer's disease
donepezil, galantamine, rivastigmine
5465 | |
— | Standardized Mini-Mental State Examination (SMMSE) (PDF, 690KB) |
— | Global Deterioration Scale (GDS) (PDF, 198KB) |
Antiviral
letermovir
5816 |
Arthritis: ankylosing spondylitis
adalimumab, etanercept, golimumab, infliximab, secukinumab
5364 | |
5365 | |
5366 |
Arthritis: psoriatic
adalimumab, etanercept, golimumab, infliximab, secukinumab
Arthritis: rheumatoid
For cyclosporine and leflunomide, please use the General Special Authority Request (PDF, 656KB).
abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab
Attention deficit hyperactivity disorder (ADHD)
mixed-amphetamine salts ER, lisdexamfetamine, methylphenidate ER (Concerta-type generics), atomoxetine
5472 | Medication Coverage for Attention Deficit and Hyperactivity Disorder (PDF, 606KB) |
Blood disorders
deferasirox, iron isomaltoside, iron sucrose
5407 | Deferasirox Coverage: Initial/Switch (PDF, 360KB) |
5818 | Intravenous Iron for Iron Deficiency Anemia (PDF, 90KB) |
Cancer treatment supportive care
filgrastim
5470 | Filgrastim (Grastofil Type) (PDF, 544KB) |
Cardiovascular conditions
dabigatran, ticagrelor, ivabradine, sacubitril-valsartan, ARBs (candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan)
Diabetes
empagliflozin, empagliflozin-metformin, insulin detemir, insulin glargine, insulin pump, linagliptin, pioglitazone, saxagliptin, semaglutide
5375 | Continuous Subcutaneous Insulin Infusion (Insulin Pump) (PDF, 473KB) |
5396 | Insulin Glargine and Insulin Detemir (PDF, 500KB) |
5826 | Empagliflozin, semaglutide: Second-Line Anti-Diabetic Medications (PDF 747KB) |
5481 | Linagliptin, saxagliptin, pioglitazone: Third-Line Anti-Diabetic Medications (PDF, 633KB) |
Gastrointestinal disorders
proton pump inhibitors, adalimumab, infliximab, rifaximin, vedolizumab, obeticholic acid
General autoimmune conditions
rituximab
5848 | Rituximab for Autoimmune Conditions (PDF, 725KB) |
Hepatitis
Hepatitis B: adefovir, entecavir, interferon alpha, lamivudine, tenofovir
Hepatitis C: asunaprevir, daclatasvir, ledipasvir-sofosbuvir, pegylated interferon plus ribavirin, simeprevir, sofosbuvir, velpatasvir-sofosbuvir, sofosbuvir-velpatasvir-voxilaprevir, glecaprevir-pibrentasvir
Hypercholesterolemia
Inflammatory conditions
tocilizumab
5496 | Tocilizumab for Giant Cell Arteritis (PDF, 316KB) |
Metabolic conditions
sapropterin
5815 | sapropterin form (PDF, 734KB) |
Migraine
fremanezumab, galcanezumab
5822 | CGRP Antagonists for Migraine Prevention (PDF, 1.02MB) |
Multiple sclerosis
alemtuzurnab, cladribine, dimethyl fumarate, fingolimod, glatiramer, interferon beta, natalizumab, ocrelizumab, rituximab, siponimod, teriflunomide
Neurodegenerative conditions
Neuromyelitis Optica Spectrum Disorder (NMOSD)
rituximab, tocilizumab
5851 | Rituximab / Tocilizumab for neuromyelitis optica spectrum disorder (PDF, 710KB) |
Parkinson's disease
apomorpine, levodopa-carbidopa
5809 | Apomorphine (PDF, 648KB) |
5810 | Duodopa (PDF, 599KB) |
Respiratory conditions
aclidinium, aclidinium/formoterol, glycopyrronium, glycopyrronium/indacaterol, indacaterol, salmeterol, salmeterol/ fluticasone, tiotropium 18 mcg, tiotropium/olodaterol, umeclidinium/vilanterol, umeclidinium/vilanterol/ fluticasone, vilanterol/fluticasone, benralizumab, mepolizumab, nintedanib, pirfenidone
Skin disorders
adalimumab, etanercept, infliximab, secukinumab, ustekinumab, ixekizumab
Vasculitis
Venous thromboembolic disease
dalteparin, enoxaparin, nadroparin, tinzaparin
Glucose monitoring systems
Insulin pumps
Additional blood glucose test strips
Compounded medications