Special Authority Request Forms

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Forms—Selecting and Completing SA Forms

All PharmaCare SA Requests must be completed by a practising medical prescriber.

Select the appropriate form from the lists below:

If there is no specific form for the drug/indication, consult the full list of Special Authority drugs to access the criteria and correct form.

Please note: Some web browsers do not support all the features of PDF forms, such as fillable fields, and may produce errors. We recommend you download and open the form using the latest version of Adobe Reader.


Instructions:

1. Type the information into the form onscreen, then print the form—or print the form first and complete it by hand.

2. Sign the form.

3. Fax toll-free in B.C. to 1 800 609-4884 

Note: PharmaCare no longer provides supplies of printed forms.

 

Forms—Drugs

  donepezil, galantamine, rivastigmine

5465 Donepezil, Galantamine and Rivastigmine (PDF)  
Standardized Mini-Mental State Examination (SMMSE) (PDF)                                                  
Global Deterioration Scale (GDS) (PDF)

 Mixed-amphetamine salts ER, lisdexamfetamine, methylphenidate ER (Concerta-type generics), atomoxetine

5472 Medication Coverage for Attention Deficit and Hyperactivity Disorder (ADHD) (PDF)

 deferasirox

5407 Deferasirox Coverage — Initial / Switch (PDF)                                         

 filgrastim

5470 Filgrastim (Grastofil Type) (PDF)                                                

apixaban, dabigatran, rivaroxaban, ticagrelor

5391 Apixaban / Dabigatran / Rivaroxaban for Atrial Fibrillation (PDF)                         
5395 Ticagrelor for Acute Coronary Syndromes (PDF)

linagliptin, pioglitazone, saxagliptin, insulin detemir, insulin glargine

5358 Linagliptin / Pioglitazone / Saxagliptin Coverage (PDF)                           
5396 Insulin Glargine and Insulin Detemir (PDF)

proton pump inhibitors, adalimumab, infliximab, vedolizumab 

5350 Proton Pump Inhibitors (PPIs) (PDF)
5368 Biologics for Moderate to Severe Active Crohn’s / Fistulizing Crohn’s (PDF)                        
5374 Worksheet (based on Harvey-Bradshaw Index) (PDF)
5388 Biologics for Ulcerative Colitis (PDF) 
5466 Medical Assistance in Dying (PDF)                                                                        

 aclidinium, glycopyrronium, tiotropium, umeclidinium

5362 COPD​ (PDF)                                                                                                 

 adalimumab, etanercept, infliximab, secukinumab, ustekinumab

5379 Psoriasis Area and Severity Index (PASI) Worksheet (PDF)                                   
5380 Biologics for Moderate to Severe Psoriasis (PDF)

 

Forms—Medical Devices and Supplies

5398 Additional Blood Glucose Test Strips (PDF)                                                                                 

Forms—Compounded Medications

5479 Compound Coverage Request (PDF)