Special Authority Request Forms

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.

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. 

 

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 (PDF)

 deferasirox

5407 Deferasirox Coverage: Initial/Switch (PDF)                                         
 

Cancer Treatment Supportive Care

 filgrastim

5470 Filgrastim (Grastofil Type) (PDF)                                                

apixaban, dabigatran, rivaroxaban, ticagrelor, ivabradine,  sacubitril-valsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan

5391 Apixaban/Dabigatran/Rivaroxaban for Atrial Fibrillation (PDF)                         
5395 Ticagrelor for Acute Coronary Syndromes (PDF)
5484 sacubitril-valsartan for heart failure (PDF)
5488 Ivabradine for heart failure (PDF)
5492 ARBs: candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan (PDF)

linagliptin, pioglitazone, saxagliptin, insulin detemir, insulin glargine

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

Hepatitis B: adefovir, entecavir, interferon alpha, lamivudine, tenofovir

Hepatitis C: asunaprevir, daclatasvir, elbasvir-grazoprevir, ledipasvir-sofosbuvir, pegylated interferon plus ribavirin, simeprevir, sofosbuvir, velpatasvir-sofosbuvir,  sofosbuvir-velpatasvir-voxilaprevir, glecaprevir-pibrentasvir

5372 Chronic Hepatitis B: Initial/Renewal (PDF)
5473 Sofosbuvir in Combination with Ribavirin for Chronic Hepatitis C (PDF)
5474 Daclatasvir in Combination with Sofosbuvir with/without Ribavirin for Chronic Hepatitis C (PDF)
5476  Velpatasvir Plus Sofosbuvir With/Without Ribavirin for Chronic Hepatitis C (PDF)
5477  Elbasvir Plus Grazoprevir With/Without Ribavirin for Chronic Hepatitis C (PDF)
5478 Ledipasvir Plus Sofosbuvir With/Without Ribavirin for Chronic Hepatitis C (PDF)
5486 Sofosbuvir-velpatasvir-voxilaprevir for Chronic Hepatitis C (PDF)
5494 Glecaprevir plus pibrentasvir (PDF)

tocilizumab

5496 Tocilizumab for Giant Cell Arteritis (PDF)

evolocumab

5493 Evolocumab for  Heterozygous Familial Hypercholesterolemia (PDF)                              
5466

Medical Assistance in Dying (PDF)                                                                        

 aclidinium,glycopyrronium, mepolizumab, nintedanib, pirfenidone, tiotropium, umeclidinium

5362 COPD​ (PDF)                                                                                                 
5468 Nintedanib and Pirfenidone for Idiopathic Pulmonary Fibrosis (PDF)
5489 Mepolizumab for  severe eosinophilic asthma (PDF)

 adalimumab, etanercept, infliximab, secukinumab, ustekinumab,  ixekizumab

5379 Psoriasis Area and Severity Index (PASI) Worksheet (PDF)                                   
5380 Biologics for Moderate to Severe Psoriasis (PDF)
5485 Adalimumab for the treatment of active moderate to severe hidradenitis suppurativa (PDF)

 

Forms—Medical Devices and Supplies

5398 Additional Blood Glucose Test Strips (PDF)                                                                                 

Forms—Compounded Medications

5479 Compound Coverage Request (PDF)