Special Authority Request Forms

All PharmaCare Special Authority requests must be completed by a practicing medical prescriber.

If you cannot find a form in the lists below, consult the full list of Special Authority drugs.

Jump to: Forms for drugs  |  Forms for medical devices and supplies  |  Forms for compounded medications


How to complete a form

Fill out the form on your computer, then print; or print and complete by hand. Fax to 1-800-609-4884.
Incomplete applications will be rejected and returned.

How to avoid delays:

  • Complete all request form fields
  • Write legibly
  • Sign the form
  • Include the diagnosis
  • Submit a request once only

Steps we are taking to address the backlog:

  • Hiring more SA staff
  • Streamlining workflow
  • Expanding work hours
  • Increasing support from HIBC
  • Directing non-urgent calls to HIBC

Please do not fax requests for status updates. Instead, call the Medical Practitioner Line (toll-free: 1-866-905-4912).

Further resources: How to submit a Special Authority request | Prescriber Checklist (PDF, 158KB)

Forms—drugs

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

5472 Medication Coverage for Attention Deficit and Hyperactivity Disorder (PDF, 606KB)

linagliptin, pioglitazone, saxagliptin, insulin detemir, insulin glargine

5481 Third-Line Anti-Diabetic Medications (PDF, 633KB)
5396 Insulin Glargine and Insulin Detemir (PDF, 500KB)

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, 189KB)
5473 Sofosbuvir in Combination with Ribavirin for Chronic Hepatitis C (PDF, 413KB)
5476  Velpatasvir Plus Sofosbuvir With/Without Ribavirin for Chronic Hepatitis C (PDF, 413KB)
5477  Elbasvir Plus Grazoprevir With/Without Ribavirin for Chronic Hepatitis C (PDF, 416KB)
5478 Ledipasvir Plus Sofosbuvir With/Without Ribavirin for Chronic Hepatitis C (PDF, 419KB)
5486 Sofosbuvir-velpatasvir-voxilaprevir for Chronic Hepatitis C (PDF, 414KB)
5494 Glecaprevir plus pibrentasvir (PDF, 663KB)

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

5362 Inhalers for Chronic Obstructive Pulmonary Disease (COPD​) (PDF, 403KB)
5468 Nintedanib and Pirfenidone for Idiopathic Pulmonary Fibrosis (PDF, 532KB)
5489 Benralizumab and Mepolizumab for  severe eosinophilic asthma (PDF, 431 KB)

 

Forms—medical devices and supplies