Special Authority forms by condition

Last updated: January 23, 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, insulin pumps and blood glucose test strips | Compounded medications

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General Special Authority request (use only if there is no specific form below)

eForms are simpler and quicker than faxing. Enrol now.

5328	Log in to eForms General Special Authority Request (PDF, 656KB)

Alzheimer's disease

donepezil, galantamine, rivastigmine

5465	Log in to eForms Donepezil, Galantamine and Rivastigmine (PDF, 350KB)
—	Standardized Mini-Mental State Examination (SMMSE) (PDF, 690KB)
—	Global Deterioration Scale (GDS) (PDF, 198KB)

Antiviral

letermovir

5816	Log in to eForms Letermovir Special Authority Request Form (PDF, 358KB)

Arterial thromboembolic disease

rivaroxaban

5811	Log in to eForms Rivaroxaban for Concomitant Coronary Artery Disease and Peripheral Artery Disease (PDF, 362KB)

Arthritis: ankylosing spondylitis

adalimumab, etanercept, golimumab, infliximab, secukinumab

5364	BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) (PDF, 64KB)
5365	Log in to eForms Adalimumab/Etanercept/Golimumab/Infliximab/secukinumab for Ankylosing Spondylitis: Initial/Switch (PDF, 242KB)
5366	Log in to eForms Adalimumab/Etanercept/Golimumab/Infliximab/secukinumab for Ankylosing Spondylitis: Renewal (PDF, 237KB)

Arthritis: psoriatic

adalimumab, etanercept, golimumab, infliximab, secukinumab

5360	Adalimumab/Etanercept/Golimumab/Infliximab/secukinumab for Psoriatic Arthritis: Initial/Switch (PDF, 241KB)
5361	Adalimumab/Etanercept/Golimumab/Infliximab/secukinumab for Psoriatic Arthritis: Renewal (PDF, 224KB)
5364	BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) (PDF, 64KB)
5383	Patient Health Assessment Questionnaire (HAQ) (PDF, 528KB)

Arthritis: rheumatoid

For cyclosporine and leflunomide, please use the General Special Authority Request (PDF, 656KB).

abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab

5345	Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis: Initial/Switch (PDF, 604KB)
5354	Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis: Renewal (PDF, 406KB)
5373	Rituximab for Rheumatoid Arthritis: Initial/Renewal (PDF, 388KB)
5383	Patient Health Assessment Questionnaire (HAQ) (PDF, 528KB)

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, rivaroxaban, ticagrelor, ivabradine, sacubitril-valsartan, ARBs (candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan)

5391	Dabigatran/Rivaroxaban for Atrial Fibrillation (PDF, 478KB)
5395	Ticagrelor for Acute Coronary Syndromes (PDF, 460KB)
5484	Sacubitril-valsartan for heart failure (PDF, 382KB)
5488	Ivabradine for heart failure (PDF, 302KB)
5492	ARBs: candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan (PDF, 672KB)

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

5350	Proton Pump Inhibitors (PDF, 472KB)
5368	Biologics for Moderate to Severe Active Crohn’s/Fistulizing Crohn’s: Initial/Switch (PDF, 751KB)
5495	Biologics for Moderate to Severe Active Crohn’s/Fistulizing Crohn’s: Renewal (PDF, 607KB)
5374	Worksheet (based on Harvey-Bradshaw Index) (PDF, 514KB)
5388	Biologics for Ulcerative Colitis: Initial/Switch (PDF, 940KB)
5497	Biologics for Ulcerative Colitis: Renewal (PDF, 608KB)
5483	Rifaximin (PDF, 299KB)
5490	Obeticholic acid for primary biliary cholangitis (PDF, 315KB)

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

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)
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)

Hypercholesterolemia

evolocumab

5493	Evolocumab for Heterozygous Familial Hypercholesterolemia (PDF, 586KB)

Inflammatory conditions

tocilizumab

5496	Tocilizumab for Giant Cell Arteritis (PDF, 316KB)

Metabolic conditions

sapropterin

5815	sapropterin form (PDF, 734KB)

Migraine

fremanezumab

5822	Fremanezumab (PDF, 1.01MB)

Multiple sclerosis

alemtuzurnab, cladribine, dimethyl fumarate, fingolimod, glatiramer, interferon beta, natalizumab, ocrelizumab, rituximab, siponimod, teriflunomide

5351	Disease Modifying Drugs for Multiple Sclerosis: Initial/Renewal/Switch (PDF, 785KB)
5385	Natalizumab (Tysabri) for Multiple Sclerosis: Initial/Renewal (PDF, 568KB)
5394	Fingolimod for Multiple Sclerosis: Initial/Renewal (PDF, 323KB)
5482	Alemtuzumab (Lemtrada) for Multiple Sclerosis (PDF, 519KB)
5813	Ocrelizumab for Primary Progressive Multiple Sclerosis (PDF, 594KB)
5820	Cladribine (Mavenclad) for Multiple Sclerosis (PDF, 919KB)
5821	Siponimod (Mayzent) for Secondary Multiple Sclerosis (PDF, 1MB)

Neurodegenerative conditions

edaravone

5814	Edaravone for Amyotrophic Lateral Sclerosis (ALS) (PDF, 93KB)

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

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)
5824	Asthma Triple Inhaler (ICS-LABA-LAMA) (PDF, 1.08MB)

Skin disorders

adalimumab, etanercept, infliximab, secukinumab, ustekinumab, ixekizumab

5379	Psoriasis Area and Severity Index (PASI) Worksheet (PDF, 529KB)
5380	Biologics for Moderate to Severe Psoriasis (PDF, 365KB)
5485	Adalimumab for the treatment of active moderate to severe hidradenitis suppurativa (PDF, 310KB)

Vasculitis

rituximab

5393	Rituximab for Granulomatosis with Polyangiitis or Microscopic Polyangiitis: Initial/Renewal (PDF, 500KB)

Venous thromboembolic disease

dalteparin, enoxaparin, nadroparin, tinzaparin

5338	Dalteparin/Enoxaparin (Biosimilar)/Nadroparin/Tinzaparin Low Molecular Weight Heparin (PDF, 548KB)
5469	Dalteparin/Tinzaparin/Enoxaparin (Biosimilar) for Treatment of Venous Thromboembolism in Cancer Patients (PDF, 573KB)