Special Authority forms by condition

Last updated: November 18, 2022

Use Special Authority eForms to submit requests. eForms are easier to submit and return decisions quicker than faxing.

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.

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


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

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

empagliflozin, empagliflozin-metformin, linagliptin, pioglitazone, saxagliptin, insulin detemir, insulin glargine

5375 Continuous Subcutaneous Insulin Infusion (Insulin Pump) (PDF, 473KB)
5396 Insulin Glargine and Insulin Detemir (PDF, 500KB)
5481 Third-Line Anti-Diabetic Medications (PDF, 633KB)

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)

fremanezumab

5822 Fremanezumab (PDF, 1.01MB)

apomorpine, levodopa-carbidopa

5809 Apomorphine (PDF, 648KB)
5810 Duodopa (PDF, 599KB)

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)

 

Continuous glucose monitor, insulin pumps, blood glucose test strips

 Compounded medications