Special Authority forms by condition
Last updated: November 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/FGM, insulin pumps and blood glucose test strips | Compounded medications
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5328 |
5852 |
donepezil, galantamine, rivastigmine
5465 | |
— | Standardized Mini-Mental State Examination (SMMSE) (PDF, 690KB) |
— | Global Deterioration Scale (GDS) (PDF, 198KB) |
letermovir
5816 |
rivaroxaban
5811 |
adalimumab, etanercept, golimumab, infliximab, secukinumab
5364 | |
5365 | |
5366 |
adalimumab, etanercept, golimumab, infliximab, secukinumab
For cyclosporine and leflunomide, please use the General Special Authority Request (PDF, 656KB).
abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab
mixed-amphetamine salts ER, lisdexamfetamine, methylphenidate ER (Concerta-type generics), atomoxetine
5472 | Medication Coverage for Attention Deficit and Hyperactivity Disorder (PDF, 606KB) |
deferasirox, iron isomaltoside, iron sucrose
5407 | Deferasirox Coverage: Initial/Switch (PDF, 360KB) |
5818 | Intravenous Iron for Iron Deficiency Anemia (PDF, 90KB) |
dabigatran, rivaroxaban, ticagrelor, ivabradine, sacubitril-valsartan, ARBs (candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan)
empagliflozin, empagliflozin-metformin, insulin detemir, insulin glargine, insulin pump, linagliptin, pioglitazone, saxagliptin, semaglutide
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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) |
proton pump inhibitors, adalimumab, infliximab, rifaximin, vedolizumab, obeticholic acid
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
tocilizumab
5496 | Tocilizumab for Giant Cell Arteritis (PDF, 316KB) |
sapropterin
5815 | sapropterin form (PDF, 734KB) |
fremanezumab
5822 | Fremanezumab (PDF, 1.01MB) |
alemtuzurnab, cladribine, dimethyl fumarate, fingolimod, glatiramer, interferon beta, natalizumab, ocrelizumab, rituximab, siponimod, teriflunomide
rituximab, tocilizumab
5851 | Rituximab / Tocilizumab for neuromyelitis optica spectrum disorder (PDF, 710KB) |
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
adalimumab, etanercept, infliximab, secukinumab, ustekinumab, ixekizumab
dalteparin, enoxaparin, nadroparin, tinzaparin
Glucose monitors, insulin pumps, blood glucose test strips
Compounded medications