Special Authority request forms

New in 2022: Special Authority eForms for easier and faster submissions and decisions.

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

On this page: Forms for drugs | Forms for medical devices and supplies | Forms for compounded medications

How to complete a paper Special Authority request

All PharmaCare Special Authority requests must be completed by a practicing medical prescriber. 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. Read up on the digital option (Special Authority eForms) for easier, faster submissions and decisions.

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)

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)

 

Forms—medical devices and supplies

 Forms—compounded medications