Special Authority forms by condition

Last updated on July 30, 2024

Special Authority eForms are easier to submit and return decisions quicker than faxing paper forms.

Special Authority requests must be completed by a licensed medical prescriber.

Patients can find find out if Special Authority requests have been approved at Health Gateway. Prescribers can call the toll-free Medical Practitioner Line at 1-866-905-4912. Do not send a request by fax.

If you can't find the form you need below, search the Special Authority drugs list

Jump to: CGM/FGM, insulin pumps and blood glucose test strips | Compounded medications


 

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

 eForms are simpler and quicker than faxing. Enrol now. 

5328
 

Atopic dermatitis

 

Antiviral

 

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)
 

Cancer treatment supportive care

 

Cardiovascular conditions

 

Diabetes

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

For diabetes-related supplies, visit glucose monitors, insulin pumps, blood glucose test strips

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)
 

General autoimmune conditions

 

Graft vs. host disease

 

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)
 

Inflammatory conditions

 

Kidney disease

 

Metabolic conditions

 sapropterin

5815 sapropterin form (PDF, 734KB)
 

Migraine

fremanezumab, galcanezumab, eptinezumab

5822 CGRP Antagonists for Migraine Prevention (PDF, 1.02MB)
 

Neurodegenerative conditions

Amifampridine (gov.bc.ca) for Lambert-Eaton Myasthenic Syndrome – I think it goes under neurodegenerative conditions

amifampridine, edaravone

5828 Amifampridine for Lambert-Eaton myasthenic syndrome
5814 Edaravone for Amyotrophic Lateral Sclerosis (ALS) (PDF, 93KB)
 

Parkinson's disease

levodopa-carbidopa

5810 Duodopa (PDF, 599KB)
 

Respiratory conditions

aclidinium, aclidinium/formoterol, glycopyrronium, glycopyrronium/indacaterol, indacaterol, nintedanib, salmeterol, salmeterol/ fluticasone, tiotropium 18 mcg, tiotropium/olodaterol, umeclidinium/vilanterol, umeclidinium/vilanterol/ fluticasone, vilanterol/fluticasone, benralizumab, mepolizumab, nintedanib, pirfenidone

Nintedanib for Progressive Pulmonary Fibrosis

5823 Nintedanib for progressive pulmonary fibrosis (PDF, 398KB)
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)

 

Glucose monitors, insulin pumps, blood glucose test strips

 Compounded medications

 

Compounded medications