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
5852 |
Alzheimer's disease
donepezil, galantamine, rivastigmine
5465 | |
— | Standardized Mini-Mental State Examination (SMMSE) (PDF, 690KB) |
— | Global Deterioration Scale (GDS) (PDF, 198KB) |
Antiviral
letermovir
5816 |
Arthritis: ankylosing spondylitis
adalimumab, etanercept, golimumab, infliximab, secukinumab
5364 | |
5365 | |
5366 |
Arthritis: psoriatic
adalimumab, etanercept, golimumab, infliximab, secukinumab
Arthritis: rheumatoid
For cyclosporine and leflunomide, please use the General Special Authority Request (PDF, 656KB).
abatacept, adalimumab, certolizumab, etanercept, golimumab, infliximab, rituximab, tocilizumab
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, luspatercept
5407 | Deferasirox coverage: Initial/Switch (PDF, 360KB) |
5818 | Intravenous iron for iron deficiency anemia (PDF, 90KB) |
5827 | Luspatercept for anemia associated with beta-thalassemia (PDF, 130KB) |
Cancer treatment supportive care
filgrastim
5470 | Filgrastim (Grastofil Type) (PDF, 544KB) |
Cardiovascular conditions
dabigatran, ticagrelor, ivabradine, sacubitril-valsartan, ARBs (candesartan, eprosartan, icosapent ethyl, irbesartan, losartan, olmesartan, telmisartan, valsartan)
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) |
Gastrointestinal disorders
proton pump inhibitors, adalimumab, infliximab, rifaximin, vedolizumab, obeticholic acid
General autoimmune conditions
rituximab
5848 | Rituximab for autoimmune conditions (PDF, 725KB) |
Graft vs. host disease
Ruxolitinib
5850 | Ruxolitinib for Graft vs host disease (PDF, 220KB) |
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
Hypercholesterolemia
Inflammatory conditions
tocilizumab
5496 | Tocilizumab for giant cell arteritis (PDF, 316KB) |
Kidney disease
finerenone
5856 | finerenone for end-stage kidney disease |
Metabolic conditions
sapropterin
5815 | sapropterin form (PDF, 734KB) |
Migraine
atogepant, eptinezumab, fremanezumab, galcanezumab
5822 | CGRP Antagonists for Migraine Prevention (PDF, 1.02MB) |
Multiple sclerosis
alemtuzurnab, cladribine, dimethyl fumarate, fingolimod, glatiramer, interferon beta, natalizumab, ocrelizumab, rituximab, siponimod, teriflunomide
Neurodegenerative conditions
amifampridine, edaravone
5828 | Amifampridine for Lambert-Eaton myasthenic syndrome (PDF, 100KB) - |
5814 | Edaravone for Amyotrophic Lateral Sclerosis (ALS) (PDF, 93KB) |
Neuromyelitis optica spectrum disorder (NMOSD)
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
Skin disorders
adalimumab, bimekizumab, etanercept, infliximab, risankizumab, secukinumab, ustekinumab, ixekizumab
5379 | Psoriasis Area and Severity Index (PASI) Worksheet (PDF, 529KB) |
5380 | Biologics for moderate to severe psoriasis (PDF, 365KB) |
5485 | Targeted therapies for hidradenitis suppurativa (PDF, 848KB) |
Vasculitis
Venous thromboembolic disease
dalteparin, enoxaparin, nadroparin, tinzaparin
Glucose monitoring systems
Insulin pumps
Additional blood glucose test strips
Compounded medications