Special Authority Request Forms – Drugs and Medical Supplies

All PharmaCare Special Authority Request forms must be completed by a practising medical prescriber.

To find a form:

  1. Select an indication below.
  2. If there is no specific form listed for a drug, consult the full list of Special Authority drugs to access the criteria and correct form.

To fill out a Special Authority Request form:

  1. Type the information into the form onscreen, then print — or — print the form and complete by hand.
  2. For detailed instructions on completing the form, see the Prescriber Checklist (PDF 110K)
  3. Sign the form.
  4. Fax toll-free in B.C. to 1 800 609-4884

Note: PharmaCare no longer provides supplies of printed forms.

Alzheimer’s Disease
(donepezil, galantamine, rivastigmine)

Arthritic Conditions

Blood Disorders
(deferasirox)

Cardiovascular Conditions
(apixaban, dabigatran, rivaroxaban, ticagrelor)

Diabetes
(insulin pumps, linagliptin, sitagliptin, pioglitazone)

Gastrointestinal Disorders
(adalimumab, infliximab, proton pump inhibitors)

Hepatitis

  • Hepatitis B
    (adefovir, entecavir, interferon alpha, lamivudine, tenofovir)
  • Hepatitis C
    (pegylated interferon / ribavirin)

Multiple Sclerosis
(Disease Modifying Drugs - dimethyl fumarate, fingolimod, glatiramer, interferon beta, natalizumab)

Respiratory Conditions
(glycopyrronium, tiotropium)

Skin Disorders
(adalimumab, etanercept, infliximab, ustekinumab)

Vasculitis
(rituximab)

Venous Thromboembolic Disease
(dalteparin, enoxaparin, nadroparin, tinzaparin)

 


 

5328

General Special Authority Request (PDF 523K) - Use only if there is no specific form below

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Alzheimer's Disease

5369

Initial Coverage of Cholinesterase Inhibitors (PDF 149K)

5370

Cholinesterase Inhibitors — Renewal / Switching (PDF 163K)

5371

Cholinesterase Inhibitors — Switching for Tolerability (PDF 141K)

Global Deterioration Scale (GDS) (PDF 172K)

Standardized Mini-Mental State Examination (SMMSE) (PDF 127K)

Arthritis—Ankylosing Spondylitis

5364

BASDAI (Bath Ankylosing Spondylitis — Disease Activity Index) (PDF 72K)

5365

Adalimumab / Etanercept / Golimumab / Infliximab for Ankylosing Spondylitis — Initial / Switch (PDF 226K)

5366

Adalimumab / Etanercept / Golimumab / Infliximab for Ankylosing Spondylitis — Renewal (PDF 205K)

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Arthritis—Psoriatic

5360

Adalimumab / Etanercept / Golimumab / Infliximab for Psoriatic Arthritis — Initial / Switch (PDF 222K)

5361

Adalimumab / Etanercept / Golimumab / Infliximab for Psoriatic Arthritis — Renewal (PDF 188K)

5364

BASDAI (Bath Ankylosing Spondylitis — Disease Activity Index) (PDF 72K)

5383

Patient Health Assessment Questionnaire (HAQ) (PDF 526K)

Arthritis—Rheumatoid

5345

Abatacept / Adalimumab / Certolizumab / Etanercept / Golimumab / Infliximab / Tocilizumab for Rheumatoid Arthritis — Initial / Switch (PDF 333K)
Revised coverage of abatacept: Effective January 9, 2014

5354

Abatacept / Adalimumab / Certolizumab / Etanercept / Golimumab / Infliximab / Tocilizumab for Rheumatoid Arthritis — Renewal (PDF 315K)
Revised coverage of abatacept: Effective January 9, 2014

5373

Rituximab for Rheumatoid Arthritis — Initial / Renewal (PDF 142K)

5383

Patient Health Assessment Questionnaire (HAQ) (PDF 526K)

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Blood Disorders

5407

Deferasirox Coverage — Initial / Switch (PDF 143K)

Cardiovascular Conditions

5391

Apixaban / Dabigatran / Rivaroxaban for Atrial Fibrillation (PDF 302K)
Coverage of dabigatran: Effective May 23, 2012
Coverage of rivaroxaban for atrial fibrillation: Effective August 2, 2012
Coverage of apixaban for atrial fibrillation: Effective September 19, 2013

5395

Ticagrelor for Acute Coronary Syndromes (PDF 293K)
Coverage of ticagrelor: Effective September 13, 2012

Diabetes

5358

Linagliptin / Pioglitazone / Sitagliptin Coverage (PDF 133K)
Revised coverage of pioglitazone: Effective March 17, 2011

5375

Continuous Subcutaneous Insulin Infusion (Insulin Pump) — Initial / Renewal (PDF 296K)
For patients age 25 or younger
Revised coverage for insulin pumps: Effective April 1, 2014

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Gastrointestinal Disorders

5350

Proton Pump Inhibitors (PPIs) (PDF 127K)

5368

Adalimumab / Infliximab for Moderate to Severe Active Crohn’s / Fistulizing Crohn’s Disease (PDF 594K)

5374

Worksheet (based on Harvey-Bradshaw Index) (PDF 514K)

Hepatitis

5356

Pegylated Interferon / Ribavirin — Coverage for the Treatment of Chronic Hepatitis C in Naive Patients (PDF 139K)

5372

Chronic Hepatitis B — Initial / Renewal (PDF 199K)
Coverage of tenofovir: Effective November 12, 2009

5390

Boceprevir with Peginterferon Plus Ribavirin for Chronic Hepatitis C (PDF 170K)
Coverage of boceprevir: Effective March 13, 2012

5392

Telaprevir with Peginterferon Plus Ribavirin for Chronic Hepatitis C (PDF 313K)
Coverage of telaprevir: Effective July 5, 2012

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Multiple Sclerosis

5351

Disease Modifying Drugs for Multiple Sclerosis — Initial / Renewal / Switch (PDF 567K)
Coverage of dimethyl fumarate: Effective June 25, 2014

5385

Natalizumab (Tysabri®) for Multiple Sclerosis — Initial / Renewal (PDF 543K)

5394

Fingolimod (Gilenya®) for Multiple Sclerosis — Initial / Renewal (PDF 313K)
Coverage of fingolimod: Effective May 16, 2013

Respiratory Conditions

5362

Glycopyrronium and Tiotropium (PDF 299K)
Coverage of glycopyrronium: Effective September 19, 2013

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Skin Disorders

5379

Psoriasis Area and Severity Index (PASI) Worksheet (PDF 529K)
Coverage: Effective November 30, 2009

5380

Adalimumab / Etanercept / Infliximab / Ustekinumab — For the Treatment of Moderate to Severe Plaque Psoriasis — Initial / Switch / Renewal (PDF 181K)
Coverage: Effective November 30, 2009

Vasculitis

5393

Rituximab for Granulomatosis with Polyangiitis or Microscopic Polyangiitis — Initial / Renewal (PDF 301K)
Coverage: Effective May 16, 2013

Venous Thromboembolic Disease

5338

Dalteparin / Enoxaparin / Nadroparin / Tinzaparin — Low Molecular Weight Heparin (PDF 133K)
Revised coverage of dalteparin and enoxaparin: Effective July 17, 2012