Special Authority Request Forms

All forms must be completed by a practising medical practitioner, as appropriate, on behalf of a patient.

To submit a Special Authority Request:

Type information onto the form on screen, then print - or print the form and complete by hand.
Sign the form.
Fax to Pharmaceutical Services:

To find a form or worksheet:

Select an indication below.
If no specific form is listed, use the General Special Authority Request form.

Alzheimer’s Disease
(donepezil, galantamine, rivastigmine)

Ankylosing Spondylitis
(adalimumab, etanercept, golimumab, infliximab)
Psoriatic Arthritis
(adalimumab, etanercept, golimumab, infliximab)
Rheumatoid Arthritis
(cyclosporine, leflunomide, adalimumab, certolizumab, etanercept, golimumab, infliximab, abatacept, rituximab, tocilizumab)

Blood Disorders
(deferasirox)

Diabetes
(pioglitazone, sitagliptin, insulin pumps)

Gastrointestinal Disorders
(adalimumab, infliximab, proton pump inhibitors)

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

Respiratory Conditions
(tiotropium)

Skin Disorders
(adalimumab, etanercept, infliximab, ustekinumab)

Venous Thromboembolic Disease
(low molecular weight heparin)

5328	General Special Authority Request (PDF 132K) - Use only if there is no specific form below

5369	Initial Coverage of Cholinesterase Inhibitors (PDF 160K)
5370	Renewal/Switching Cholinesterase Inhibitors (PDF 200K)
5371	Switching for Tolerability for Cholinesterase Inhibitors (PDF 170K)
—	Global Deterioration Scale (GDS) (PDF 18K)
—	Standardized Mini-Mental State Examination (SMMSE) (PDF 129K)

5365	Adalimumab / Etanercept / Golimumab / Infliximab for Ankylosing Spondylitis—Initial Coverage (PDF 269K)
5366	Adalimumab / Etanercept/ Golimumab / Infliximab for Ankylosing Spondylitis—Renewal Coverage (PDF 223K)
5364	BASDAI (Bath Ankylosing Spondylitis-Disease Activity Index) (PDF 77K)

5360	Adalimumab / Etanercept / Golimumab / Infliximab for Psoriatic Arthritis—Initial Coverage (PDF 243K)
5361	Adalimumab / Etanercept / Golimumab / Infliximab for Psoriatic Arthritis—Renewal Coverage (PDF 210K)
5364	BASDAI (Bath Ankylosing Spondylitis-Disease Activity Index) (PDF 77K)
5383	Patient Health Assessment Questionnaire (HAQ) (PDF 535K)

5345	Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis - Initial/Switch (PDF 169K)
5354	Abatacept/Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis - Renewal (PDF 154K)
5373	Rituximab for Rheumatoid Arthritis - Initial/Renewal (PDF 149K)
5383	Patient Health Assessment Questionnaire (HAQ) (PDF 535K)

5407	Deferasirox Coverage - Initial and Renewal (PDF 156K)

5358	Pioglitazone / Sitagliptin (PDF 149K) – Revised coverage of pioglitazone: Effective March 17, 2011.
5375	Insulin Pump - Initial Coverage (PDF 142K) – For patients age 18 or younger.
5376	Insulin Pump - Subsequent Coverage (PDF 144K) – For patients age 18 or younger.
5377	Patient / Family Agreement for an Insulin Pump (PDF 179K) – Revised May 8, 2012.

5350	Proton Pump Inhibitors Request for Coverage (PDF 139K)
5368	Adalimumab/Infliximab for Moderate to Severe Active Crohn’s Disease and Fistulizing Crohn’s Disease (PDF 635K)
5374	Worksheet (Based on Harvey Bradshaw Index) (PDF 523K)

5372	Chronic Hepatitis B - Initial and Renewal Coverage (PDF 195K) (Coverage of tenofovir: Effective November 12, 2009.)
5356	Pegylated Interferon/Ribavirin Coverage for the Treatment of Chronic Hepatitis C in Naive Patients (PDF 157K)
5390	Boceprevir with Peginterferon Plus Ribavirin for Chronic Hepatitis C (PDF 165K) (Coverage of boceprevir: Effective March 13, 2012.)

5351	Disease Modifying Drug Coverage for Multiple Sclerosis (PDF 550K)
5385	Special Authority Request for Natalizumab (Tysabri®) for Multiple Sclerosis (PDF 544K)

5362	Tiotropium Coverage (PDF 418K)

5380	Adalimumab / Etanercept / Infliximab / Ustekinumab – For the Treatment of Moderate to Severe Plaque Psoriasis (PDF 176K) (Coverage Effective November 30, 2009.)
5379	Psoriasis Area and Severity Index (PASI) Worksheet (PDF 524K) (Coverage Effective November 30, 2009.)

5338	Low Molecular Weight Heparin Coverage (PDF 127K)