Special Authority Request Forms

Special Authority Request information can be typed onto the PDF form and then printed or the form can be printed and completed by hand.

Completed request forms must be signed, and faxed to the number indicated on the form. All forms must be completed by a licensed practitioner or hospital pharmacist.

In Victoria, fax to: (250) 952-1065

In BC, fax to toll-free 1-800-609-4884

5328 - Special Authority Request ^{(PDF 129K)}

5332 - Cyclosporin / Leflunomide for Rheumatoid Arthritis Coverage ^{(PDF 165K)}

5338 - Low Molecular Weight Heparin Coverage ^{(PDF 123K)}

5345 - Adalimumab/Etanercept/Infliximab and Abatacept/Rituximab for Rheumatoid Arthritis-Initial or Switching Coverage ^{(PDF 187K)}

5354 - Adalimumab / Etanercept / Infliximab for Rheumatoid Arthritis-Annual Renewal ^{(PDF 160K)}

Patient Health Assessment Questionnaire ^{(PDF
42K
)} - for use with forms 5345, 5354, 5360, 5361 and 5373.

5368 - Adalimumab/Infliximab for Moderate to Severe Active Crohn’s Disease and Fistulizing Crohn’s Disease ^{(PDF 635K)}
Coverage of adalimumab becomes effective September 9, 2008.

5374 - Worksheet (Based on Harvey Bradshaw Index) ^{(PDF 523K)}

5350 - Proton Pump Inhibitors Request for Coverage ^{(PDF 133K)}

5351 - Disease Modifying Drug Coverage for Multiple Sclerosis ^{(PDF 155K)}

5352 - Disease Modifying Drug Coverage for Multiple Sclerosis - Change of Medication ^{(PDF 152K)}

5353 - Disease Modifying Drug Coverage for Multiple Sclerosis - Annual Therapy Review ^{(PDF 151K)}

5356 - Pegylated Interferon/Ribavirin Coverage for the Treatment of Chronic Hepatitis C in Naive Patients ^{(PDF 158K)}

5358 - Pioglitazone / Rosiglitazone ^{(PDF 166K)}

5360 – Adalimumab / Etanercept / Infliximab for Psoriatic Arthritis - Initial Coverage ^{(PDF 183K)}
Note: Infliximab for psoriatic arthritis coverage becomes effective March 14, 2008.

5361 – Adalimumab / Etanercept / Infliximab for Psoriatic Arthritis - Renewal Coverage ^{(PDF 164K)}
Note: Infliximab for psoriatic arthritis coverage becomes effective March 14, 2008.

5362 - Tiotropium Coverage^{(PDF 276K)}

5364 - BASDAI (Bath Ankylosing Spondylitis-Disease Activity Index) ^{(PDF 78K)}

5365 – Adalimumab / Etanercept / Infliximab for Ankylosing Spondylitis – Initial Coverage^{(PDF 184K)}
Note: Ankylosing Spondylitis coverage becomes effective March 14, 2008.

5366 – Adalimumab / Etanercept/ Infliximab for Ankylosing Spondylitis – Renewal Coverage^{(PDF 195K)}
Note: Ankylosing Spondylitis coverage becomes effective March 14, 2008.

For information on the new streamlined forms for the Alzheimer's Drug Therapy Initiative and to find out how you can provide additional feedback, please see our Special Authority information page.
5369 - Initial Coverage of Cholinesterase Inhibitors ^{(PDF 204K)}
5370 - Renewal/Switching Cholinesterase Inhibitors ^{(PDF 199K)}
5371 - Switching for Tolerability for Cholinesterase Inhibitors ^{(PDF 170K)}

5372 – Chronic Hepatitis B—Initial and Renewal Coverage^{(PDF 225K)}
Coverage of tenofovir: Effective November 12, 2009.

5373 – Abatacept/Rituximab—Coverage Renewal^{(PDF 199K)}

Note: Forms 5375 and 5376 must be accompanied by a copy of form 5377 completed by the patient or their parent or guardian.

5375 – Continuous Subcutaneous Insulin Infusion (Insulin Pump) – Initial Coverage^{(PDF 148K)}
Note: Coverage for insulin pumps becomes effective November 17, 2008.

5376 – Continuous Subcutaneous Insulin Infusion (Insulin Pump) – Subsequent Coverage^{(PDF 150K)}
Note: Coverage for insulin pumps becomes effective November 17, 2008.

5377 – Patient/Family Agreement for an Insulin Pump^{(PDF 175K)}