PEI Pharmacare Forms

For Medical Professionals

Ankylosing Spondylitis Special Authorization Request Form [PDF | 113 KB]

Crohn's Disease Special Authorization Request Form [PDF | 190 KB] 

DPP-4 / SGLT2 Inhibitors Special Authorization Request Form [PDF | 190 KB]

Enfuvirtide Special Authorization Request Form [PDF | 31 KB]

Long Acting Insulin Analogues Special Authorization Request Form [PDF | 180 KB]

Nintedanib / Pirfenidone Special Authorization Request Form 

Plaque Psoriasis Special Authorization Request Form [PDF | 320 KB]

Psoriatic Arthritis Special Authorization Request Form [PDF | 152 KB]

Retinal Disease Treatment Special Authorization Request Form [PDF | 352 KB]

Rheumatoid Arthritis Special Authorization Request Form [PDF | 169 KB]

Semaglutide Special Authorization Request Form 

Standard Special Authorization Request Form [PDF | 34 KB]

Ulcerative Colitis Special Authorization Request Form [PDF | 257 KB]

Program Application Forms

Catastrophic Drug Program Application Form [PDF | 351 KB]

Diabetes Referral Form [PDF | 112 KB]

Erythropoietin Program Approval Form [PDF | 21 KB]

Family Health Benefit Program Application Form [PDF | 548 KB]

High Cost Drug Program Application Form [PDF | 564 KB]

Home Oxygen Program Application Form [PDF | 75 KB]

Ostomy Supplies Program Patient Application Form [PDF | 414 KB]

Ostomy Supplies Program Registration Form for Health Care Providers [PDF | 227 KB]

Substance Use Harm Reduction Drug Program Patient Registration Form   [PDF | 257 KB]

Ukrainian Evacuee and Government Assistance Refugee Income Waiver and Status Confirmation Form [PDF] 

Published date: 
May 14, 2024
Health and Wellness

General Inquiries

Department of Health and Wellness
4th Floor North, Shaw Building
105 Rochford Street
Charlottetown, PE   C1A 7N8

Phone: 902-368-6414
Fax: 902-368-4121

DeptHW@gov.pe.ca