PEI Pharmacare Special Authorization Forms for Medical Professionals

Special Authorization Forms

Alzheimer's Disease Special Authorization Request Form [PDF | 76 KB]

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

Cancer Drug Special Authorization Request Form 1 [PDF | 396 KB]  (Filgrastim, Capecitabine, Imatinib, Dasatinib, Erolotinib, Sunitinib, Pazopanib, Fludarabine, Sorafenib, Crizotinib, Tretinoin, Nilotinib, Temozolomide, Lenalidomide)

Cancer Drug Special Authorization Request Form 2 [PDF | 71 KB]  (Abiraterone, Afatinib, Enzalutamide, Vemurafenib

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

Dabigatran, Rivaroxaban, Apixaban Special Authorization Request Form [PDF | 67 KB]

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

Enfuvirtide Special Authorization Request Form [PDF | 31 KB]

Idiopathic Pulmonary Fibrosis Special Authorization Request Form [PDF | 70 KB]

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

Low Molecular Weight Heparin Special Authorization Request Form [PDF | 30 KB]

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

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

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

Standard Special Authorization Request Form [PDF | 34 KB]

Program Application Forms

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]

Multiple Sclerosis Medications Program Medical Screening Form [PDF | 157 KB]

 

 

Published date: 
September 7, 2017

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