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Displaying 1 - 10 of 71.

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Psoriatic Arthritis Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/psoriatic_arthritis_special_authorization_request_form.pdf
2023-07-25
Special authorization request form to be completed by your physician or diagnosing specialist.  
SPECIAL AUTHORIZATION REQUEST PSORIATIC ARTHRITIS Fax requests to (902) 368-4905 OR mail requests to PEI Pharmacare, P.O. Box 2000, Charlottetown, PE, C1A 7N8...

Standard Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/standard_special_authorization_request_form.pdf
2023-06-29
Some medications in the PEI Pharmacare Formulary are approved on a, special authorization, basis only. If your physician prescribes a drug in this category, you can submit a Standard Special Authorization Request form to have a medication, considered, for coverage.
SPECIAL AUTHORIZATION REQUEST STANDARD SPECIAL AUTHORIZATION Fax requests to (902) 368-4905, email to drugprograms@gov.pe.ca OR mail requests to PEI Pharmacare, P.O. Box 2000, Charlottetown, PE, C1A 7N8 SECTION 1 – PATIENT INFORMATION PERSONAL...

Ankylosing Spondylitis Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/ankylosing_spondylitis_special_authorization_request_form.pdf
2023-06-27
Special authorization request form to be completed by your physician or diagnosing specialist.
SPECIAL AUTHORIZATION REQUEST ANKYLOSING SPONDYLITIS Fax requests to (902) 368-4905 OR mail requests to PEI...

Plaque Psoriasis Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/anti-tnf_agents_for_psoriasis_special_authorization_request_form.pdf
2023-06-27
Special authorization request form to be completed by your physician or diagnosing specialist.
SPECIAL AUTHORIZATION REQUEST PLAQUE PSORIASIS Fax requests to (902) 368-4905, email to drugprograms@gov.pe.ca OR mail requests to PEI...

Crohn's Disease Special Authorization Request Form

https://www.princeedwardisland.ca/en/form/crohns-disease-special-authorization-request-form
2023-06-27
Special authorization request form to be completed by your physician or diagnosing specialist.

Apixaban, Dabigatran, Edoxaban, Rivaroxaban Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/apixaban_dabigatran_edoxaban_rivaroxaban_special_authorization_request_form.pdf
2023-06-27
Special authorization request form to be completed by your physician or diagnosing specialist.  
SPECIAL AUTHORIZATION REQUEST Apixaban (Eliquis®) Dabigatran (Pradaxa®) Edoxaban (Lixiana®) Rivaroxaban (Xarelto®) Fax requests to (902) 368-...

DPP-4 / SGLT2 Inhibitors Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/dpp-4_sglt2_inhibitors_special_authorization_request_form.pdf
2023-06-27
Special authorization request form to be completed by your physician or diagnosing specialist.
SPECIAL AUTHORIZATION REQUEST DPP-4/SGLT2 INHIBITORS Fax requests to (902) 368-4905 OR mail requests to PEI Pharmacare...

Long Acting Insulin Analogues Special Authorization Request Form

https://www.princeedwardisland.ca/sites/default/files/forms/long_acting_insulin_analogues_special_authorization_request_form.pdf
2023-06-27
Special authorization request form to be completed by your physician or diagnosing specialist.  
SPECIAL AUTHORIZATION REQUEST LONG ACTING INSULIN ANALOGUES Fax requests to (902) 368-4905 OR mail requests to PEI Pharmacare, P.O. Box 2000, Charlottetown, PE, C1A...

Family Health Benefit Application Form

https://www.princeedwardisland.ca/sites/default/files/forms/family_health_benefit_application_form.pdf
2023-05-09
Complete this form to apply for the Family Health Benefit Drug Program.
Family Health Benefit Personal Information (please print) Applicant Spouse (if applicable) Surname Surname First Name Initial First Name Initial PEI Health Care Card number PEI Health Care Card number (PHN) Date of...

High Cost Drug Program Application Form

https://www.princeedwardisland.ca/sites/default/files/forms/high_cost_drug_program_application.pdf
2023-05-09
Complete this form if you need assistance paying for expensive medications. You may be eligible for coverage of approved medication costs through the High Cost Drug Program.  
High Cost Drug Program Personal Information (please print) Applicant Spouse (if applicable) Surname Surname First Name Initial First Name Initial PEI Health Care Card number PEI Health Care Card...
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