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]
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]