PEI Pharmacare Special Authorization Forms for Medical Professionals

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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]

Multiple Sclerosis Medications Program Special Authorization Request Form  [PDF | 155 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]

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]
 

Date de publication : 
le 25 Mars 2019
Santé Î.-P.-É.

Renseignements généraux

Santé Î.-P.-É​.
16, rue Garfield
C.P. 2000
Charlottetown (Î.-P.-É.) C1A 7N8

Téléphone : 902-368-6130
Télécopieur : 902-368-6136

healthpei@gov.pe.ca

Vie privée et santé

Information aux médias
Téléphone : 902-368-6135

Conseil d’administration de Santé Î.-P.-É.
Téléphone : 902-368-4637

En cas d’urgence médicale, appelez au 911 ou rendez-vous aux urgences.

Si vous avez besoin d’aide ou d’information en matière de santé, appelez au 811.

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