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Standard Special Authorization Request Form
2024-04-02
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.
Erythropoietin Program Approval Form
https://www.princeedwardisland.ca/sites/default/files/forms/erythropoietin_program_approval_form.pdf
2024-04-02
Complete this form if you have been diagnosed with chronic renal failure, or are receiving kidney dialysis. You may be eligible for coverage of anemia treatment medications, which will eliminate the need for frequent blood transfusions.
Catastrophic Drug Program Application Form
2024-04-02
Complete this form to apply for coverage of medication through the Catastrophic Drug Program.
Ankylosing Spondylitis Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.
Crohn's Disease Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.
Enfuvirtide Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.
Long Acting Insulin Analogues Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.
Plaque Psoriasis Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.
Psoriatic Arthritis Special Authorization Request Form
2024-04-02
Special authorization request form to be completed by your physician or diagnosing specialist.