Access most of the drug special authorization forms including special access forms from this page. This is a compilation to simplify hunt for special authorization forms for Pharmacy teams, with more to come. CURRENT DATABASE IS SHOWING FORMS FOR CANADIAN PHAMACIES ONLY. PLEASE CONTACT US WITH YOUR REGIONAL REQUIREMENTS SO THAT WE CAN ADD MORE FORMS.
COMMONLY USED FORMS
| General Form | FAMPYRA | REPATHA |
| BOTOX | FREESTYLE LIBRE 2 | STELARA |
| CIMZIA | HUMIRA | XTANDI |
| ENBREL | REMICADE |
*Source/Credits: https://www.express-scripts.ca/prior-authorization-forms
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Prior Authorization Forms | Express Scripts Canada (express-scripts.ca)
COMMONLY USED FORMS
*Source/Credits: https://www.providerconnect.ca/admincontent/drugauthorizationforms.aspx?carrier=gsc
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*Source/Credit: https://www.canadalife.com/support/forms/forms-for-coverage-through-an-advisor/request-an-assessment-for-drug-nursing-or-continuous-glucose-mo/prior-authorization-drugs.html
Unlisted Drug Product - Exceptional Access Program (EAP) Form
Senior's Copay Program Application Form
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Ministry of Health - Ministries - Central Forms Repository (CFR) (gov.on.ca)
*Source/Credits: Ministry of Health Ontario
COMMONLY USED FORMS
*Source/Credits: https://www.ab.bluecross.ca/dbl/forms.php
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Pharmacare Application & Consent Authorization Form
Pharmacare Benefit Year Projected Income Worksheet
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Pharmacare Forms and Worksheets | Health | Province of Manitoba (gov.mb.ca)
*Source/Credits: Manitoba Health
DRUG COST ASSISTANCE - SPECIAL SUPPORT PROGRAM
Side A application form (CRA consent)
Side B application form (Manual income submission)
SENIOR'S DRUG PLAN
Form B (Manual income submission)
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Extended Benefits and Drug Plan
*Source/credits: Ministry of Health - Government of Saskatchewan
COMMONLY USED FORMS
*eForms
**Source/Credits: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority/sa-drug-list
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Special Authority Request Forms