{"id":156,"date":"2023-12-04T21:24:16","date_gmt":"2023-12-04T21:24:16","guid":{"rendered":"https:\/\/rxtools.ca\/?page_id=156"},"modified":"2023-12-05T20:16:03","modified_gmt":"2023-12-05T20:16:03","slug":"special-auth-forms","status":"publish","type":"page","link":"https:\/\/rxtools.ca\/index.php\/special-auth-forms\/","title":{"rendered":"Special Auth Forms"},"content":{"rendered":"
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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.<\/h4><\/div>\n<\/div><\/div><\/div>
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\n\t\t\t\t\t\t\t\tExpress Scripts (CAN)\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t
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COMMONLY USED FORMS<\/strong><\/p>\n\n\n\n\n<\/colgroup>\n\n\n\n\n\n
General Form<\/a><\/span><\/td>\nFAMPYRA<\/a><\/span><\/td>\nREPATHA<\/a><\/span><\/td>\n<\/tr>\n
BOTOX<\/a><\/span><\/td>\nFREESTYLE LIBRE 2<\/a><\/span><\/td>\nSTELARA<\/a><\/span><\/td>\n<\/tr>\n
CIMZIA<\/a><\/span><\/td>\nHUMIRA<\/a><\/span><\/td>\nXTANDI<\/a><\/span><\/td>\n<\/tr>\n
ENBREL<\/a><\/span><\/td>\nREMICADE<\/a><\/span><\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*Source\/Credits: https:\/\/www.express-scripts.ca\/prior-authorization-forms<\/p>\n

MORE <\/strong>FORMS<\/strong><\/p>\n

Prior Authorization Forms | Express Scripts Canada (express-scripts.ca)<\/a><\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t

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COMMONLY USED FORMS<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
General Form<\/a><\/td>\nBUTRANS<\/a><\/td>\nCOPAXONE<\/a><\/td>\nINTUNIV XR<\/a><\/td>\nMYRBETRIQ<\/a><\/td>\nSAXENDA<\/a><\/td>\n<\/tr>\n
ALPHAGAN P<\/a><\/td>\nBYSTOLIC<\/a><\/td>\nCOSOPT<\/a><\/td>\nINVOKAMET<\/a><\/td>\nNUCYNTA ER<\/a><\/td>\nSIMBRINZA<\/a><\/td>\n<\/tr>\n
ANDROGEL<\/a><\/td>\nCIALIS<\/a><\/td>\nDUOTRAV<\/a><\/td>\nINVOKANA<\/a><\/td>\nNUCYNTA IR<\/a><\/td>\nSYNJARDY<\/a><\/td>\n<\/tr>\n
ANORO ELLIPTA<\/a><\/td>\nCIALIS - BPH<\/a><\/td>\nENBREL (AS)<\/a><\/td>\nJANUMET<\/a><\/td>\nONGLYZA<\/a><\/td>\nTOVIAZ<\/a><\/td>\n<\/tr>\n
ARANESP<\/a><\/td>\nCIMZIA (AS)<\/a><\/td>\nENBREL (JIA)<\/a><\/td>\nJANUVIA<\/a><\/td>\nPROLIA<\/a><\/td>\nTRAJENTA<\/a><\/td>\n<\/tr>\n
ARICEPT<\/a><\/td>\nCIMZIA (PA)<\/a><\/td>\nENBREL (PA)<\/a><\/td>\nJARDIANCE<\/a><\/td>\nREMICADE (AS)<\/a><\/td>\nTRESIBA<\/a><\/td>\n<\/tr>\n
AZOPT<\/a><\/td>\nCIMZIA (PSORIASIS)<\/a><\/td>\nENBREL (PSORIASIS)<\/a><\/td>\nJENTADUETO<\/a><\/td>\nREMICADE (PSORIASIS)<\/a><\/td>\nTRULICITY<\/a><\/td>\n<\/tr>\n
Biosimilar Exception Form<\/a><\/td>\nCIMZIA (RA)<\/a><\/td>\nENBREL (RA)<\/a><\/td>\nKADIAN SR<\/a><\/td>\nREMICADE (RA)<\/a><\/td>\nVIAGRA<\/a><\/td>\n<\/tr>\n
BOTOX (BLADDER)<\/a><\/td>\nCODEINE CONTIN CR<\/a><\/td>\nENTRESTO<\/a><\/td>\nKOMBOGLYZE<\/a><\/td>\nREMICADE (UC)<\/a><\/td>\nVICTOZA<\/a><\/td>\n<\/tr>\n
BOTOX (HYPERHIDROSIS)<\/a><\/td>\nCOMBIGAN<\/a><\/td>\nFETZIMA<\/a><\/td>\nLOVENOX<\/a><\/td>\nREPATHA<\/a><\/td>\nVIMPAT<\/a><\/td>\n<\/tr>\n
BOTOX (MIGRAINE)<\/a><\/td>\nCONSTELLA<\/a><\/td>\nFOQUEST<\/a><\/td>\nM-ESLON<\/a><\/td>\nRESTASIS<\/a><\/td>\nVYVANSE<\/a><\/td>\n<\/tr>\n
BOTOX (NEUROLOGIC)<\/a><\/td>\nCONTRAVE<\/a><\/td>\nFYCOMPA<\/a><\/td>\nMS CONTIN<\/a><\/td>\nRYBELSUS<\/a><\/td>\nXIGDUO<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*Source\/Credits: https:\/\/www.providerconnect.ca\/admincontent\/drugauthorizationforms.aspx?carrier=gsc<\/p>\n

MORE <\/strong>FORMS<\/strong><\/p>\n

providerConnect - Drug Authorization Forms<\/a><\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t

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Drug Prior Authorization Form<\/strong><\/a><\/p>\n

More Information<\/a><\/strong><\/p>\n

*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<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t

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Unlisted Drug Product - Exceptional Access Program (EAP) Form<\/a><\/p>\n

Senior's Copay Program Application Form<\/a><\/p>\n

MORE INFORMATION<\/strong><\/p>\n

Exceptional Access Program<\/a><\/p>\n

Ministry of Health - Ministries - Central Forms Repository (CFR) (gov.on.ca)<\/a><\/p>\n

*Source\/Credits: Ministry of Health Ontario<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t

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COMMONLY USED FORMS<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n
General Form<\/a><\/td>\nDenosumab\/Zoledronic Acid for Osteoporosis<\/a><\/td>\n<\/tr>\n
Adalimumab\/Golimumab\/Infliximab\/Tofacitinib\/Vedolizumab for Ulcerative Colitis<\/a><\/td>\nDonepezil\/Galantamine\/Rivastigmine<\/a><\/td>\n<\/tr>\n
Adalimumab\/Vedolizumab for Crohn's\/Infliximab for Crohn's\/Fistulizing Crohn's<\/a><\/td>\nDPP-4\/SGLT2 Inhibitors\/GLP-1 Receptor Agonist<\/a><\/td>\n<\/tr>\n
Alendronate\/Raloxifene\/Risedronate for Osteoporosis<\/a><\/td>\nEplerenone\/Ivabradine\/Sacubitril+Valsartan\u00a0<\/a><\/td>\n<\/tr>\n
Aripiprazole\/Paliperidone\/Risperidone Prolonged Release Injection<\/a><\/td>\nFentanyl\u00a0<\/a><\/td>\n<\/tr>\n
Atomoxetine for Attention Deficit Hyperactivity Disorder (ADHD)\u00a0<\/a><\/td>\nImiquimod\u00a0<\/a><\/td>\n<\/tr>\n
Biosimilar Initiative\/Tiering Exception<\/a><\/td>\nLong-Acting Fixed-Dose Combination Products for Asthma\/COPD<\/a><\/td>\n<\/tr>\n
Biosimilars Initiative Support\u00a0<\/a><\/td>\nMontelukast<\/a><\/td>\n<\/tr>\n
Celecoxib<\/a><\/td>\nRivaroxaban 2.5 mg<\/a><\/td>\n<\/tr>\n
Dabigatran\/Edoxaban\/Rivaroxaban\u00a0<\/a><\/td>\nTacrolimus Topical Ointment\u00a0<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*Source\/Credits: https:\/\/www.ab.bluecross.ca\/dbl\/forms.php<\/p>\n

MORE FORMS<\/strong><\/p>\n

Seniors Financial Assistance application form<\/a><\/p>\n

DBL Forms | Alberta.ca (bluecross.ca)<\/a><\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t

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Pharmacare Application & Consent Authorization Form<\/a><\/p>\n

Pharmacare Benefit Year Projected Income Worksheet<\/a><\/p>\n

MORE INFORMATION<\/strong><\/p>\n

Pharmacare Forms and Worksheets | Health | Province of Manitoba (gov.mb.ca)<\/a><\/p>\n

*Source\/Credits: Manitoba Health<\/p>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t

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DRUG COST ASSISTANCE - SPECIAL SUPPORT PROGRAM<\/strong><\/p>\n

Side A application form (CRA consent)<\/a><\/p>\n

Side B application form (Manual income submission)<\/a><\/p>\n

SENIOR'S DRUG PLAN<\/strong><\/p>\n

Form A<\/a> (CRA consent)<\/a><\/strong><\/p>\n

Form B<\/a> (Manual income submission)<\/a><\/strong><\/p>\n

MORE INFORMATION<\/strong><\/p>\n

Extended Benefits and Drug Plan<\/a><\/p>\n

*Source\/credits: Ministry of Health - Government of Saskatchewan<\/p>\n

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COMMONLY USED FORMS<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
acetaminophen 500 mg<\/a>*<\/td>\ndextroamphetamine-amphetamine<\/a><\/td>\nlansoprazole 15 mg or 30 mg<\/a>\u00a0(RDP - PPI Drugs<\/a>\u00a0and\u00a0LCD<\/a>)<\/td>\nrivaroxaban for the treatment of venous thromboembolic events (DVT or PE)<\/a>*<\/td>\n<\/tr>\n
aripiprazole<\/a>\u00a0\u2014\u00a0(Plan G)<\/a><\/td>\ndonepezil<\/a><\/td>\nlinagliptin and linagliptin-metformin<\/a><\/td>\nsacubitril-valsartan<\/a><\/td>\n<\/tr>\n
atomoxetine<\/a><\/td>\nduloxetine<\/a><\/td>\nlisdexamfetamine<\/a><\/td>\nsemaglutide<\/a>*<\/td>\n<\/tr>\n
benzydamine<\/a><\/td>\ndutasteride<\/a>*<\/td>\nmometasone nasal spray<\/a><\/td>\nsildenafil<\/a><\/td>\n<\/tr>\n
botulinum neurotoxin type A, with complexing proteins, also known as onabotulinumtoxinA<\/a><\/td>\nempagliflozin and empagliflozin-metformin<\/a>*<\/td>\nolanzapine<\/a>\u00a0\u00a0\u2014\u00a0(Plan G)<\/a><\/td>\nsimvastatin<\/a>\u00a0\u00a0\u2014\u00a0(RDP - Statin Drugs<\/a>)<\/td>\n<\/tr>\n
brexpiprazole<\/a>\u00a0(Plan G)<\/a><\/td>\nezetimibe<\/a><\/td>\nolmesartan<\/a><\/td>\nsolifenacin<\/a><\/td>\n<\/tr>\n
budesonide in combination with glycopyrronium and formoterol<\/a><\/td>\nfamotidine<\/a>\u00a0\u00a0\u2014\u00a0 (RDP - H2 Blocker Drugs<\/a>)<\/td>\nomeprazole 20 mg<\/a>\u00a0\u00a0\u2014\u00a0(RDP - PPI Drugs<\/a>\u00a0and\u00a0LCD<\/a>)<\/td>\ntacrolimus ointment<\/a><\/td>\n<\/tr>\n
budesonide nebules<\/a><\/td>\nfentanyl patch<\/a><\/td>\nondansetron<\/a><\/td>\ntadalafil 20 mg<\/a><\/td>\n<\/tr>\n
budesonide-formoterol<\/a><\/td>\nfinasteride<\/a>*<\/td>\noseltamivir<\/a><\/td>\ntestosterone cypionate<\/a>*<\/td>\n<\/tr>\n
bupropion<\/a>\u00a0(Plan G)<\/a>*<\/td>\nflash glucose monitor<\/a><\/td>\npantoprazole magnesium<\/a>\u00a0\u00a0\u2014 (RDP - PPI Drugs<\/a>\u00a0and\u00a0LCD<\/a>*<\/td>\ntestosterone enanthate<\/a>*<\/td>\n<\/tr>\n
candesartan<\/a>*<\/td>\nfluticasone furoate-umeclidinium-vilanterol<\/a><\/td>\npantoprazole sodium 40 mg<\/a>\u00a0\u00a0\u2014\u00a0(RDP - PPI Drugs<\/a>\u00a0and\u00a0LCD<\/a>)<\/td>\nticagrelor<\/a>*<\/td>\n<\/tr>\n
carvedilol<\/a>*<\/td>\nfluticasone furoate-vilanterol<\/a><\/td>\nperindopril<\/a>\u00a0\u00a0\u2014\u00a0(RDP - ACE Inhibitor Drugs<\/a>)*<\/td>\ntiotropium<\/a><\/td>\n<\/tr>\n
celecoxib<\/a>*<\/td>\nfluticasone propionate-salmeterol<\/a><\/td>\npimecrolimus cream<\/a><\/td>\ntiotropium-olodaterol<\/a><\/td>\n<\/tr>\n
clotrimazole<\/a><\/td>\ngabapentin<\/a>\u00a0\u2014\u00a0(Plan G)<\/a><\/td>\npramipexole<\/a><\/td>\ntretinoin topical<\/a><\/td>\n<\/tr>\n
codeine sustained release<\/a><\/td>\ngliclazide<\/a>*<\/td>\nrivaroxaban for atrial fibrillation<\/a>*<\/td>\nvarenicline<\/a>\u00a0\u00a0\u2014\u00a0(Plan G)<\/a><\/td>\n<\/tr>\n
continuous glucose monitor<\/a><\/td>\ninsulin detemir<\/a><\/td>\nrivaroxaban for concomitant coronary artery disease and peripheral artery disease<\/a><\/td>\nzopiclone<\/a>\u00a0\u00a0\u2014\u00a0(Plan G)<\/a>*<\/td>\n<\/tr>\n
denosumab<\/a><\/td>\nlactulose<\/a><\/td>\nrivaroxaban for prophylaxis of venous thromboembolism<\/a><\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

*eForms<\/p>\n

**Source\/Credits: https:\/\/www2.gov.bc.ca\/gov\/content\/health\/practitioner-professional-resources\/pharmacare\/prescribers\/special-authority\/sa-drug-list<\/p>\n

MORE <\/strong>FORMS<\/strong><\/p>\n

Special Authority Request Forms<\/a><\/p>\n

Special Authority drug list<\/a><\/p>\n

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<\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"

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 …<\/p>\n

Special Auth Forms<\/span> Read More »<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_mi_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"site-sidebar-layout":"default","site-content-layout":"default","ast-global-header-display":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","footnotes":""},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/pages\/156"}],"collection":[{"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/comments?post=156"}],"version-history":[{"count":24,"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/pages\/156\/revisions"}],"predecessor-version":[{"id":196,"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/pages\/156\/revisions\/196"}],"wp:attachment":[{"href":"https:\/\/rxtools.ca\/index.php\/wp-json\/wp\/v2\/media?parent=156"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}