Drug Benefit List - Forms

Special Authorization Forms

These special authorization forms must be completed and signed by an authorized prescriber (e.g. physician, dentist or optometrist) who is requesting coverage on your behalf. In some instances, the patient may also be required to sign the forms.

They can be printed, then completed and signed by hand, or they can be filled in on-line, printed and then signed before sending to Alberta Blue Cross.

For more information on criteria for special authorization please click here PDF.

Drug Special Authorization Request Form PDF (ABC 20061)

Abatacept for Juvenile Idiopathic Arthritis Special Authorization Request Form PDF (ABC 31291)

Abatacept/Adalimumab/Anakinra/Etanercept/Golimumab/Infliximab/Tocilizumab for Rheumatoid Arthritis Special Authorization Request Form PDF (ABC 30902)

Adalimumab for Crohn’s/ Infliximab for Crohn’s/Fistulizing Crohn’s Disease Special Authorization Request Form PDF(ABC 31200)

Adalimumab/Etanercept/Golimumab/Infliximab for Ankylosing Spondylitis Special Authorization Request Form PDF(ABC 31195)

Adalimumab/Etanercept/Golimumab/Infliximab for Psoriatic Arthritis Special Authorization Request Form PDF(ABC 30964)

Adalimumab/Etanercept/Infliximab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form PDF (ABC 31192)

Alendronate/Raloxifene/Risedronate for Osteoporosis Special Authorization Request Form PDF(ABC 31086)

Boceprevir + Peginterferon Alfa/Ribavirin Special Authorization Request Form PDF(ABC 31424)

Celecoxib Special Authorization Request Form PDF(ABC 31140)

Clopidogrel Special Authorization Request FormPDF (ABC 30786)

Apixaban/Dabigatran/Rivaroxaban Special Authorization Request FormPDF (ABC 31482)

Darbepoetin/Epoetin Special Authorization Request Form PDF(ABC 30888)

Denosumab/Zoledronic Acid for Osteoporosis Special Authorization Request Form PDF(ABC 31377)

Donepezil/Galantamine/Rivastigmine Special Authorization Request Form PDF(ABC 30776)

Dutasteride/Finasteride Special Authorization Request Form PDF(ABC 31257)

Eculizumab Special Authorization Request Form PDF(ABC 31386)

Eculizumab Consent Form PDF(ABC 31408)

Etanercept for Juvenile Idiopathic Arthritis Special Authorization Request Form PDF(ABC 30948)

Ezetimibe Special Authorization Request FormPDF(ABC 30925)

Febuxostat Special Authorization Request Form PDF(ABC 31376)

Fentanyl Special Authorization Request Form PDF(ABC 31169)

Filgrastim/Pegfilgrastim Special Authorization Request Form PDF(ABC 31150)

Fingolimod Hydrochloride Special Authorization Request Form PDF(ABC 60000)

Glatiramer Acetate/Interferon Beta-1A/Interferon Beta-1B Special Authorization Request Form PDF(ABC 60001)

Imiquimod Special Authorization Request Form PDF(ABC 31222)

Montelukast/Zafirlukast Special Authorization Request Form PDF (ABC 31313)

Natalizumab Special Authorization Request Form PDF (ABC 60003)

Omalizumab Special Authorization Request Form PDF (ABC 31406)

Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form
PDF(ABC 31258)

Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form PDF(ABC 30944)

Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request FormPDF(ABC 30932)

Rituximab for Rheumatoid Arthritis Special Authorization Request Form PDF (ABC 31205)

Saxagliptin/Sitagliptin/Sitagliptin+Metformin/ Linagliptin Special Authorization Request FormPDF(ABC 31461)

Select Quinolones Special Authorization Request FormPDF(ABC 30966)

Rituximab for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request Form PDF (ABC 31420)

Tacrolimus Topical Ointment Special Authorization Request Form PDF (ABC 31488)

Telaprevir + Peginterferon Alfa/Ribavirin Special Authorization Request Form PDF (ABC 31418)

Tocilizumab for Systemic Juvenile Idiopathic Arthritis Special Authorization Request Form PDF (ABC 31419)

Valganciclovir Special Authorization Request FormPDF (ABC 31483)


Forms for physicians

Eligible MS Disease Modifying Therapies PDF
Registration form for MS Neurologist status

Select Quinolone Antibiotics PDF
Registration form for Designated Prescriber status

Your Comments are Important to Us

Please note: This is not a mechanism for appeal for a specific patient but pertains to drug product eligibility in general.

On-line version

PDF version PDF

 

For program information and application forms check:

Coverage for Seniors
Non-Group Coverage
Palliative Care Drug Coverage
Alberta Child Health Benefit Program

 

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NOTICE:
The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.

Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross who publishes them on behalf of Alberta Health and Alberta Human Services.

Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL (iDBL), and any such changes to the Interactive DBL (iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper/CD version or updates.