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 
.
Drug Special Authorization Request Form
(ABC 60015)
Abatacept for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form
(ABC 60010)
Alemtuzumab/Fingolimod/Natalizumab for Multiple Sclerosis Special Authorization Request Form
(ABC 60000)
Alendronate/Raloxifene/Risedronate for Osteoporosis Special Authorization Request Form
(ABC 60043)
Antivirals for Chronic Hepatitis C Special Authorization Request Form
(ABC 60022)
Apixaban/Dabigatran/Rivaroxaban Special Authorization Request Form
(ABC 60019)
Aripiprazole/Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form
(ABC 60024)
Celecoxib Special Authorization Request Form (ABC 60032)
Darbepoetin/Epoetin Special Authorization Request Form (ABC
60006)
Denosumab/Zoledronic Acid for Osteoporosis Special Authorization Request Form (ABC 60007)
Deferiprone Special Authorization Request Form (ABC 60054)
Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (ABC
60034)
DPP-4/SGLT2 Inhibitors Special Authorization Request Form (ABC 60012)
Eculizumab Consent Form (ABC 60035)
Eculizumab Special Authorization Request Form (ABC 60009)
Ezetimibe Special Authorization Request Form (ABC 60036)
Febuxostat Special Authorization Request Form (ABC 60037)
Fentanyl Special Authorization Request Form (ABC 60005)
Filgrastim/Pegfilgrastim/Plerixafor Special Authorization Request Form (ABC 60013)
Fingolimod/Natalizumab Special Authorization Request Form (ABC 60000)
Imiquimod Special Authorization Request Form (ABC 60038)
Golimumab/Infliximab/Vedolizumab for Ulcerative Colitis Special Authorization Request Form (ABC 60008)
Ivacaftor Special Authorization Request Form (ABC 60004)
Montelukast/Zafirlukast Special Authorization Request Form (ABC 60039)
Nintedanib/Pirfenidone Special Authorization Request Form (ABC 60051)
Omalizumab Special Authorization Request Form (ABC 60020)
Ombitasvir/Paritaprevir/Ritonavir+Dasabuvir Special Authorization Request (ABC 60026)
Oral Vancomycin/Fidaxomicin Special Authorization Request Form (ABC
60014)
Peginterferon Alfa-2a for Chronic Hepatitis C Special Authorization Request Form (ABC
60045)
Peginterferon Alfa-2a+Ribavirin/Peginterferon Alfa-2b+Ribavirin Special Authorization Request Form (ABC
60044)
Proton-Pump Inhibitors Pricing Authorization Request Form (ABC 60049)
Rituximab for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request (ABC 60018)
Rituximab for Rheumatoid Arthritis Special Authorization Request Form (ABC 60046)
Select
Quinolones Special Authorization Request Form (ABC 60042)
Simeprevir + Peginterferon Alfa/Ribavirin Special Authorization Request Form (ABC 60016)
Tacrolimus Topical Ointment Special Authorization Request Form (ABC 60047)
Tocilizumab for Systemic Juvenile Idiopathic Arthritis Special Authorization Request Form (ABC 60048)
Forms for physicians
Eligible MS Disease Modifying Therapies
Registration form for MS Neurologist status
Jetrea - Application for Registered Prescriber Status
Registration form for Registered Prescriber status
Select Quinolone Antibiotics
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.
For program information and application forms check:
Coverage
for Seniors
Non-Group
Coverage
Palliative
Coverage
Alberta Child
Health Benefit Program
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 version or updates.
