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 60015)

Abatacept for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form PDF (ABC 60010)

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/Tocilizumab for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form PDF (ABC 60011)

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)

Apixaban/Dabigatran/Rivaroxaban Special Authorization Request Form PDF (ABC 60019)

Aripiprazole/Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form PDF (ABC 60024)

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

Celecoxib Special Authorization Request Form PDF(ABC 31140)

Clopidogrel Special Authorization Request Form PDF (ABC 30786)

Darbepoetin/Epoetin Special Authorization Request Form PDF (ABC 60006)

Denosumab/Zoledronic Acid for Osteoporosis Special Authorization Request Form PDF (ABC 60007)

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

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

DPP-4 Inhibitors Special Authorization Request Form PDF(ABC 60012)

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

Eculizumab Consent Form PDF(ABC 31408)

Eculizumab Special Authorization Request Form PDF(ABC 60009)

Ezetimibe Special Authorization Request Form PDF (ABC 30925)

Febuxostat Special Authorization Request Form PDF (ABC 31376)

Fentanyl Special Authorization Request Form PDF(ABC 60005)

Filgrastim / Pegfilgrastim / Plerixafor Special Authorization Request Form PDF(ABC 60013)

Fingolimod Hydrochloride Special Authorization Request Form PDF(ABC 60000)

Fluticasone Furoate + Vilanterol Trifenatate / Indacaterol Maleate + Glycopyrronium Bromide/ Umeclidinium Bromide + Vilanterol Trifenatate Special Authorization Request Form PDF(ABC 60025)

Imiquimod Special Authorization Request Form PDF (ABC 31222)

Infliximab for Ulcerative Colitis Special Authorization Request Form PDF(ABC 60008)

Ivacaftor Special Authorization Request Form PDF (ABC 60004)

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

Natalizumab Special Authorization Request Form PDF (ABC 60003)

Omalizumab Special Authorization Request Form PDF (ABC 60020)

Ombitasvir/Paritaprevir/Ritonavir+Dasabuvir Special Authorization Request PDF (ABC 60026)

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 Form PDF (ABC 30932)

Rituxan for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request PDF (ABC 60018)

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

Select Quinolones Special Authorization Request Form PDF (ABC 30966)

Simeprevir + Peginterferon Alfa/Ribavirin Special Authorization Request Form PDF(ABC 60016)

Sofosbuvir Special Authorization Request Form PDF(ABC 60022)

Sofosbuvir/Ledipasvir Special Authorization Request Form PDF (ABC 60023)

Tacrolimus Topical Ointment Special Authorization Request FormPDF (ABC 31488)

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

Valganciclovir Special Authorization Request FormPDF (ABC 60017)


Forms for physicians

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

Jetrea - Application for Registered Prescriber Status PDF
Registration form for Registered Prescriber 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 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 version or updates.