5328 special authority request
This is a fill and print form
SPECIAL AUTHORITY REQUEST
Ministry of Health Services
Fax requests in Victoria to 250-952-1065 or, from elsewhere in BC, to 1-800-609-4884 (toll free).
OR mail requests to: Pharmacare, Box 9655, Stn Prov Govt, Victoria, BC V8W 9P2
This facsimile is Doctor-Patient privileged and contains confidential information intended only for Pharmacare. Any other distribution, copying or disclosure is strictly prohibited.
If you have received this fax in error, please destroy it and notify us by telephone at 604-682-6849 in Vancouver/Lower Mainland, 250-952-2866 in Victoria or 1-800-554-0250 in the restof BC (Monday to Friday, 8 a.m. to 8 p.m.).
Use this form to request: • Exemptions to the Reference Drug Program (RDP)
Forms with information missing
• Exemptions to the Low-Cost Alternative Program (LCA)• Restricted Benefits
will be returned for completion.
Should approval be granted for this Special Authority request, Pharmacare’s authorization is solely for the purpose of providing prescription benefit for the cost of the requestedmedication. Pharmacare makes no representation about the suitability of the requested medication for the patient’s, or any other, medical condition or problem.
Please see reverse for category definitions and instructions on completing this form.
SECTION 1 – PRESCRIBER INFORMATION
SECTION 2 – PATIENT INFORMATION
Personal information on this form is collected for the operations of Pharmacare, Ministry of Health Services. The information will be used so that Pharmacare can decide whetherprescription benefit will be provided for the cost of the requested medication. If you have any questions about the collection of this information, call (604) 682-6849 in Vancouver/Lower Mainland, (250) 952-2866 in Victoria or 1-800-554-0250 in the rest of BC, and ask to consult a Pharmacist concerning Special Authorities. Personal information will be usedand disclosed in accordance with the privacy protection provisions of the Freedom of Information and Protection of Privacy Act.
When patient available, please complete:
I authorize the prescriber to release information to Pharmacare to obtain Special Authorityfor prescription benefit, including access to specific health information related to theSpecial Authority request in the custody of the prescriber, as appropriate.
SECTION 3 – MEDICATION DETAIL INFORMATION
REQUESTED DRUG EXEMPTION (INDICATE BOTH MEDICATION AND DOSAGE REQUESTED)
INDICATION(S) FOR SPECIAL AUTHORITY
on Reference Drug /
Low-Cost Alternative / First-Line Agent
(please list medications tried)
to Reference Drug /
Low-Cost Alternative / First-Line Agent (please list
medications tried and specify adverse reaction)
Drug / Drug Interaction
with Reference Drug
or First-Line Agent (please list both drugs that
and other patient-specific indicators
Pharmacare may request additional documentation
to support this Special Authority request for certainnon-referenced drugs (e.g., terbinafine, interferon,carvedilol, finasteride, etc.).
PHARMACARE USE ONLY
ADDITIONAL INFORMATION REQUIRED (SEE BELOW)
Fax the Special Authority Request to:
OR Mail to:
PO Box 9655 Stn Prov Govt, Victoria BC V8W 9P2
Please allow 48 hours (excluding weekends) for RDP Exemptions, and two weeks for LCA Exemptions and Restricted Benefits.
COMPLETING THE SPECIAL AUTHORITY REQUEST FORM:
2. Attention to the information requirements will ensure a complete and timely review. Requests containing insufficient
information will not be approved and will be returned to the physician. All sections of the form must be completed.
3. Extension of Coverage: If it is anticipated that a patient will continue to require the product beyond the approval
period, the physician must apply for an extension of coverage at least two (2) weeks prior to expiration. (Note:
Coverage will not
be continued automatically.) Retroactive coverage will not be provided.
Requests for exten-
sions should include a comment on the patient's response/progress on therapy.
4. Some specialty drugs require completion of a different request form (e.g., cyclosporin and leflunomide for rheumatoid
arthritis, low molecular weight heparin, rebetron, interferon alpha and lamivudine for Hepatitis B, infliximab andetanercept for rheumatoid arthritis and inflixamab for Crohn’s Disease).
• Results will be provided automatically by mail or fax unless otherwise requested.
• Approval is subject to the usual and customary eligibility and deductible criteria. Approval does not necessarily imply
• Special Authority approval is not retroactive.
• All BC residents registered with the Ministry of Health Services are eligible for Pharmacare coverage.
1. Reference Drug Program (RDP):
Pharmacare provides coverage up to the cost of the Referenced
Product within a therapeutic category. (Please refer to your Reference-Based Pricing Policy binder forspecific information.)
2. Low-Cost Alternative (LCA) Program:
Coverage is provided up to the current Low-Cost Alternative price.
3. Restricted Benefit:
A drug is not usually considered first-line therapy where there is limited clinical evidence
or where there is significant cost consideration.
The following categories of drugs are generally not
eligible for special authority:
• investigational drugs
• drugs available without a prescription
• drugs used in non-approved indications, or as part of a clinical trial
• smoking cessation aids
• diet therapy
• new drugs currently under review by Pharmacare
• brand-name products that the brand manufacturer also markets under a generic label.
Information für Patientinnen und Patienten den, Allergien haben oder andere Arzneimittel Medibudget Lesen Sie diese Packungsbeilage sorgfältig, (auch selbstgekaufte!) einnehmen oder äusser-denn sie enthält wichtige Informationen. Dragées laxatives Dieses Arzneimittel haben Sie entweder persön-lich von Ihrem Arzt oder Ihrer Ärztin verschrie- Dürfen Medibudget Abführdragées B
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