Provincial special authorization and exception drug forms, NIHB and Health Canada Special Access Program requests, and private insurers' prior authorization forms.
When a drug is not a regular benefit, the prescriber makes the case on a form. BC calls it Special Authority; Alberta, New Brunswick and Newfoundland and Labrador say special authorization; Manitoba uses Exception Drug Status, Nova Scotia exception status drugs, Ontario the Exceptional Access Program and Québec médicaments d'exception. General request forms include BC's HLTH 5328, Ontario's Request for an Unlisted Drug Product (4406-87), RAMQ's form 3633 and New Brunswick's FORM-791E.
Federal programs work differently. For First Nations and Inuit clients, the pharmacy asks the NIHB Drug Exception Centre, which may fax an exception or limited use form to the prescriber. Health Canada's Special Access Program uses Forms A, B and C to request and report on drugs not marketed in Canada. Private insurers publish their own prior authorization forms. Online routes are often preferred: BC asks for eForms, Ontario recommends SADIE and RAMQ uses its online service.
The prescriber requests NIHB coverage for a drug not on the NIHB Drug Benefit List for a First Nations or Inuit client, with clinical justification.
The practitioner requests emergency access to a drug not marketed in Canada for a specific patient with a serious or life-threatening condition.
The prescriber applies for a client receiving end-of-life care to get access to the NIHB end-of-life drug list.
Prior approval for NIHB limited-use drug benefits that are covered only when set criteria are met.
The practitioner requests a non-marketed drug ahead of time for future emergency use when the patient is not yet identified, with a valid reason for needing it in advance.
Mandatory report to Health Canada on the results of using a drug obtained through the SAP, including adverse reactions.
HLTH 5328General Special Authority request for PharmaCare coverage of a drug, device or supply when no drug-specific SA form exists.
Family of drug-, device- and supply-specific Special Authority request forms (e.g., diabetes devices, GLP-1s, biologics, ADHD medication, PPIs, CGRP antagonists) that prescribers complete to obtain PharmaCare coverage.
Registers a palliative patient for PharmaCare Plan P drug coverage and refers them to home and community care for palliative supplies and equipment.
Applies for no-cost psychiatric medication coverage (Plan G) for a patient with a clinical need and financial hardship, including 3-month bridge coverage after hours.
Special Authority for PharmaCare coverage of limited-coverage proton pump inhibitors.
Special Authority for PharmaCare coverage of glucose monitoring systems (Dexcom G6/G7, FreeStyle Libre 2/3 Plus).
Special Authority for PharmaCare coverage of semaglutide for type 2 diabetes.
ABC 60015General request for special authorization coverage of a drug on the Alberta Drug Benefit List when no drug-specific SA form applies.
Family of drug-specific special authorization request forms for Alberta government-sponsored drug coverage.
General prescriber request for Exception Drug Status coverage of a Part 3 drug under Manitoba Pharmacare and other provincial drug programs.
Family of drug-specific EDS request forms (e.g., CGRP agents, atopic dermatitis biologics, Entresto, Kerendia, Praluent/Repatha, Vascepa, asthma biologics, MS drugs, oral anti-diabetics).
Drug-specific Exception Drug Status request for oral anti-diabetic medications.
Drug-specific EAP request e-forms that capture the reimbursement criteria for particular drugs.
Inscription à l'aide financière pour malades souffrant d'insuffisance rénale terminale
Registers end-stage renal disease patients for publicly funded erythropoietin under the Special Drugs Program.
2772-87EAutorisation spéciale (allergène)
Prescriber authorization so allergen extracts (immunotherapy) are covered as an ODB benefit.
3057-87Produits nutritionnels
Prescriber form that makes nutrition products reimbursable under ODB when prescribed as the patient's sole source of nutrition and the listed criteria are met.
Demande de produit médicamenteux ne figurant pas dans la liste
Standard prescriber request for ODB coverage of a drug not listed (or not covered for this use) on the ODB Formulary. Usable for any EAP drug.
Formulaire de demande et de consentement Programme de dépistage de maladies métaboliques héréditaires
Application and consent to enrol a patient in the Inherited Metabolic Diseases (IMD) Program.
Demande initiale – Politique d'examen pour l'accès compassionnel aux médicaments
Physician request for drug funding for an ODB-eligible patient under the Compassionate Review Policy.
4940-87ERequest for ODB coverage of OxyNEO (new, renewal or appeal), including prescriber attestations on misuse risk and opioid stewardship.
Programme d’Accès Exceptionnel – Formulaire de demande d’exemption pour les produits biosimilaires
Prescriber request to exempt a patient from Ontario's biosimilar switch policy (stay on, or switch back to, an EAP-funded originator biologic).
Request for Payment Authorization – Exception Drug
Prescriber's request for public drug-plan coverage of an exception drug (Liste des médicaments, Annex IV) when the drug isn't codified or no code fits the patient.
Request for Payment Authorization – Exceptional Patient Measure
Prescriber's request for public-plan coverage of a drug not on the Liste des médicaments, or of an exception drug for an indication not on the List, under the exceptional patient measure.
Request for Payment Authorization (Outside Québec) – Exception Drug
Same request as form 3633, for prescribers outside Québec who have not joined Québec's health insurance plan.
Request for Payment Authorization (Outside Québec) – Exceptional Patient Measure
Same request as form 3996, for prescribers outside Québec who have not joined Québec's health insurance plan.
Request for Exceptional Reimbursement of the Cost of an Innovator Drug
Prescriber asks RAMQ to reimburse the innovator (brand-name) drug when the insured person must take it for particular medical reasons; the form documents the clinical consequences (e.g. hospitalization, emergency intervention, persistent disability).
Request for Exemption from the Maximum Payable Price (MPP) – Nexium (esomeprazole), Prevacid FasTab (lansoprazole)
Prescriber requests an exemption from the maximum payable price so the public plan covers Nexium or Prevacid FasTab for the patient.
Régimes de médicaments du Nouveau-Brunswick - Demande d'autorisation spéciale
General request for coverage of a special authorization drug under the NB Prescription Drug Program or NB Drug Plan when there is no drug-specific form.
Special authorization requests for people in provincial correctional services: general, smoking cessation therapy and Paxlovid versions.
Thérapie d'abandon du tabac - Demande d'autorisation spéciale
Special authorization for additional smoking cessation therapy coverage.
Filgrastim / Pegfilgrastim - Demande d'autorisation spéciale
Drug-specific special authorization for filgrastim or pegfilgrastim (chemotherapy support, non-malignant neutropenia, stem cell transplant support).
Nirmatrelvir/Ritonavir (Paxlovid) - Demande d'autorisation spéciale
Documents that the clinical criteria for Paxlovid coverage are met.
Standard request for Pharmacare coverage of an exception status drug when no specialized form applies.
Enrols a patient in end-stage terminal illness, living at home, in the Palliative Care Drug Program.
Online exception status drug request for providers with an Ocean account, an alternative to the PDF forms.
Drug- or condition-specific criteria forms for exception status drug coverage, e.g. rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, ADHD, long-acting insulin analogues, non-insulin antidiabetics, sensor-based glucose monitoring, Jardiance/Synjardy, Entresto, PPIs, asthma inhalers, COPD, MS agents, migraine prevention, hepatitis C, HIV PrEP, ulcerative colitis, Crohn's, psoriasis, atopic dermatitis.
Exception status coverage request for ADHD medications (e.g. Biphentin and other long-acting agents).
General Newfoundland and Labrador Prescription Drug Program request for special authorization drug coverage.
Criteria-based special authorization forms for specific drugs or classes: antiplatelet therapy, anti-fibrotic therapy, atopic dermatitis, biologics for asthma, chronic rhinosinusitis with nasal polyps and migraine, chronic plaque psoriasis, oral ciprofloxacin, T2DM high CV risk, hepatitis C, HIV PrEP, IBD, inhalers for asthma/COPD, insulin detemir, LMWH for VTE prevention after surgery, Paxlovid, non-insulin antidiabetics, ophthalmic VEGF inhibitors, phosphate binders, RA initiation and continuation, Tamiflu for LTC residents, blood glucose test strips, topical antipsoriatics, Cabenuva.
NLPDP special authorization for non-insulin antidiabetic agents.
Special authorization request for continuous or flash glucose monitoring coverage.
Family of drug-specific prior authorization forms for Desjardins group drug plans.
Family of drug-specific prior authorization forms for Manulife group drug plans.
Family of drug-specific prior authorization forms for Sun Life group drug plans.
Search tool for Beneva group prior authorization (exception drug) forms by drug or medical condition.
Family of drug-specific prior authorization forms for Medavie group drug plans.
PBM form search for drug prior authorization forms for the plan sponsors and insurers that Express Scripts Canada manages.
Drug-specific prior authorization forms for Empire Life group plans, retrieved through Express Scripts Canada's form search.
Standard drug special authorization request for plans administered by ClaimSecure.
0199.022Prior authorization request for drugs that need approval under Pacific Blue Cross Blue Chip plans.
Demande d'autorisation générale pour un médicament
General drug prior authorization request for drugs without their own form.
Demande de remboursement pour un médicament de marque
Requests reimbursement of a brand-name drug instead of the generic.
Demande de remboursement pour un médicament biologique de référence
Requests reimbursement of a reference (originator) biologic instead of a biosimilar.
Special authorization request for weight-loss drugs under Alberta Blue Cross plans.
Special authorization request for prescription drugs under Saskatchewan Blue Cross plans.
Demande d’autorisation d’un médicament d’exception
Exception drug authorization request under iA individual health insurance.
Formulaire d'exception pour un médicament d'origine
Requests coverage of a brand-name drug instead of the generic.
Formulaire d’autorisation préalable – Médicaments
General prior authorization request for group drug plans; iA's drug-specific variants are listed on the same page.
Formulaire d’exception pour un médicament biologique
Requests coverage of a reference biologic instead of a biosimilar.
Requests coverage of a brand-name drug when the lowest-cost interchangeable drug cannot be tolerated or is ineffective.
GRP-5008-ENRequests approval of a drug substitution under the Extended Health Benefit provisions.
Requests an exception to diabetes step-therapy rules.
Prior authorization request for medical cannabis coverage under a workplace drug plan.
Family of drug-specific prior authorization forms for Canada Life workplace drug plans.
Drug claim assessment for Quebec members under the RAMQ exception patient program.
Drug claim assessment for Quebec members prescribed a drug on the RAMQ exceptional medications list.
Requests blood glucose test strips above the provincially indicated quantities within a 365-day period.
Requests coverage of an originator biologic instead of a biosimilar.
Requests coverage of a brand-name drug instead of the lower-cost alternative.
Requests approval of a dose increase for a drug already approved under prior authorization.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Through PharmaCare Special Authority eForms. BC's forms page says eForms return decisions faster than faxed paper forms and asks prescribers not to send requests by fax. Use the drug-, device- or supply-specific form when one exists, such as HLTH 5817 for glucose monitoring systems; otherwise use the general Special Authority Request (HLTH 5328). Pharmacists can draft an eForm for the prescriber to sign.
Form 3633, the Demande d'autorisation de paiement (request for payment authorization) for an exception drug, ideally sent through RAMQ's online service, Patient et médicaments d'exception; fax it only without access. For codified exception drugs, over 40% of the list, you write the code on the prescription instead. Drugs not on the List, or exception drugs for unlisted indications, go through the exceptional patient measure (form 3996). Prescribers outside Québec use forms 4515 and 4516.
The pharmacy contacts the NIHB Drug Exception Centre, which may fax an Exception Drugs Request Form or Limited Use Benefit Request Form to the prescriber. There is no public PDF. Coverage needs a recognized indication and dose, plus evidence that the drug is superior, that alternatives are ineffective or contraindicated, or of an adverse reaction to the best-price alternative. Personal preference is not enough.
Most group insurers have a dedicated form. Canada Life uses M7088 for brand-name drugs and M6453(BIOLOGIC) for originator biologics, Desjardins uses 12126E and 21084E, iA uses F54-835A and F54-1025A, and Manulife uses GL4445 when the lowest-cost interchangeable drug is not tolerated or does not work. Canada Life's forms say the plan member pays any cost of completing them.