New Brunswick Drug Plans keeps three special authorization forms for people in provincial correctional facilities: a general request (FORM-1141E), a smoking cessation request for additional bupropion (FORM-1140E) and a Paxlovid request (FORM-1239E). They follow the public versions but identify the patient by correctional facility and Client Information System ID, with the Medicare number only if available.
The prescriber (requestor) serving correctional clients completes each form and signs with a licence or registration number; the forms are marked for Correctional Services use only.
Download the current version from the source each time; forms change without notice.
Correctional Services Special Authorization Request forms (3 forms)
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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.
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Prescribers caring for people in New Brunswick's provincial correctional facilities. Each form is marked for Correctional Services use only and asks for the facility and the client's Client Information System ID, with the Medicare number entered only if one is available.
No. Like the public Paxlovid form, FORM-1239E must be completed and kept with the prescription at the pharmacy. The pharmacy submits the claim electronically with the CPhA intervention code that corresponds to the clinical criteria checked on the form.
It requests additional bupropion 150 mg twice daily, up to 168 extra tablets a year. The requestor states whether the person has a high probability of quitting with additional therapy, how many cigarettes they smoked daily before starting bupropion, and how many they smoke now.