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NB Drug Plans Special Authorization Request (791E)

For special authorization drugs with no drug-specific request form, New Brunswick Drug Plans uses this one-page form under both the NB Prescription Drug Program and the NB Drug Plan. The requestor gives the diagnosis, rationale and previous drug therapies. Approval is granted only when the information shows the patient meets the criteria set out in the formulary.

Who completes it

The prescriber (requestor) completes all four sections and signs with a licence or registration number; there is no patient section.

Submitting and payment

How to submit it
Fax the form to the Special Authorization Unit of New Brunswick Drug Plans, or mail it to the unit in Moncton.

Good to know

  • The same form is used to request brand-name reimbursement after a hypersensitivity reaction to a non-medicinal ingredient in the generic; describe the reaction on the form.
  • Drugs are ineligible if an expert committee recommended against listing, they are still under review, another source pays, or they are not authorized for sale in Canada.
  • Approvals may be subject to renewal, and NB Drug Plans may ask for more information to confirm the drug is still effective and needed.
  • The Medicare number is marked critical for processing; forms missing information are returned, and no response can be sent without a mailing address and fax number.

Get the official form

Download the current version from the source each time; forms change without notice.

New Brunswick Drug Plans Special Authorization Request

Régimes de médicaments du Nouveau-Brunswick - Demande d'autorisation spéciale

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

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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Frequently asked questions

When do I use New Brunswick's general special authorization form?

Use FORM-791E when the drug needs special authorization and New Brunswick Drug Plans has no drug-specific form for it. Specific forms exist for filgrastim and pegfilgrastim, additional smoking cessation therapy and Paxlovid, plus correctional services versions. Criteria for each drug are published in the formulary's special authorization criteria document.

Can New Brunswick cover a brand-name drug instead of the generic?

NB Drug Plans reimburses only the lowest-cost generic when one exists, and beneficiaries who choose the brand pay the difference. It will consider brand-name requests after a hypersensitivity reaction to a non-medicinal ingredient in the generic: submit a completed Special Authorization Request form describing the reaction.

Is the NB special authorization request form available in French?

Yes. New Brunswick Drug Plans publishes the French version, 'Régimes de médicaments du Nouveau-Brunswick - Demande d'autorisation spéciale', as FORM-791F. The English FORM-791E is a one-page fillable PDF revised in April 2024.