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NB Filgrastim/Pegfilgrastim Special Authorization

New Brunswick Drug Plans covers filgrastim and pegfilgrastim through special authorization, and this one-page form captures the dose and the qualifying indication. Prescribers meet it when supporting chemotherapy, treating non-malignant neutropenia or supporting stem cell transplantation. The Special Authorization Unit reviews the request and sends its response to the requestor's mailing address or fax.

Who completes it

The prescriber (requestor) completes all five sections: requestor and patient information, the drug and dose, the indication checkboxes, and the signature with licence or registration number.

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

  • For chemotherapy support, the form asks whether chemotherapy has curative intent, then one indication: high febrile neutropenia risk, neutropenia in a previous cycle, or dose reduction or delay over a week.
  • Non-malignant indications (congenital, idiopathic, cyclic or HIV-related neutropenia) and stem cell transplantation support apply to filgrastim only, not pegfilgrastim.
  • Dose options are filgrastim 300 mcg or 480 mcg SC daily, another filgrastim dose, or pegfilgrastim 6 mg SC per cycle, with cycles or duration of therapy.
  • The Medicare number is marked critical for processing, and forms missing information are returned. A French version, FORM-968F, is available.

Get the official form

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

Filgrastim / Pegfilgrastim Special Authorization Request

Filgrastim / Pegfilgrastim - Demande d'autorisation spéciale

Official pagePDFVersion française

Fill it with Vero

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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

Which indications does the NB filgrastim form list for pegfilgrastim?

Only chemotherapy support, at 6 mg SC per cycle. The requestor states whether chemotherapy is curative and selects high risk of febrile neutropenia, febrile or profound neutropenia in a previous cycle, dose reduction or treatment delay over one week due to neutropenia, or another reason.

Is the NB filgrastim special authorization form available in French?

Yes. New Brunswick Drug Plans publishes 'Filgrastim / Pegfilgrastim - Demande d'autorisation spéciale' as FORM-968F alongside the English FORM-968E. The English version was revised in April 2024 and is listed on the NB Drug Plans formulary page with the other special authorization request forms.

How do I submit the NB filgrastim form?

Fax it to the Special Authorization Unit of New Brunswick Drug Plans, or mail it to the unit in Moncton. Include a mailing address and fax number in the requestor section; without them, NB Drug Plans says it cannot return a response.