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NLPDP Standard Special Authorization Request Form

The Newfoundland and Labrador Prescription Drug Program uses this one-page form for special authorization drugs that lack a drug-specific form. It captures the drug requested, diagnosis, previous medication trial and outcome, the reason for the request and how the diagnosis was confirmed. Pharmaceutical Services assesses requests in the order received, normally within about 10 working days.

Who completes it

The prescriber completes and signs the requestor section with a licence number; if another healthcare professional, such as a pharmacist, submits the request, they complete a separate block with their title and signature.

Submitting and payment

How to submit it
Fax or mail the form to Pharmaceutical Services, Department of Health and Community Services, in St. John's; both are printed at the top of the form.

Good to know

  • Reasons for request are contraindication, therapeutic failure, adverse event or other, each with an explanation; the diagnostic testing section asks how and when the diagnosis was confirmed.
  • The June 2022 version has no fillable fields; it states that it replaces previous forms and asks users to copy additional forms as needed.
  • Where a drug-specific form exists, such as for inhalers, biologics or test strips, that form carries the criteria for the drug.
  • If a request is declined, the prescriber can request an internal review and then a final review by a designated medical practitioner.

Get the official form

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

Special Authorization Request Form

Official pagePDF

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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

How long does an NLPDP special authorization take?

The standard form states that special authorization requests normally take approximately 10 working days to be processed. Requests are assessed in the order received, and the beneficiary and the requesting prescriber both receive written notification of the program's decision.

Can a pharmacist submit an NLPDP special authorization request?

The form has a block for a healthcare professional other than the prescriber, with title, licence number if applicable, an optional pharmacy name and a signature. The prescriber's name, licence number and signature are still part of the requestor information.

What information does the NLPDP standard form require?

Patient name, date of birth, NLPDP drug card or MCP number and address; the drug, dosage, duration and diagnosis; a previous medication trial with its outcome; the reason for the request with an explanation; how and when the diagnosis was confirmed; and requestor details with the date requested.