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Special Authority Forms
General Practitioners and specialists can download individual forms for making Special Authority applications from this page.
Alternatively, all forms are available in one indexed document, Special Authority Forms, September 2010 (165 pages, 465 KB).
If you have any queries regarding the processing of Special Authority Applications, please contact Sector Services on 0800 243 666 or by
email.
Find Exceptional Circumstances (EC) forms.
Special Authority forms
Sort by Therapeutic Group or Form Title (Chemical Name)
Alimentary Tract and Metabolism
From page 25 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0915 – Alpha Tocopheryl Acetate (1 page, 2 KB)
- SA0913 – Budesonide – Cap 3 mg Controlled Release (1 page, 3 KB)
- SA0473 - Imiglucerase (Cerezyme) therapy - initial application (6 pages, 72 KB)
- SA0473 - Imiglucerase (Cerezyme) therapy - renewal application (3 pages, 75 KB)
- SA0891 – Macrogol 3350: Movicol (1 page, 2 KB)
- SA0959 – Pioglitazone (1 page, 2 KB)
- SA1003 – Ursodeoxycholic Acid (1 page, 3 KB)
- SA1002 – Vitabdeck (1 page, 2 KB)
Blood and Blood Forming Organs
From page 39 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0975 – Enoxaparin sodium (1 page, 3 KB)
- SA0922 – Erythropoietin (1 page, 3 KB)
- SA0796 – Ezetimibe (2 pages, 5 KB)
- SA0826 – Ezetimibe with Simvastatin: Vytorin (1 page, 4 KB)
- SA0932 – Pravastatin (1 page, 2 KB)
Cardiovascular System
From page 46 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0933 – Candesartan (1 page, 3 KB)
- SA0967 - Endothelian receptor antagonists (26 pages, 222 KB)
- SA0911 – Losartan with or without hydrochlorothiazide (1 page, 2 KB)
- SA0934 – Midodrine (1 page, 2 KB)
- SA0256 – Perhexiline Maleate (1 page, 2 KB)
- SA0968 - Phosphodieterase type 5 inhibitors - sildenafil (26 pages, 222 KB)
- SA0969 - Prostacyclin analogues - iloprost (26 pages, 222 KB)
Dermatologicals
From page 56 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0954 – Acitretin (1 page, 3 KB)
- SA0923 – Imiquimod (1 page, 3 KB)
- SA0955 – Isotretinoin (1 page, 3 KB)
Genito-Urinary System
From page 67 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0928 – Finasteride (1 page, 2 KB)
- SA0998 – Solifenacin succinate (1 page, 2 KB)
- SA1032 – Tamsulosin (1 page, 2 KB)
Hormone Preparations - Systemic Excluding Contraceptive Hormones
From page 74 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA1031 – Cabergoline (1 page, 2 KB)
- SA0090 – Desmopressin – Inj 4 µg per ml, 1 ml (1 page, 2 KB)
- SA0755 - Growth Hormone Therapy Criteria and application forms for Paediatrics and adults (35 pages, 1158 KB)
- SA1018 – Hormone Replacement Therapy - Systemic (1 page, 3 KB)
Infections - Agents for Systemic Use
From page 81 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0829 – Adefovir dipivoxil (1 page, 3 KB)
- SA1025 – Antiretrovirals (3 pages, 9 KB)
- SA0964 – Azithromycin (1 page, 3 KB)
- SA0988 – Clarithromycin (1 page, 3 KB)
- SA0845 – Enfuvirtide (1 page, 3 KB)
- SA0977 – Entecavir (1 page, 3 KB)
- SA0832 – Lamivudine (2 pages, 6 KB)
- SA0952 – Pegylated Interferon alpha-2A (2 pages, 6 KB)
- SA0997 – Tenofovir (1 page, 3 KB)
- SA0957 – Valaciclovir (1 page, 2 KB)
Musculoskeletal System
From page 97 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA1026 – Adalimumab (8 pages, 24 KB)
- SA1039 – Alendronate Tab 70 mg - with or without Cholecalciferol (2 pages, 8 KB)
- SA0868 – Etanercept (1 page, 4 KB)
- SA1034 – Meloxicam (1 page, 2 KB)
- SA1035 – Zoledronic acid (3 pages, 11 KB)
Nervous System
From page 109 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0987 – Aprepitant (1 page, 2 KB)
- SA0920 – Aripiprazole (1 page, 2 KB)
- SA0951 – Atomoxetine (1 page, 3 KB)
- SA0863 – Buspirone Hydrochloride (1 page, 2 KB)
- SA0907 – Dexamphetamine Sulphate (3 pages, 8 KB)
- SA0935 – Fentanyl patches (1 page, 2 KB)
- SA1009 – Gabapentin (2 pages, 6 KB)
- SA0973 - Gabapentin (Neurontin) - no further approvals (1 page, 7 KB)
- SA0939 – Hyoscine (Scopolamine) (1 page, 2 KB)
- SA0921 – Levetiracetam (3 pages, 114 KB)
- SA0906 – Lignocaine with Prilocaine (1 page, 2 KB)
- SA0864 – Mianserin Hydrochloride (1 page, 2 KB)
- SA0994 – Mirtazapine (1 page, 3 KB)
- SA0855 – Multiple Sclerosis treatments, Initial Application for beta-interferon or glatiramer acetate (8 pages, 183 KB)
- SA0855 – Multiple Sclerosis treatments, Renewal Application form for beta-interferon or glatiramer acetate (5 pages, 171 KB)
- SA0909 – Naltrexone (1 page, 3 KB)
- SA0741 – Olanzapine tabs (1 page, 3 KB)
- SA0739 – Olanzapine wafers (1 page, 2 KB)
- SA0887 – Ondansetron (1 page, 2 KB)
- SA0926 – Risperidone microspheres (1 page, 3 KB)
- SA0927 – Risperidone orally disintegrating tablets (1 page, 2 KB)
- SA0789 – Venlafaxine (1 page, 3 KB)
- SA1010 – Vigabatrin (2 pages, 6 KB)
Oncology Agents and Immunosuppressants
From page 136 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0879 – Anagrelide Hydrochloride (1 page, 3 KB)
- SA0941 – Bicalutamide (1 page, 2 KB)
- SA1040 – Capecitabine (1 page, 3 KB)
- SA0976 - Dasatinib for treatment of Chronic Myeloid Leukaemia (CML) (2 pages, 17 KB)
- SA0880 – Docetaxel (2 pages, 4 KB)
- SA1000 – Exemestane (1 page, 3 KB)
- SA1012 – Gemcitabine hydrochloride (2 pages, 5 KB)
- SA0643 – Imatinib mesylate for treatment of chronic myeloid leukaemia or gastrointestinal stromal tumour (GIST) (3 pages, 38 KB)
- SA0878 – Irinotecan (1 page, 2 KB)
- SA0960 – Mycophenolate (1 page, 2 KB)
- SA1016 – Octreotide (somatostatin analogue) (3 pages, 8 KB)
- SA0900 – Oxaliplatin (1 page, 3 KB)
- SA0961 – Rituximab (2 pages, 5 KB)
- SA0866 – Sirolimus (Rapamune) (1 page, 2 KB)
- SA0669 – Tacrolimus (1 page, 2 KB)
- SA0831 – Temozolomide (1 page, 2 KB)
- SA0882 – Thalidomide (1 page, 3 KB)
- SA1017 – Trastuzumab (1 page, 3 KB)
- SA1013 – Vinorelbine (2 pages, 5 KB)
Respiratory System and Allergies
From page 152 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0611 – Dornase Alfa - Entry and Stopping Criteria for Treatment (18 pages, 216 KB)
- SA0872 – Tiotropium Bromide (1 page, 3 KB)
Sensory Organs
From page 158 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0895 – Pilocarpine – Eye drops 2% single dose (1 page, 2 KB)
Extemporaneously Compounded Preparations and Galenicals
From page 167 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)Special Foods
From page 171 of the Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)- SA0585 – Adult Products High Calorie: Two Cal HN (2 pages, 5 KB)
- SA0581 – Carbohydrate and Fat: Duocal Super Soluble Powder (2 pages, 4 KB)
- SA0588 – CORD Products: Pulmocare (1 page, 3 KB)
- SA0594 – Diabetic Products: Diasip, Diason, Glucerna, Glucerna RTH, Resource Diabetic, Resource Diabetic RTH (1 page, 3 KB)
- SA0615 – Fat Modified Products: Monogen (1 page, 2 KB)
- SA0899 – Fat: Calogen, Liquigen, MCT oil (Nutricia) (2 pages, 4 KB)
- SA0732 – Foods used for Homocystinuria or maple syrup urine disease: Maxamaid MSUD, Maxamum MSUD, MSUD Aid, XMET Maxamum (1 page, 2 KB)
- SA0589 – High Protein Products: Fortimel (1 page, 3 KB)
- SA0604 – Infant Formulae – For Milk Intolerance: Delact, S26 Soy, Karicare Goats Milk Infant Formula (1 page, 3 KB)
- SA0601 – Infant Formulae – For Williams Syndrome: Locasol (1 page, 2 KB)
- SA0757 – Infant Formulae – Lactose Intolerance and Cows’ Milk Protein Intolerance: Karicare All Ages (1 page, 2 KB)
- SA0962 – Metabolic Mineral Mixture (1 page, 2 KB)
- SA0582 – Protein: Protifar 90, Promod, Resource Beneprotein (1 page, 2 KB)
- SA0587 – Renal Products: Nepro (vanilla), NovaSource Renal, Nutrison Concentrated RTH, Renilon 7.5 (1 page, 3 KB)
- SA0592 – Specialised And Elemental Products: Alitraq, Elemental 028 Extra, Peptisorb RTH, Vital HN, Vivonex TEN (1 page, 3 KB)
Page updated on 01 Sep 2010
Linked documents
Special Authority Forms, September 2010 (165 pages, 465 KB)
SPECIAL AUTHORITY FORMS September 2010 Contents Panel Approvals… 4 Alimentary Tract and Metabolism … 5 Blood and Blood Forming Organs…. 13 Cardiovascular System ….. 20 Dermatologicals …. 25 Genito-Urinary System… 29 Hormone Preparations - Systemic Excluding Contraceptive Hormones… 34 Infections…
Pharmaceutical Schedule, September 2010 (224 pages, 1252 KB)
r September 2010 Volume 17 Number 2 Editors Kaye Wilson & Scott Brydon email: schedule@pharmac.govt.nz Telephone +64 4 460 4990 Facsimile +64 4 460 4995 Level 9, 40 Mercer Street PO Box 10 254 Wellington Freephone Information Line 0800 66…
SA0473 - Imiglucerase (Cerezyme) therapy - initial application (6 pages, 72 KB)
Initial application form for imiglucerase (Cerezyme) therapy Send completed applications to: Gaucher Panel Co-ordinator PHARMAC P O Box 10-254 WELLINGTON Fax: (04) 460 4995 Phone: (04) 460 4990 Email: gaucherpanel@pharmac.govt.nz Date of Application: _________________________________________ Patient Name: NHI number: Date of…
SA0473 - Imiglucerase (Cerezyme) therapy - renewal application (3 pages, 75 KB)
Renewal application for imiglucerase (Cerezyme) therapy Send completed applications to: Gaucher Panel Co-ordinator PHARMAC P O Box 10-254 WELLINGTON Fax: (04) 460 4995 Phone: (04) 460 4990 Email: gaucherpanel@pharmac.govt.nz Date of Application: _________________________________________ Patient Name: NHI number: _________________________________________ Date of…
SA0855 – Multiple Sclerosis treatments, Initial Application for beta-interferon or glatiramer acetate (8 pages, 183 KB)
INITIAL APPLICATION FOR FUNDING OF BETA-INTERFERON OR GLATIRAMER ACETATE Please send applications to: The Co-ordinator MSTAC PHARMAC P O Box 10-254 WELLINGTON Phone: 04 460 4990 Facsimile: 04 916 7571 Email: mstaccoordinator@pharmac.govt.nz Applications must be complete and accompanied by all…
SA0855 – Multiple Sclerosis treatments, Renewal Application form for beta-interferon or glatiramer acetate (5 pages, 171 KB)
RENEWAL APPLICATION FOR FUNDING OF BETA-INTERFERON OR GLATIRAMER ACETATE For patients who are currently being treated with beta-interferon or glatiramer acetate (with New Zealand government funding) Please send applications to: The Co-ordinator MSTAC PHARMAC P O Box 10-254 WELLINGTON Phone:…