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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, July 2009 (160 pages, 448 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.

Acitretin and isotretinoin

Special Circumstance application form for acitretin and isotretinoin (1 page, 97 KB) - this Special Circumstance approval number will only cover repeat dispensings of acitretin or isotretinoin where the original was dispensed prior to 1 March 2009. Any original dispensing made on or after 1 March 2009 will require a Special Authority approval number.

Special Authority forms

Sort by Therapeutic Group or Form Title (Chemical Name)

Alimentary Tract and Metabolism

From page 25 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0925 – Acarbose (1 page, 2 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)

• SA0834 – Insulin Glargine (1 page, 3 KB)

• SA0891 – Macrogol 3350 (1 page, 2 KB)

• SA0963 – MultivitaminsPaediatric Seravit: Ketovite, Ketovite, Paediatric Seravit (1 page, 2 KB)

• SA0959 – Pioglitazone (1 page, 2 KB)

• SA0914 – Ursodeoxycholic Acid – Cap 300 mg (1 page, 3 KB)

Blood and Blood Forming Organs

From page 39 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0788 – Atorvastatin (1 page, 4 KB)

• SA0867 – Clopidogrel (3 pages, 8 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 48 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0933 – Candesartan (1 page, 3 KB)

• SA0967 - Endothelian receptor antagonists - bosentan (30 pages, 219 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 (30 pages, 219 KB)

• SA0969 - Prostacyclin analogues - iloprost (30 pages, 219 KB)

Dermatologicals

From page 58 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0954 – Acitretin (1 page, 3 KB)

• SA0923 – Imiquimod (1 page, 3 KB)

• SA0955 – Isotretinoin (1 page, 3 KB)

Genito-Urinary System

From page 69 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0500 – Combined oral contraceptives; and Progestogen-only contraceptives (1 page, 3 KB)

• SA0928 – Finasteride (1 page, 2 KB)

Hormone Preparations - Systemic Excluding Contraceptive Hormones

From page 75 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0835 – Buserelin (2 pages, 6 KB)

• SA0175 – Cabergoline (1 page, 2 KB)

• SA0090 – Desmopressin – Inj 4 µg per ml, 1 ml (1 page, 2 KB)

• SA0839 – Goserelin (2 pages, 6 KB)

• SA0755 - Growth hormone therapy guidelines and application forms (20 pages, 447 KB)

• SA0312 – Hormone Replacement Therapy – Systemic (1 page, 3 KB)

• SA0837 – Leuprorelin (2 pages, 6 KB)

• SA0782 – Levonorgestrel – releasing intrauterine system 20µg/24 hr (1 page, 3 KB)

Infections - Agents for Systemic Use

From page 84 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0829 – Adefovir dipivoxil (1 page, 3 KB)

• SA0779 – Antiretrovirals (2 pages, 6 KB)

• SA0964 – Azithromycin (1 page, 3 KB)

• SA0657 – Clarithromycin (1 page, 3 KB)

• SA0845 – Enfuvirtide (1 page, 3 KB)

• SA0784 – Interferon Alpha-2A with ribavirin (1 page, 2 KB)

• SA0832 – Lamivudine (2 pages, 6 KB)

• SA0952 – Pegylated Interferon alpha-2A (2 pages, 6 KB)

• SA0953 – Pegylated Interferon alpha-2B with Ribavirin (1 page, 2 KB)

• SA0957 – Valaciclovir (1 page, 2 KB)

Musculoskeletal System

From page 100 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0812 – Adalimumab (2 pages, 7 KB)

• SA0949 – Alendronate for Paget's Disease: Alendronate Tab 40 mg (1 page, 2 KB)

• SA0948 – Alendronate Tab 70 mg - with or without Cholecalciferol (2 pages, 7 KB)

• SA0291 – Anti-inflammatory Non Steroidal Drugs (NSAIDs) (1 page, 2 KB)

• SA0868 – Etanercept (1 page, 4 KB)

Nervous System

From page 107 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 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)

• SA0938 – Domperidone (1 page, 2 KB)

• SA0935 – Fentanyl patches (1 page, 2 KB)

• SA0936 – Gabapentin (2 pages, 6 KB)

• SA0939 – Hyoscine (Scopolamine) (1 page, 2 KB)

• SA0921 – Levetiracetam (3 pages, 114 KB)

• SA0906 – Lignocaine with Prilocaine (1 page, 2 KB)

• SA0924 – Methylphenidate Hydrochloride Extended Release: Concerta, Ritalin LA (1 page, 3 KB)

• SA0908 – Methylphenidate Hydrochloride: Rubifen, Rubifen SR, Ritalin, Ritalin SR (3 pages, 8 KB)

• SA0864 – Mianserin Hydrochloride (1 page, 2 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)

• SA0937 – Vigabatrin (2 pages, 6 KB)

Oncology Agents and Immunosuppressants

From page 133 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0879 – Anagrelide Hydrochloride (1 page, 3 KB)

• SA0941 – Bicalutamide (1 page, 2 KB)

• SA0869 – Capecitabine (1 page, 3 KB)

• SA0470 – Cyclosporin A (2 pages, 5 KB)

• SA0880 – Docetaxel (2 pages, 4 KB)

• SA0877 – Gemcitabine Hydrochloride (1 page, 3 KB)

• SA0643 – Imatinib mesylate for treatment of chronic myeloid leukaemia or gastrointestinal stromal tumour (GIST) (3 pages, 40 KB)

• SA0878 – Irinotecan (1 page, 2 KB)

• SA0943 – Letrozole (1 page, 3 KB)

• SA0960 – Mycophenolate (1 page, 2 KB)

• SA0563 – Octreotide (somatostatin analogue) (1 page, 3 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)

• SA0885 – Trastuzumab (1 page, 3 KB)

• SA0901 – Vinorelbine (1 page, 3 KB)

Respiratory System and Allergies

From page 149 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0611 – Dornase Alfa - Entry and Stopping Criteria for Treatment (17 pages, 403 KB)

• SA0958 – Inhaled Corticosteroids with Long-Acting Beta-Adrenoceptor Agonists (1 page, 3 KB)

• SA0872 – Tiotropium Bromide (1 page, 3 KB)

• SA0053 – Wasp venom allergy treatment; and Bee Venom Allergy Treatment (1 page, 2 KB)

Sensory Organs

From page 156 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0895 – Pilocarpine – Eye drops 2% single dose (1 page, 2 KB)

Various

From page 161 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

Extemporaneously Compounded Preparations and Galenicals

From page 166 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

Special Foods

From page 169 of the Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)

• SA0585 – Adult Products High Calorie: Two Cal HN (2 pages, 5 KB)

• SA0702 – Adult Products Standard: Ensure Plus, Ensure Plus RTH, Fibresource, Fibresource RTH, Fortisip, Fortisip Multi Fibre, Isosource 1.5, Isosource Standard, Isosource Standard RTH, Jevity RTH, Nutrison Energy Multi Fibre, Nutrison Multi Fibre, Nutrison Standard RTH, Osmolite RTH, Resource Plus (2 pages, 6 KB)

• SA0581 – Carbohydrate and Fat: Duocal Super Soluble Powder (2 pages, 4 KB)

• SA0912 – Carbohydrate: Moducal, Morrex Maltodextrin, Polycal, Polycose (2 pages, 5 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)

• SA0595 – Food Thickeners: Karicare Food Thickener, Resource Thicken Up (1 page, 2 KB)

• SA0732 – Foods used for Homocystinuria or maple syrup urine disease: Maxamaid MSUD, Maxamum MSUD, MSUD Aid, XMET Maxamum (1 page, 2 KB)

• SA0733 – Foods used for PKU: Aminogran Food Supplement, Aminogran Mineral Mix, Analog LCP, Aproten, Loprofin, Loprofin Mix, Maxamaid XP, Maxamum XP, Metabolic Mineral Mixture, Minaphlex, Phlexy 10 (1 page, 3 KB)

• SA0722 – Gluten Free Foods: Gluten Free Bread Mix 100% Bakels, Healtheries Wheat and Gluten Free Baking, Horleys Bread Mix, Horleys Flour, NZB Low Gluten Bread Mix, Orgran (1 page, 2 KB)

• SA0589 – High Protein Products: Fortimel (1 page, 3 KB)

• SA0603 – Infant Formulae – For Gastrointestinal And Other Malabsorptive Problems: Neocate, Neocate Advance, Neocate LCP, Pepti Junior, Vivonex Pediatric (1 page, 2 KB)

• SA0604 – Infant Formulae – For Milk Intolerance: Delact, S26 Soy, Karicare Goats Milk Infant Formula (1 page, 3 KB)

• SA0602 – Infant Formulae – For Premature Infants: S26LBW, Similac Special Care (1 page, 2 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)

• SA0583 – Oral Supplements: Ensure, Nutridrink, Sustagen Hospital Formula (2 pages, 4 KB)

• SA0607 – Paediatric Product For Children Awaiting Liver Transplant: Generaid Plus (1 page, 2 KB)

• SA0606 – Paediatric Product For Children With Chronic Renal Failure: Kindergen Plus (1 page, 2 KB)

• SA0896 – Paediatric Products: Fortini, Fortini Multifibre, Nutrini Energy RTH, Nutrini RTH, Pediasure, Pediasure RTH, Resource Just for Kids (1 page, 3 KB)

• SA0586 – Products for Undialysed End Stage Renal Failure: Suplena (1 page, 3 KB)

• SA0582 – Protein: Promod, Protifar 90 (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 Jul 2009

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