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)
- 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)- 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)
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)
- 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)
- 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)
- SA0872 – Tiotropium Bromide (1 page, 3 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)
- 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: 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
Linked documents
Special Authority Forms, July 2009 (160 pages, 448 KB)
SPECIAL AUTHORITY FORMS July 2009 Contents Panel Approvals… 4 Alimentary Tract and Metabolism … 5 Blood and Blood Forming Organs…. 14 Cardiovascular System ….. 24 Dermatologicals …. 29 Genito-Urinary System… 33 Hormone Preparations - Systemic Excluding Contraceptive Hormones… 36 Infections…
Special Circumstance Application form for Acitretin/Isotretinoin (1 page, 97 KB)
Special Circumstance Application form for Acitretin/Isotretinoin Please fax this form to: Ministry of Health, Sector Services – 0800 100 131 Note: The Special Circumstance approval number will only cover repeat dispensings of acitretin or isotretinoin where the original was dispensed…
Pharmaceutical Schedule, July 2009 (224 pages, 1228 KB)
Introducing PHARMAC 2 July 2009 Volume 16 Number 1 Section A Section B General Rules 12 Alimentary Tract & Metabolism 25 Editors Julie Lagan & Scott Brydon email: schedule@pharmac.govt.nz Telephone +64 4 460 4990 Facsimile +64 4 460 4995 Level…
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:…