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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, December 2009 (162 pages, 458 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)

• SA0925 – Acarbose (1 page, 2 KB)

• SA0954 – Acitretin (1 page, 3 KB)

• SA0974 – Adalimumab (6 pages, 19 KB)

• SA0829 – Adefovir dipivoxil (1 page, 3 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)

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

• SA0990 – Alendronate Tab 70 mg - with or without Cholecalciferol (2 pages, 7 KB)

• SA0915 – Alpha Tocopheryl Acetate (1 page, 2 KB)

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

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

• SA0779 – Antiretrovirals (2 pages, 6 KB)

• SA0987 – Aprepitant (1 page, 2 KB)

• SA0920 – Aripiprazole (1 page, 2 KB)

• SA0951 – Atomoxetine (1 page, 3 KB)

• SA0788 – Atorvastatin (1 page, 4 KB)

• SA0964 – Azithromycin (1 page, 3 KB)

• SA0941 – Bicalutamide (1 page, 2 KB)

• SA0913 – Budesonide – Cap 3 mg Controlled Release (1 page, 3 KB)

• SA0835 – Buserelin (2 pages, 6 KB)

• SA0863 – Buspirone Hydrochloride (1 page, 2 KB)

• SA0175 – Cabergoline (1 page, 2 KB)

• SA0933 – Candesartan (1 page, 3 KB)

• SA0869 – Capecitabine (1 page, 3 KB)

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

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

• SA0988 – Clarithromycin (1 page, 3 KB)

• SA0867 – Clopidogrel (3 pages, 8 KB)

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

• SA0588 – CORD Products: Pulmocare (1 page, 3 KB)

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

• SA0907 – Dexamphetamine Sulphate (3 pages, 8 KB)

• SA0594 – Diabetic Products: Diasip, Diason, Glucerna, Glucerna RTH, Resource Diabetic, Resource Diabetic RTH (1 page, 3 KB)

• SA0880 – Docetaxel (2 pages, 4 KB)

• SA0938 – Domperidone (1 page, 2 KB)

• SA0611 – Dornase Alfa - Entry and Stopping Criteria for Treatment (18 pages, 216 KB)

• SA0967 - Endothelian receptor antagonists - bosentan (26 pages, 369 KB)

• SA0845 – Enfuvirtide (1 page, 3 KB)

• SA0975 – Enoxaparin sodium (1 page, 3 KB)

• SA0977 – Entecavir (1 page, 3 KB)

• SA0922 – Erythropoietin (1 page, 3 KB)

• SA0868 – Etanercept (1 page, 4 KB)

• SA0796 – Ezetimibe (2 pages, 5 KB)

• SA0826 – Ezetimibe with Simvastatin: Vytorin (1 page, 4 KB)

• SA0615 – Fat Modified Products: Monogen (1 page, 2 KB)

• SA0899 – Fat: Calogen, Liquigen, MCT oil (Nutricia) (2 pages, 4 KB)

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

• SA0928 – Finasteride (1 page, 2 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, Minaphlex, Phlexy 10 (1 page, 3 KB)

• SA0936 – Gabapentin (2 pages, 6 KB)

• SA0973 - Gabapentin (Neurontin) - no further approvals (1 page, 7 KB)

• SA0877 – Gemcitabine Hydrochloride (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)

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

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

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

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

• SA0643 – Imatinib mesylate for treatment of chronic myeloid leukaemia or gastrointestinal stromal tumour (GIST) (3 pages, 38 KB)

• SA0473 - Imiglucerase (Cerezyme) therapy - initial application (6 pages, 72 KB)

• SA0473 - Imiglucerase (Cerezyme) therapy - renewal application (3 pages, 75 KB)

• SA0923 – Imiquimod (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)

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

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

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

• SA0878 – Irinotecan (1 page, 2 KB)

• SA0955 – Isotretinoin (1 page, 3 KB)

• SA0832 – Lamivudine (2 pages, 6 KB)

• SA0921 – Levetiracetam (3 pages, 114 KB)

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

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

• SA0911 – Losartan with or without hydrochlorothiazide (1 page, 2 KB)

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

• SA0962 – Metabolic Mineral Mixture (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)

• SA0934 – Midodrine (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)

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

• SA0960 – Mycophenolate (1 page, 2 KB)

• SA0909 – Naltrexone (1 page, 3 KB)

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

• SA0741 – Olanzapine tabs (1 page, 3 KB)

• SA0739 – Olanzapine wafers (1 page, 2 KB)

• SA0887 – Ondansetron (1 page, 2 KB)

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

• SA0900 – Oxaliplatin (1 page, 3 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)

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

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

• SA0256 – Perhexiline Maleate (1 page, 2 KB)

• SA0968 - Phosphodieterase type 5 inhibitors - sildenafil (26 pages, 369 KB)

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

• SA0959 – Pioglitazone (1 page, 2 KB)

• SA0932 – Pravastatin (1 page, 2 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)

• SA0926 – Risperidone microspheres (1 page, 3 KB)

• SA0927 – Risperidone orally disintegrating tablets (1 page, 2 KB)

• SA0961 – Rituximab (2 pages, 5 KB)

• SA0976 Dasatinib for treatment of Chronic Myeloid Leukaemia (CML) (2 pages, 17 KB)

• SA0866 – Sirolimus (Rapamune) (1 page, 2 KB)

• SA0592 – Specialised And Elemental Products: Alitraq, Elemental 028 Extra, Peptisorb RTH, Vital HN, Vivonex TEN (1 page, 3 KB)

• SA0669 – Tacrolimus (1 page, 2 KB)

• SA0831 – Temozolomide (1 page, 2 KB)

• SA0997 – Tenofovir (1 page, 3 KB)

• SA0882 – Thalidomide (1 page, 3 KB)

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

• SA0885 – Trastuzumab (1 page, 3 KB)

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

• SA0957 – Valaciclovir (1 page, 2 KB)

• SA0789 – Venlafaxine (1 page, 3 KB)

• SA0937 – Vigabatrin (2 pages, 6 KB)

• SA0901 – Vinorelbine (1 page, 3 KB)

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

Page current as of 01 Dec 2009

Linked documents

Special Authority Forms, December 2009 (162 pages, 458 KB)
SPECIAL AUTHORITY FORMS December 2009 Contents Panel Approvals… 4 Alimentary Tract and Metabolism … 5 Blood and Blood Forming Organs…. 14 Cardiovascular System ….. 25 Dermatologicals …. 30 Genito-Urinary System… 34 Hormone Preparations - Systemic Excluding Contraceptive Hormones… 37 Infections…

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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…

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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…

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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…

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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:…

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