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<< Pharmaceutical Schedule

Special Authority Forms

General Practitioners and specialists can download individual Special Authority applications forms below or:

• Click here (215 pages, 2023 KB) to download all of the Special Authority forms in one document.
• Click here for Named Patient Pharmaceutical Assessment (NPPA) forms.

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Sector Services contact details

• If you have any queries regarding the processing of paper based or declined Special Authority applications, please contact Sector Services on 0800 243 666.
  

• If you are experiencing any processing errors or issues accessing the Electronic Special Authority system, please contact Sector Services on 0800 505 125 or email onlinehelpdesk@moh.govt.nz.

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Special Authority forms

(Sort by: Therapeutic Group / Chemical Name)

Alimentary Tract and Metabolism

From page 24 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA1294 - Accu-ChekBlood glucose test strips (1 page, 230 KB)

• SA1155 – Budesonide - Cap 3 mg Controlled Release (2 pages, 23 KB)

• SA1320 – Diazoxide (1 page, 14 KB)

• SA1329 – Glyceryl trinitrate Oint 0.2% (1 page, 13 KB)

• SA0473 - Imiglucerase (Cerezyme) therapy - entry and exit criteria (6 pages, 113 KB)

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

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

• SA1240 - Insulin pump consumables
  SA1240 - Insulin pump consumables (10 pages, 762 KB)

• SA1237 - Insulin Pumps
  SA1237 - Insulin Pumps (10 pages, 762 KB)

• SA0891 – Macrogol 3350 (1 page, 14 KB)

• SA1036 – Multivitamins: Paediatric Seravit (1 page, 14 KB)

• SA1291 – Optium blood glucose test strips (1 page, 231 KB)

• SA1188 – Ursodeoxycholic Acid (1 page, 15 KB)

• SA1002 – Vitabdeck (1 page, 13 KB)

Blood and Blood Forming Organs

From page 45 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA1270 – Dalteparin Sodium (1 page, 15 KB)

• SA1042 – Deferiprone (1 page, 13 KB)

• SA1174 – Enoxaparin sodium (1 page, 15 KB)

• SA0922 – Erythropoietin (1 page, 17 KB)

• SA1259 – Filgrastim (1 page, 15 KB)

• SA1201 – Prasugrel (1 page, 15 KB)

• SA1066 – Rivaroxaban (1 page, 14 KB)

Cardiovascular System

From page 52 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA1223 – Candesartan (1 page, 13 KB)

• SA0967 - Endothelian receptor antagonists (30 pages, 303 KB)

• SA1045 – Ezetimibe (2 pages, 23 KB)

• SA1046 – Ezetimibe with Simvastatin: Vytorin (1 page, 16 KB)

• SA1321 – Hydralazine (1 page, 13 KB)

• SA1349 – Metolazone (1 page, 13 KB)

• SA0934 – Midodrine (1 page, 14 KB)

• SA1271 – Minoxidil (1 page, 13 KB)

• SA1263 – Nicorandil (1 page, 14 KB)

• SA1260 – Perhexiline Maleate (1 page, 14 KB)

• SA1327 – Propranolol (1 page, 14 KB)

• SA0969 - Prostacyclin analogues - iloprost (30 pages, 303 KB)

• SA1293 - Pulmonary Arterial Hypertension (30 pages, 303 KB)

• SA1293 – Sildenafil (1 page, 14 KB)

Dermatologicals

From page 64 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0954 – Acitretin (1 page, 14 KB)

• SA0923 – Imiquimod (1 page, 16 KB)

• SA0955 – Isotretinoin (1 page, 15 KB)

• SA1225 – Ivermectin (2 pages, 25 KB)

Genito-Urinary System

From page 76 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0500 – Combined oral contraceptives; and Progestogen-only contraceptives (1 page, 16 KB)

• SA0928 – Finasteride (1 page, 13 KB)

• SA1083 – Potassium Citrate (1 page, 14 KB)

• SA0998 – Solifenacin succinate (1 page, 13 KB)

• SA1032 – Tamsulosin (1 page, 13 KB)

• SA1272 – Tolterodine (1 page, 13 KB)

Hormone Preparations - Systemic Excluding Contraceptive Hormones

From page 82 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA1031 – Cabergoline (1 page, 14 KB)

• SA0090 – Desmopressin – Inj 4 µg per ml, 1 ml (1 page, 14 KB)

• SA1279 - Growth Hormone Therapy Criteria and application forms for Paediatrics and adults (36 pages, 214 KB)

• SA1018 – Hormone Replacement Therapy - Systemic (1 page, 14 KB)

• SA0782 – Levonorgestrel – releasing intrauterine system 20mcg/24 hr (1 page, 17 KB)

• SA1199 – Propylthiouracil (1 page, 14 KB)

Infections - Agents for Systemic Use

From page 89 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0829 – Adefovir dipivoxil (1 page, 16 KB)

• SA1318 – Albendazole (1 page, 14 KB)

• SA1025 – Antiretrovirals (4 pages, 49 KB)

• SA1131 – Clarithromycin (1 page, 14 KB)

• SA0845 – Enfuvirtide (1 page, 14 KB)

• SA0977 – Entecavir (1 page, 16 KB)

• SA1148 – fluconazole oral liquid (1 page, 14 KB)

• SA1322 – Itraconazole (1 page, 14 KB)

• SA0832 – Lamivudine (2 pages, 24 KB)

• SA1065 – Moxifloxacin (1 page, 15 KB)

• SA1324 – Paromomycin (1 page, 14 KB)

• SA1134 – Pegylated Interferon alpha-2A (2 pages, 25 KB)

• SA1285 – Posaconazole (1 page, 14 KB)

• SA1326 – Primaquine (1 page, 13 KB)

• SA1328 – Pyrimethamine (1 page, 13 KB)

• SA1331 – Sulfadiazine (1 page, 13 KB)

• SA1047 – Tenofovir (2 pages, 26 KB)

• SA1332 – Tetracycline (1 page, 13 KB)

• SA0957 – Valaciclovir (1 page, 14 KB)

• SA1274 – Valganciclovir (2 pages, 23 KB)

• SA1273 – Voriconazole (1 page, 14 KB)

Musculoskeletal System

From page 110 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0949 – Alendronate for Paget's Disease: Alendronate Tab 40 mg (1 page, 14 KB)

• SA1039 – Alendronate Tab 70 mg - with or without Cholecalciferol (2 pages, 27 KB)

• SA1319 – Benzbromarone (1 page, 15 KB)

• SA1289 – Capsaicin (1 page, 13 KB)

• SA1034 – Meloxicam (1 page, 13 KB)

• SA1138 – Raloxifene (1 page, 16 KB)

• SA1038 Special Authority for Manufacturers Price (1 page, 49 KB)

• SA1139 – Teriparatide (1 page, 14 KB)

• SA1187 – Zoledronic acid (3 pages, 37 KB)

Nervous System

From page 118 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0987 – Aprepitant (1 page, 14 KB)

• SA0920 – Aripiprazole (1 page, 14 KB)

• SA0951 – Atomoxetine (1 page, 15 KB)

• SA1062 - beta-interferon or glatiramer acetate (13 pages, 248 KB)

• SA0863 – Buspirone Hydrochloride (1 page, 14 KB)

• SA1149 – Dexamphetamine Sulphate (2 pages, 24 KB)

• SA1071 – Gabapentin (1 page, 15 KB)

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

• SA0939 – Hyoscine (Scopolamine) (1 page, 15 KB)

• SA1125 – Lacosamide (1 page, 14 KB)

• SA0906 – Lignocaine with Prilocaine (1 page, 14 KB)

• SA1151 – Methylphenidate Hydrochloride Extended Release: Concerta, Ritalin LA (1 page, 15 KB)

• SA1150 – Methylphenidate Hydrochloride: Rubifen, Rubifen SR, Ritalin, Ritalin SR (2 pages, 24 KB)

• SA1048 – Mianserin Hydrochloride (1 page, 15 KB)

• SA0994 – Mirtazapine (1 page, 14 KB)

• SA1126 – Modavigil (1 page, 14 KB)

• SA0909 – Naltrexone (1 page, 14 KB)

• SA1146 – Olanzapine depot injection (1 page, 14 KB)

• SA0926 – Risperidone microspheres (1 page, 15 KB)

• SA0927 – Risperidone orally disintegrating tablets (1 page, 14 KB)

• SA1330 – Stiripentol (1 page, 14 KB)

• SA1203 – Suboxone (2 pages, 23 KB)

• SA1161 – Varenicline tartrate (1 page, 15 KB)

• SA1061 – Venlafaxine (1 page, 14 KB)

• SA1072 – Vigabatrin (1 page, 16 KB)

Oncology Agents and Immunosuppressants

From page 147 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA1156 – Adalimumab (9 pages, 94 KB)

• SA0941 – Bicalutamide (1 page, 13 KB)

• SA1127 – bortezomib (2 pages, 23 KB)

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

• SA1044 – Erlotinib (1 page, 14 KB)

• SA1157 – Etanercept (8 pages, 85 KB)

• SA1226 – Gefitinib (1 page, 14 KB)

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

• SA1191 – Lapatinib (1 page, 15 KB)

• SA1041 – Mycophenolate mofetil (1 page, 14 KB)

• SA1016 – Octreotide (somatostatin analogue) (3 pages, 34 KB)

• SA1190 – Pazopanib (2 pages, 25 KB)

• SA1325 – Pegaspargase (1 page, 14 KB)

• SA1152 – Rituximab (5 pages, 52 KB)

• SA0866 – Sirolimus (Rapamune) (1 page, 15 KB)

• SA1266 – Sunitinib (3 pages, 34 KB)

• SA0669 – Tacrolimus (1 page, 13 KB)

• SA1063 – Temozolomide (1 page, 14 KB)

• SA1124 – Thalidomide (1 page, 14 KB)

• SA1192 – Trastuzumab (3 pages, 33 KB)

Respiratory System and Allergies

From page 175 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0611 – Dornase Alfa - Entry and Stopping Criteria for Treatment (18 pages, 151 KB)

• SA1179 – Inhaled Corticosteroids with Long-Acting Beta-Adrenoceptor Agonists (1 page, 14 KB)

• SA1227 – Montelukast (1 page, 15 KB)

• SA1193 – Tiotropium Bromide (1 page, 21 KB)

• SA0053 – Wasp venom allergy treatment; and Bee Venom Allergy Treatment (1 page, 14 KB)

Sensory Organs

From page 183 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA0895 – Pilocarpine – Eye drops 2% single dose (1 page, 14 KB)

Various

From page 187 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

Extemporaneously Compounded Preparations and Galenicals

From page 193 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

Special Foods

From page 197 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

• SA1195 – Adult Products High Calorie: Two Cal HN, Nutrison Concentrated (2 pages, 23 KB)

• SA1219 – Amino acid formula: Elecare, Neocate, Vivonex (1 page, 14 KB)

• SA1091 – Carbohydrate and Fat: Duocal Super Soluble Powder (2 pages, 23 KB)

• SA1090 – Carbohydrate: Moducal, Polycal (2 pages, 23 KB)

• SA1094 – CORD Products: Pulmocare (1 page, 14 KB)

• SA1095 – Diabetic products: Diason RTH, Glucerna Select RTH, Diasip, Glucerna Select, Resource Diabetic (1 page, 14 KB)

• SA1220 – Extensively hydrolysed formula: Pepti Junior Gold (2 pages, 25 KB)

• SA1096 – Fat Modified Products: Monogen (1 page, 14 KB)

• SA1092 – Fat: Calogen, Liquigen, MCT oil (Nutricia) (2 pages, 23 KB)

• SA1106 – Food Thickeners: Karicare Food Thickener (1 page, 14 KB)

• SA1108 – Foods and Supplements For Inborn Errors Of Metabolism: Easiphen Liquid, Loprofin Mix, Loprofin, Minaphlex, MSUD Maxamaid, MSUD Maxamum, Phlexy 10, PKU Anamix Junior LQ, PKU Lophlex LQ, PKU Anamix Infant, XP Maxamaid, XP Maxamum, XMET Maxamum (1 page, 13 KB)

• SA1107 – Gluten Free Foods: Bakels Gluten Free Health Bread Mix, Horleys Bread Mix, Horleys Flour, NZB Low Gluten Bread Mix, Orgran, Healtheries Simple Baking Mix (1 page, 13 KB)

• SA1197 – High fat formula with vitamins, minerals and trace elements and low in protein and carbohydrate: KetoCal (1 page, 14 KB)

• SA1097 – High Protein Products: Fortimel Regular (1 page, 14 KB)

• SA1110 – Infant Formulae - For Williams Syndrome: Locasol (1 page, 14 KB)

• SA1196 – Paediatric enteral feed with fibre 0.75 kcal/ml: Nutrini Low Energy Multi Fibre (1 page, 14 KB)

• SA1098 – Paediatric Product For Children Awaiting Liver Transplant: Generaid Plus (1 page, 14 KB)

• SA1099 – Paediatric Product For Children With Chronic Renal Failure: Kindergen (1 page, 14 KB)

• SA1224 – Paediatric Products: Nutrini, Pediasure, Fortini (1 page, 14 KB)

• SA1198 – Preterm post-discharge infant formula powder: S-26 Gold Premgro (1 page, 13 KB)

• SA1103 – Products for Undialysed End Stage Renal Failure: Suplena (1 page, 14 KB)

• SA1093 – Protein: Protifar, Promod, Resource Beneprotein (1 page, 14 KB)

• SA1101 – Renal Products: Nepro, NovaSource Renal, Renilon 7.5 (1 page, 14 KB)

• SA1102 – Specialised And Elemental Products: Alitraq, Elemental 028 Extra, Peptisorb, Vital HN, Vivonex TEN (1 page, 15 KB)

• SA1228 – Standard Supplements: Ensure, Fortisip, Isosource, Jevity, Nutrison, Osmolite, Sustagen (6 pages, 63 KB)

National Immunisation Schedule

From page 226 of the Pharmaceutical Schedule, June 2013 (256 pages, 1504 KB)

Page updated on 01 Jun 2013

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