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Special Authority Forms

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

• Click here (182 pages, 511 KB) to download all of the Special Authority forms in one document.
• Click here for Exceptional Circumstances (EC) 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 by email.

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Special Authority forms

(Sort by: Therapeutic Group / Chemical Name)

Alimentary Tract and Metabolism

From page 26 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA1155 – Budesonide - Cap 3 mg Controlled Release (2 pages, 5 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)

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

• SA1036 – Multivitamins: Paediatric Seravit (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 40 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA1042 – Deferiprone (1 page, 2 KB)

• SA1174 – Enoxaparin sodium (1 page, 3 KB)

• SA0922 – Erythropoietin (1 page, 3 KB)

• SA1045 – Ezetimibe (2 pages, 5 KB)

• SA1046 – Ezetimibe with Simvastatin: Vytorin (1 page, 3 KB)

• SA1066 – Rivaroxaban (1 page, 2 KB)

Cardiovascular System

From page 47 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA0933 – Candesartan (1 page, 3 KB)

• SA0967 - Endothelian receptor antagonists (26 pages, 222 KB)

• SA0934 – Midodrine (1 page, 2 KB)

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

• SA0969 - Prostacyclin analogues - iloprost (26 pages, 222 KB)

• SA1086 - Sildenafil (27 pages, 169 KB)

Dermatologicals

From page 56 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA0954 – Acitretin (1 page, 3 KB)

• SA0923 – Imiquimod (1 page, 3 KB)

• SA0955 – Isotretinoin (1 page, 3 KB)

Genito-Urinary System

From page 66 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

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

• SA0928 – Finasteride (1 page, 2 KB)

• SA1083 – Potassium Citrate (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 72 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 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, 2164 KB)

• SA1018 – Hormone Replacement Therapy - Systemic (1 page, 3 KB)

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

Infections - Agents for Systemic Use

From page 79 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

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

• SA1025 – Antiretrovirals (3 pages, 9 KB)

• SA1130 – Azithromycin (1 page, 3 KB)

• SA1131 – Clarithromycin (1 page, 2 KB)

• SA0845 – Enfuvirtide (1 page, 3 KB)

• SA0977 – Entecavir (1 page, 3 KB)

• SA1148 – fluconazole oral liquid (1 page, 2 KB)

• SA0832 – Lamivudine (2 pages, 6 KB)

• SA1065 – Moxifloxacin (1 page, 3 KB)

• SA1134 – Pegylated Interferon alpha-2A (2 pages, 6 KB)

• SA1047 – Tenofovir (2 pages, 7 KB)

• SA0957 – Valaciclovir (1 page, 2 KB)

Musculoskeletal System

From page 97 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA1156 – Adalimumab (9 pages, 27 KB)

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

• SA1039 – Alendronate Tab 70 mg - with or without Cholecalciferol (2 pages, 8 KB)

• SA1157 – Etanercept (8 pages, 25 KB)

• SA1034 – Meloxicam (1 page, 2 KB)

• SA1138 – Raloxifene (1 page, 4 KB)

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

• SA1139 – Teriparatide (1 page, 3 KB)

• SA1035 – Zoledronic acid (3 pages, 11 KB)

Nervous System

From page 114 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA0987 – Aprepitant (1 page, 2 KB)

• SA0920 – Aripiprazole (1 page, 2 KB)

• SA0951 – Atomoxetine (1 page, 3 KB)

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

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

• SA1149 – Dexamphetamine Sulphate (2 pages, 5 KB)

• SA1071 – Gabapentin (1 page, 3 KB)

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

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

• SA1125 – Lacosamide (1 page, 3 KB)

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

• SA1151 – Methylphenidate Hydrochloride Extended Release: Concerta, Ritalin LA (1 page, 3 KB)

• SA1150 – Methylphenidate Hydrochloride: Rubifen, Rubifen SR, Ritalin, Ritalin SR (2 pages, 5 KB)

• SA1048 – Mianserin Hydrochloride (1 page, 3 KB)

• SA0994 – Mirtazapine (1 page, 3 KB)

• SA1126 – Modavigil (1 page, 3 KB)

• SA0909 – Naltrexone (1 page, 3 KB)

• SA1146 – Olanzapine depot injection (1 page, 3 KB)

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

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

• SA1161 – Varenicline tartrate (1 page, 3 KB)

• SA1061 – Venlafaxine (1 page, 3 KB)

• SA1072 – Vigabatrin (1 page, 4 KB)

Oncology Agents and Immunosuppressants

From page 141 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

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

• SA0941 – Bicalutamide (1 page, 2 KB)

• SA1127 – bortezomib (2 pages, 5 KB)

• SA1049 – Capecitabine (2 pages, 5 KB)

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

• SA1044 – Erlotinib (1 page, 2 KB)

• SA1087 – Gemcitabine hydrochloride (3 pages, 8 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)

• SA1041 – Mycophenolate mofetil (1 page, 2 KB)

• SA1016 – Octreotide (somatostatin analogue) (3 pages, 8 KB)

• SA0900 – Oxaliplatin (1 page, 3 KB)

• SA1152 – Rituximab (5 pages, 12 KB)

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

• SA1162 – Sunitinib (2 pages, 5 KB)

• SA0669 – Tacrolimus (1 page, 2 KB)

• SA1063 – Temozolomide (1 page, 3 KB)

• SA1124 – Thalidomide (1 page, 2 KB)

• SA1163 – Trastuzumab (2 pages, 5 KB)

• SA1013 – Vinorelbine (2 pages, 5 KB)

Respiratory System and Allergies

From page 160 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

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

• SA1179 – 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 167 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

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

Various

From page 172 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

Extemporaneously Compounded Preparations and Galenicals

From page 178 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

Special Foods

From page 182 of the Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)

• SA1105 – Adult Products High Calorie: Two Cal HN (2 pages, 5 KB)

• SA1111 – Amino acid formula (1 page, 3 KB)

• SA1091 – Carbohydrate and Fat: Duocal Super Soluble Powder (2 pages, 5 KB)

• SA1090 – Carbohydrate: Moducal, Morrex Maltodextrin, Polycal, Polycose (2 pages, 5 KB)

• SA1094 – CORD Products: Pulmocare (1 page, 2 KB)

• SA1095 – Diabetic products (1 page, 2 KB)

• SA1112 – Extensively hydrolysed formula (3 pages, 7 KB)

• SA1096 – Fat Modified Products: Monogen (1 page, 2 KB)

• SA1092 – Fat: Calogen, Liquigen, MCT oil (Nutricia) (2 pages, 5 KB)

• SA1106 – Food Thickeners: Karicare Food Thickener, Resource Thicken Up (1 page, 2 KB)

• SA1108 – Foods and Supplements For Inborn Errors Of Metabolism (1 page, 2 KB)

• SA1107 – 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)

• SA1097 – High Protein Products: Fortimel (1 page, 3 KB)

• SA1109 – Infant Formulae - For Premature Infants: S26LBW, Similac Special Care (1 page, 2 KB)

• SA1110 – Infant Formulae - For Williams Syndrome: Locasol (1 page, 2 KB)

• SA1098 – Paediatric Product For Children Awaiting Liver Transplant: Generaid Plus (1 page, 2 KB)

• SA1099 – Paediatric Product For Children With Chronic Renal Failure: Kindergen (1 page, 2 KB)

• SA1100 – Paediatric Products: Nutrini, Pediasure, Fortini (1 page, 3 KB)

• SA1103 – Products for Undialysed End Stage Renal Failure: Suplena (1 page, 2 KB)

• SA1093 – Protein: Protifar, Promod, Resource Beneprotein (1 page, 2 KB)

• SA1101 – Renal Products: Nepro, NovaSource Renal, Nutrison Concentrated RTH, Renilon 7.5 (1 page, 2 KB)

• SA1102 – Specialised And Elemental Products: Alitraq, Elemental 028 Extra, Peptisorb RTH, Vital HN, Vivonex TEN (1 page, 3 KB)

• SA1104 – Standard Supplements (5 pages, 13 KB)

Page updated on 01 Feb 2012

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