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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.
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.
| 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)- 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)
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)
- 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)
- 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)
- SA0872 – Tiotropium Bromide (1 page, 3 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)
- 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)
- SA1097 – High Protein Products: Fortimel (1 page, 3 KB)
- SA1110 – Infant Formulae - For Williams Syndrome: Locasol (1 page, 2 KB)
- SA1100 – Paediatric Products: Nutrini, Pediasure, Fortini (1 page, 3 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
Linked documents
Special Authority Forms, December 2011 (182 pages, 511 KB)
SPECIAL AUTHORITY FORMS December 2011 Contents Panel Approvals… 4 Alimentary Tract and Metabolism … 5 Blood and Blood Forming Organs…. 13 Cardiovascular System ….. 21 Dermatologicals …. 25 Genito-Urinary System… 29 Hormone Preparations - Systemic Excluding Contraceptive Hormones… 35 Infections…
Pharmaceutical Schedule, February 2012 (240 pages, 1358 KB)
r SVN Revision: 7839 Date: 26/1/2012 User: geeringj on dell-ext509 TEXSchedule February 2012 Volume 19 Number 0 Editors: Kaye Wilson, Rebecca Bloor & Donna Jennings email: schedule@pharmac.govt.nz Telephone +64 4 460 4990 Facsimile +64 4 460 4995 Level 9, 40…
SA0473 - Imiglucerase (Cerezyme) therapy - entry and exit criteria (6 pages, 113 KB)
Schedule 1: Access criteria for treatment with imiglucerase (Cerezyme). Guidelines for use of imiglucerase. a) The diagnosis of symptomatic type 1 Gaucher disease must have been established by the demonstration of specific deficiency of glucocerebrosidase in leukocytes or cultured skin…
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…