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Special Authority Forms

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

• Click here (192 pages, 540 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 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, June 2012 (240 pages, 1314 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)

• SA1188 – Ursodeoxycholic Acid (1 page, 3 KB)

• SA1002 – Vitabdeck (1 page, 2 KB)

Blood and Blood Forming Organs

From page 40 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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)

• SA1201 – Prasugrel (1 page, 3 KB)

• SA1066 – Rivaroxaban (1 page, 2 KB)

Cardiovascular System

From page 48 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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 57 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 KB)

• SA0954 – Acitretin (1 page, 3 KB)

• SA0923 – Imiquimod (1 page, 3 KB)

• SA0955 – Isotretinoin (1 page, 3 KB)

Genito-Urinary System

From page 67 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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 73 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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)

• SA1199 – Propylthiouracil (1 page, 2 KB)

Infections - Agents for Systemic Use

From page 80 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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 98 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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)

• SA1187 – Zoledronic acid (3 pages, 11 KB)

Nervous System

From page 115 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 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, June 2012 (240 pages, 1314 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)

• SA1191 – Lapatinib (1 page, 3 KB)

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

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

• SA0900 – Oxaliplatin (1 page, 3 KB)

• SA1190 – Pazopanib (2 pages, 5 KB)

• SA1152 – Rituximab (5 pages, 12 KB)

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

• SA1200 – Sunitinib (2 pages, 5 KB)

• SA0669 – Tacrolimus (1 page, 2 KB)

• SA1063 – Temozolomide (1 page, 3 KB)

• SA1124 – Thalidomide (1 page, 2 KB)

• SA1192 – Trastuzumab (3 pages, 8 KB)

• SA1013 – Vinorelbine (2 pages, 5 KB)

Respiratory System and Allergies

From page 162 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 KB)

• SA0611 – Dornase Alfa - Entry and Stopping Criteria for Treatment (18 pages, 892 KB)

• SA1179 – Inhaled Corticosteroids with Long-Acting Beta-Adrenoceptor Agonists (1 page, 3 KB)

• SA1193 – Tiotropium Bromide (1 page, 3 KB)

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

Sensory Organs

From page 169 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 KB)

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

Various

From page 173 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 KB)

Extemporaneously Compounded Preparations and Galenicals

From page 178 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 KB)

Special Foods

From page 182 of the Pharmaceutical Schedule, June 2012 (240 pages, 1314 KB)

• SA1195 – Adult Products High Calorie: Two Cal HN, Nutrison Concentrated (2 pages, 5 KB)

• SA1111 – Amino acid formula: Elecare, Neocate, Vivonex (1 page, 3 KB)

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

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

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

• SA1095 – Diabetic products: Diason RTH, Glucerna Select RTH, Diasip, Glucerna Select, Resource Diabetic (1 page, 2 KB)

• SA1112 – Extensively hydrolysed formula: Pepti Junior Gold (3 pages, 8 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 (1 page, 2 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, 2 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, 2 KB)

• SA1197 – High fat formula with vitamins, minerals and trace elements and low in protein and carbohydrate: KetoCal (1 page, 2 KB)

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

• SA1109 – Infant Formulae - For Premature Infants: S26LBW Gold RTF (1 page, 2 KB)

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

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

• SA1198 – Preterm post-discharge infant formula powder: S-26 Gold Premgro (1 page, 2 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, Renilon 7.5 (1 page, 2 KB)

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

• SA1104 – Standard Supplements: Ensure, Fortisip, Isosource, Jevity, Nutrison, Osmolite, Sustagen (5 pages, 14 KB)

Page current as of 01 Jun 2012

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