Drug Benefit List - Forms

The iDBL is a real time document that is updated daily.

Printable Drug Benefit List and Related Publications

Special Authorization Forms

Note:These special authorization forms must be completed and signed by an authorized prescriber (e.g. physician, dentist or optometrist) who is requesting coverage on your behalf. In some instances, the patient may also be required to sign the forms.

They can be printed, then completed and signed by hand, or they can be filled in on-line, printed and then signed before sending to Alberta Blue Cross ® .

• Abatacept for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form (PDF) (ABC 60010)
• Abatacept/Adalimumab/Anakinra/Baricitinib/Certolizumab/Etanercept/Golimumab/Infliximab/Sarilumab/Tocilizumab/Tofacitinib/Upadacitinib for Rheumatoid Arthritis Special Authorization Request Form (PDF) (ABC 60027)
• Abrocitinib/Dupilumab/Upadacitinib for Atopic Dermatitis Special Authorization Request Form (PDF) (ABC 60099)
• Adalimumab for Hidradenitis Suppurativa Special Authorization Request Form (PDF) (ABC 60058)
• Adalimumab/Bimekizumab/Etanercept/Guselkumab/Infliximab/Ixekizumab/Risankizumab/Secukinumab/Tildrakizumab/Ustekinumab for Plaque Psoriasis Special Authorization Request Form (PDF) (ABC 60030)
• Adalimumab/Certolizumab/Etanercept/Golimumab/Guselkumab/Infliximab/Ixekizumab/Secukinumab/Upadacitinib for Psoriatic Arthritis Special Authorization Request Form (PDF) (ABC 60029)
• Adalimumab/Certolizumab/Etanercept/Golimumab/Infliximab/Secukinumab/Upadacitinib for Ankylosing Spondylitis Special Authorization Request Form (PDF) (ABC 60028)
• Adalimumab/Etanercept/Tocilizumab for Polyarticular Juvenile Idiopathic Arthritis Special Authorization Request Form (PDF) (ABC 60011)
• Adalimumab/Golimumab/Infliximab/Ozanimod/Tofacitinib/Upadacitinib/Vedolizumab for Ulcerative Colitis Special Authorization Request Form (PDF) (ABC 60008)
• Adalimumab/Risankizumab/Upadacitinib/Vedolizumab for Crohn's/Infliximab for Crohn's/Fistulizing Crohn's Special Authorization Request Form (PDF) (ABC 60031)
• Alemtuzumab for Multiple Sclerosis Special Authorization Request Form (PDF) (ABC 60079)
• Alendronate/Raloxifene/Risedronate for Osteoporosis Special Authorization Request Form (PDF) (ABC 60043)
• Alirocumab/Evolocumab for HeFH Special Authorization Form (PDF) (ABC 60060)
• Almotriptan/Naratriptan/Rizatriptan/Sumatriptan/Zolmitriptan Special Authorization Request Form (PDF) (ABC 60124)
• Aripiprazole/Paliperidone/Risperidone Prolonged Release Injection Special Authorization Request Form (PDF) (ABC 60024)
• Anifrolumab for Systemic Lupis Erythematosus Special Authorization Request Form (ABC 60110)
• Asfotase Alfa Consent Form (PDF) (ABC 60057)
• Asfotase Alfa Special Authorization Request Form (PDF) (ABC 60063)
• Atogepant/Eptinezumab/Fremanezumab/Galcanezumab for Migraine Prevention Special Authorization Request Form (PDF) (ABC 60095)
• Atomoxetine for Attention Deficit Hyperactivity Disorder (ADHD) Special Authorization Request Form (PDF) (ABC 60109)
• Belimumab for Lupus Nephritis Special Authorization Request Form (PDF) (ABC 60114)
• Benralizumab/Dupilumab/Mepolizumab/Tezepelumab for Asthma Special Authorization Request Form (PDF) (ABC 60061)
• Biosimilar Initiative Exception Special Authorization Request Form (PDF) (ABC 60076)
• Biosimilars Initiative Support Patient List Request Form (PDF) (ABC 60077)
• Burosumab Special Authorization Request Form (PDF) (ABC 60096)
• Calcium Channel Blocking Agents (CCBs) Pricing Authorization Request Form (PDF) (ABC 60073)
• Celecoxib Special Authorization Request Form (PDF) (ABC 60032)
• Cerliponase Alpha Special Authorization Request Form (PDF) (ABC 60121)
• Cladribine/Fingolimod/Natalizumab for Multiple Sclerosis Special Authorization Request Form (PDF) (ABC 60000)
• Combination Angiotensin-Converting Enzyme Inhibitors Pricing Authorization Request Form (PDF) (ABC 60075)
• Combination CFTR Modulators Special Authorization Request Form (PDF) (ABC 60090)
• Dabigatran/Edoxaban Special Authorization Request Form (PDF) (ABC 60019)
• Dapagliflozin for Heart Failure Special Authorization Request Form (PDF) (ABC 60097)
• Darbepoetin/Epoetin Special Authorization Request Form (PDF) (ABC 60006)
• Darifenacin Hydrobromide/ Fesoterodine Fumarate/ Mirabegron/ Trospium Chloride Special Authorization Request Form (PDF) (ABC 60088)
• Deferiprone Special Authorization Request Form (PDF) (ABC 60054)
• Denosumab/Zoledronic Acid for Osteoporosis Special Authorization Request Form (PDF) (ABC 60007)
• Dimethyl Fumarate/Glatiramer Acetate/Interferon Beta-1a/Ocrelizumab/Ofatumumab/Peginterferon Beta-1a/Teriflunomide for RRMS/ Interferon Beta-1b for SPMS or RRMS Special Authorization Request Form (PDF) (ABC 60001)
• Donepezil/Galantamine/Rivastigmine Special Authorization Request Form (PDF) (ABC 60034)
• DPP-4/SGLT2 Inhibitors/GLP-1 Receptor Agonist Special Authorization Request Form (PDF) (ABC 60012)
• Eculizumab/Pegcetacoplan/Ravulizumab Consent Form (PDF) (ABC 60035)
• Eculizumab/Pegcetacoplan/Ravulizumab for Paroxysmal Nocturnal Hemoglobinuria Special Authorization Request Form (PDF) (ABC 60009)
• Edaravone Special Authorization Request Form (PDF) (ABC 60080)
• Elosulfase Alfa Special Authorization Request Form (PDF) (ABC 60115)
• Eplerenone/Ivabradine/Sacubitril+Valsartan/Vericiguat Special Authorization Request Form (PDF) (ABC 60050)
• Febuxostat Special Authorization Request Form (PDF) (ABC 60037)
• Fentanyl Special Authorization Request Form (PDF) (ABC 60005)
• Fidaxomicin Special Authorization Request Form (PDF) (ABC 60014)
• Filgrastim/Pegfilgrastim Special Authorization Request Form (PDF) (ABC 60013)
• Finerenone Special Authorization Request Form (ABC 60111)
• Foslevodopa/Foscarbidopa Infusion/Levodopa/Carbidopa Intestinal Gel Special Authorization Request Form (PDF) (ABC 60068)
• Glecaprevir/Pibrentasvir for Chronic Hepatitis C Special Authorization Request Form (PDF) (ABC 60102)
• Halobetasol Propionate + Tazarotene Topical Lotion Special Authorization Request Form (PDF) (ABC 60094)
• HMG-COA Reductase Inhibitors (Statins) Pricing Authorization Request Form (PDF) (ABC 60074)
• Icatibant/Lanadelumab for HAE Type I or II Special Authorization Request Form (PDF) (ABC 60083)
• Icosapent Ethyl Special Authorization Request Form (PDF) (ABC 60123)
• Imiquimod Special Authorization Request Form (PDF) (ABC 60038)
• Inotersen/Patisiran for hATTR-PN Special Authorization Request Form (PDF) (ABC 60084)
• Iron (Intravenous) Special Authorization Request Form (PDF) (ABC 60085)
• Ivacaftor Special Authorization Request Form (PDF) (ABC 60004)
• Long-Acting Fixed-Dose Combination Products for Asthma/COPD Special Authorization Request Form (PDF) (ABC 60025)
• Lumasiran Special Authorization Request Form (PDF) (ABC 60119)
• Luspatercept Special Authorization Request Form (PDF) (ABC 60106)
• Maribavir Special Authorization Request Form (PDF) (ABC 60118)
• Mavacamten Special Authorization Request Form (PDF) (ABC 60122)
• Mecasermin Special Authorization Request Form (PDF) (ABC 60107)
• Mepolizumab for Chronic Rhinosinusitis with Nasal Polyps Special Authorization Request Form (PDF) (ABC 60120)
• Migalastat Special Authorization Request Form (PDF) (ABC 60071)
• Montelukast Special Authorization Request Form (PDF) (ABC 60039)
• Nintedanib/Pirfenidone Special Authorization Request Form (PDF) (ABC 60051)
• Nusinersen Special Authorization Request Form (PDF) (ABC 60064)
• Obeticholic Acid Special Authorization Request Form (PDF) (ABC 60065)
• Ocrelizumab for PPMS Special Authorization Request Form (PDF) (ABC 60067)
• Omalizumab for Asthma Special Authorization Request Form (PDF) (ABC 60020)
• Omalizumab for Chronic Idiopathic Urticaria Special Authorization Request Form (PDF) (ABC 60056)
• Proton-Pump Inhibitors Pricing Authorization Request Form (PDF) (ABC 60049)
• Ravulizumab for Atypical Hemolytic Uremic Syndrome Special Authorization (PDF) (ABC 60113)
• Rifaximin Special Authorization Request Form (PDF) (ABC ABC 60112)
• Rituximab for Granulomatosis with Polyangiitis/Microscopic Polyangiitis Special Authorization Request Form (PDF) (ABC 60018)
• Rituximab for Rheumatoid Arthritis Special Authorization Request Form (PDF) (ABC 60046)
• Satralizumab Special Authorization Request Form (PDF) (ABC 60116)
• Sebelipase Alfa Special Authorization Request Form (PDF) (ABC 60089)
• Select Quinolones Special Authorization Request Form (PDF) (ABC 60042)
• Single-Entity Angiotensin-Converting Enzyme Inhibitors Pricing Authorization Request Form (PDF) (ABC 60072)
• Siponimod for Secondary Progressive Multiple Sclerosis (SPMS) Special Authorization Request Form (PDF) (ABC 60092)
• Sofosbuvir for Chronic Hepatitis C Special Authorization Request Form (PDF) (ABC 60103)
• Sofosbuvir/Ledipasvir for Chronic Hepatitis C Special Authorization Request Form (PDF) (ABC 60101)
• Sofosbuvir/Velpatasvir for Chronic Hepatitis C Special Authorization Request Form (PDF) (ABC 60100)
• Sofosbuvir/Velpatasvir/Voxilaprevir for Chronic Hepatitis C Special Authorization Request Form (PDF) (ABC 60104)
• Tacrolimus Topical Ointment Special Authorization Request Form (PDF) (ABC 60047)
• Tafamidis for ATTR-CM Special Authorization Request Form (PDF) (ABC 60086)
• Tocilizumab for Giant Cell Arteritis Special Authorization Form (PDF) (ABC 60066)
• Tocilizumab for Systemic Juvenile Idiopathic Arthritis Special Authorization Request Form (PDF) (ABC 60048)
• Velaglucerase Alfa/Taliglucerase Alfa for Gaucher Disease Special Authorization Request Form (PDF) (ABC 60070)
• Zoledronic Acid 0.8 mg/ml Injection (4mg/5ml Vial) Special Authorization Request Form (ABC 60091)

Forms for physicians

• Eligible MS Disease Modifying Therapies (PDF) Registration form for MS Neurologist status
• Opioid Agonist Therapy (OAT) Program Coverage Extension Request (PDF) Registration form for OAT Program extension request
• Select Quinolone Antibiotics (PDF) Registration form for Designated Prescriber status

Your Comments are Important to Us

Please note: This is not a mechanism for appeal for a specific patient but pertains to drug product eligibility in general.

For program information and application forms check:

• Coverage for Seniors
• Non-Group Coverage
• Palliative Coverage
• Alberta Child Health Benefit Program

The DBL, DBS and related publications require knowledgeable interpretation and are intended primarily for professional health care practitioners, pharmacies, hospitals and organizations associated with the manufacture, distribution and use of pharmaceutical preparations.

Electronic versions of all DBL and DBS related publications are unofficial versions and are provided for convenience and private use only. Official paper versions can be obtained from Alberta Blue Cross ® who publishes them on behalf of Alberta Health and Alberta Human Services.

Alberta Health reserves the right to make changes, without notice, to the List through the Interactive DBL (iDBL), and any such changes to the Interactive DBL (iDBL) are effective the date of the change (unless otherwise stated) and regardless of the date of publication in the paper version or updates.