Specific Special Authority Requests:
click the buttons to populate the form, follow the links to the SA website for more information
|
Acetaminophen for osteoarthritis, as: Monotherapy Adjunct to NSAID Aclidinium (+ Formoterol) for COPD Alendronate / Risedronate for: Osteoporotic # Steroid-induced osteoporosis Angiotensin-2 Receptor Blocker Antifungal - topicals for lower extremity dermatomycosis with: DM PVD Apixaban Bupropion for depression Carvedilol Celecoxib for: OA RA Cipro/Dexamethasone for: AOM + vent tube AOE Dapagliflozin for DM Dapagliflozin for HRrEF Detemir / Glargine DOAC for Atrial Fibrillation Donezepil Dutasteride / Finasteride Empagliflozin (+ Metformin) Formoterol for asthma Galantamine Gliclazide Glycopyrronium (+ Indacaterol) for COPD Indacaterol for COPD Indapamide ICS / LABA for asthma for COPD ( Advair Atectura Breo Symbicort Zenhale ) |
ICS-LABA-LAMA combo for asthma Levetiracetam Linagliptin (+ Metformin) LMW Heparin for Cancer or VTE Methylphenidate Long-acting Mometasone Nasal Pamidronate Perindopril Pioglitazone Proton Pump Inhibitor Raloxifene for osteoporotic # and: Intolerance Treatment failure Rivaroxaban - reason: DVT or PE only Rivastigmine Salmeterol for asthma for COPD Saxagliptin (+ Metformin) Semaglutide injection Tacrolimus Terbinafine tablets only Testosterone injectable only Tiotropium (+ Oladaterol) for COPD Umeclidinium (+ Vilanterol) Vancomycin Zopiclone for: HIV-AIDS Psychiatric Dx Failed Benzodiazepine/Hypnotic Alcohol-Drug Addiction Elderly |
Links / References / other Special Authority Forms:
|
|
|
|