Form
Ankylosing Spondylitis Special Authorization Request Form
Special authorization request form to be completed by your physician or diagnosing specialist.
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Form
Family Health Benefit Application Form
Complete this form to apply for the Family Health Benefit Drug Program.
Form
High Cost Drug Program Application Form
Complete this form if you need assistance paying for expensive medications. You may be eligible for coverage of approved medication costs through the High Cost Drug Program.
Form
Erythropoietin Program Approval Form
Complete this form if you have been diagnosed with chronic renal failure, or are receiving kidney dialysis. You may be eligible for coverage of anemia treatment medications, which will eliminate the need for frequent blood transfusions.
Form
Home Oxygen Program Application Form
Complete this form if you have been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and have been prescribed oxygen. You may be eligible for coverage of expenses through the Home Oxygen Program.
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Hepatitis Drug Program
If you have been diagnosed with hepatitis or have been in close contact with someone who has hepatitis, you may be eligible for coverage of approved medication costs through the Hepatitis Drug Program. Am I eligible? You are eligible for this program if you are a PEI resident as...
Form
Catastrophic Drug Program Application Form
Complete this form to apply for coverage of medication through the Catastrophic Drug Program.
Form
Standard Special Authorization Request Form
Some medications in the PEI Pharmacare Formulary are approved on a special authorization basis only. If your physician prescribes a drug in this category, you can submit a Standard Special Authorization Request form to have a medication considered for coverage.
Information
Phenylketonuria (PKU) Supplement Program
If you or your child has been diagnosed with phenylketonuria (PKU), you may be eligible for coverage of approved nutritional supplement costs through the Phenylketonuria Supplement Program. Am I eligible? You or your child are eligible for the program if you have: are a PEI...