Download Cambridge University Hospitals NHS Foundation Trust

Reference number
(to be added by contracts department)
Prior Approval Request Form
For drugs, procedures, and devices which require prior approval from
Primary Care Trust Commissioners before treatment is started
See Reverse of Form for List
To be completed by the relevant clinician for each individual patient
Name of drug, procedure or device for
which approval is sought.
(see list on reverse of form)
Patient Name:
Hospital Number:
Responsible Consultant:
Specialty/Service:
GP name:
PCT (leave blank if not known):
Proposed Start/Procedure Date:
Dosage/Quantity:
Duration:
Does patient meet NICE or other agreed
protocols?
(if appropriate state which ones)
Emergency – YES or NO (if yes give
reason for why cannot wait for PCT
approval before treatment):
Estimated Cost (total/per annum):
Any additional information to support request
– continue on separate sheet if required
Name of requestor:
Contact telephone number
Signed:
Date
Version 1 July 2006
Page 1 of 2
The following drugs, devices and procedures are invoiced separately on a cost by case basis by the
Hospital Trust to PCTs in line with the NHS pricing rules, providing prior approval has been given by
the relevant PCT. If prior approval is not obtained for either the treatment or for referral for
treatment elsewhere, the full cost of the drug or treatment will be charged to the relevant hospital
department or specialty. If a request is turned down by a PCT an appeals process can be initiated by
the Hospital.
Please note that this approval is required for this list even if the Drug has been approved by NICE.
The prior approval process may change in September 2006 after the Cambridgeshire and
Peterborough PCTs have considered the completed business cases that the Trust has completed.
Drugs:
AIDS/HIV antiretroviral Drugs
Anti Fungals:
- Amphotericin
- Caspofungin
- Voriconazole
Anti-TNF Drugs including:
- Adalimumab
- Etanercept
- Infliximab
BETA Interferon
Betaine
Carnitine
Cysteamine
Efalizumab
Enzyme Replacement Therapy
Hepatitis C Drugs:
- Roferon
- Viraferon
- Pegylated Interferons
- Tribivirin
- Ribavirin
- Lamivudine
Herceptin
Intravenous/sub-cutaneous human
normal immunoglobulins
Palivizumab
Pulmonary Hypertension Drugs:
- Bosentan
- Epoprostenol
- Iloprost
Riluzole
Sodium Phenylbutyrate
Somatropin
Verteporfin
All chemotherapy drugs (prior approval currently
required only for new drugs or new usages of
existing drugs EVEN if they have been approved
by NICE)
Devices:
Bespoke Orthopaedic Prosthesis
Spinal Cord Stimulators
Gliadel Wafers
Insulin Pumps and Pump Consumables
for home use – do not currently need prior
approval if in line with NICE guidance
Deep Brain Stimulators
Vagal Nerve Stimulators
Sacral Stimulators
Aneurysm Coils
Procedures/Other:
Gastric Banding and Bypass
PET scans (other than for level A evidence)
Haemophilia Blood Products
Hyperbaric oxygen treatment for non local PCTs
Low Priority Procedures (LPPs)
Cosmetic Surgery including:
- abdominoplasty
- blepharoplasty
- breast reduction / augmentation
- face lift
- liposuction
- pinnaplasty (over 16 year olds)
- rhinoplasty
- tattoo removal
Benign skin lesions
Circumcision
Dental Implants
Orthodontic Treatment (IOTN 1-3)
Reversal of sterilisation
Varicose Vein Removal (for cosmetic reasons)
Pathology free wisdom teeth removal
(more detailed information on LPPs can be viewed at
www.cambsphn.nhs.uk – look at ‘Clinical Priorities /
Cambridgeshire NHS Clinical Policies’
PLEASE CONTACT SUE FRIEND FOR FURTHER GUIDANCE OR TO CHASE PROGRESS ON A REQUEST
All requests will be acknowledged and forwarded to relevant PCT within 24 working hours (Mon to Fri) of receipt
Please return completed form (preferably by email or otherwise hard copy) to:
Sue Friend
Head of Contracts, Finance Department, Westgate, PDH
Telephone 01733 874456
Email [email protected]
Please put ‘prior approval request’ in subject header
Version 1 July 2006
Page 2 of 2