Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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