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REQUEST FOR CONTINUATION OF FUNDING FOR PbR EXCLUSION
F.A.O:
From:
Your designation:
Your contact details:
PbR excluded Drugs Team
North West London Commissioning Support Unit
E-mail: [email protected]
Tel:
E-mail:
Date:
Before providing patient identifiable data below, I can confirm that the patient (or in the case of a minor or
vulnerable adult with the parent/legal guardian/carer) has given appropriate explicit consent for sensitive
personal information on this form to be passed to the CCG and/or CSU for processing this request for
further funding and validating subsequent invoices. Consent given: ☐Yes
I would like to request further funding for the following:
Drug name:
Indication:
Ranibizumab ☐
Aflibercept ☐
Macular Oedema secondary to Retinal Vein Occlusion
Central ☐
Branch ☐
Patient NHS number:
Hospital no:
Patient birth year:
GP Practice Code:
GP Practice Postcode:
I herewith provide you with the requested information:
1. This request is for continued treatment of the same eye(s)*
☐ Yes
2. Please confirm which eye(s) is/are to be treated and their current visual acuity (BCVA)
☐Left Eye – BCVA:
☐Right Eye – BCVA:
3. Visual acuity has continued to improve?
☐ Yes
4. Visual acuity has not yet been stable for 3 consecutive months?
7. What is acquisition cost of drug including VAT (if applicable)?
☐ No
☐ No
☐ Yes
☐ No
£
/0.5mg injection
*A new application is required for:


Repeat treatment of the same eye because the visual acuity deteriorates following treatment withdrawal after initial response. Note: Funding will
only be re-approved if the patient has shown an improvement of visual acuity
Treatment of the other eye
I look forward to your response in due course.
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