Download ACC2530 Cox-2 Inhibitors - Checklist for ACC contribution to cost

ACC
2530
Cyclo-oxygenase II Selective Inhibitors (Cox2 Inhibitors) – Prescriber Checklist:
Guidelines for ACC contribution to cost
This form is used by medical practitioners and designated nurse prescribers (prescribing within their scope of
practice) in order to self-assess whether a client may be eligible for ACC contribution to the cost of Cox-2 inhibitors.
Refer also to the attached Information Sheet about applying to ACC for pharmaceutical funding
Please use this checklist before you write a prescription. Once completed, it should be kept in the client’s medical notes. It does
not have to be sent to ACC unless requested.
These guidelines have been developed using evidence-based criteria, and are aimed at promoting the safe and appropriate use
of pharmaceuticals to achieve optimal health and rehabilitation outcomes for clients. There is consistent evidence showing that
COX2 inhibitors should be used with caution, for a short term only. Cardiovascular risk/benefit should be carefully considered
before prescribing these.
PART 1: CLIENT DETAILS
Client’s name:
Date of birth:
Date of injury:
Claim number:
Injury for which this pharmaceutical is being prescribed:
PART 2: CLIENTS NOT NORMALLY ELIGIBLE FOR ACC CONTRIBUTION TO COST OF COX -2 INHIBITORS
ACC will NOT contribute to the cost of Cox-2 inhibitors if you answer ‘Yes’ to ANY of the questions below.
1. Can other subsidised NSAIDs be used instead of the Cox-2 inhibitor? (If no, state why not)
Yes
No
2. Will the Cox-2 inhibitor be used for longer than one month?
Yes
No
3. Is the injury more than one month old?
Yes
No
4. Is the client: (underline which points apply)
Yes
 less than 18 years old, or
 in the third trimester of pregnancy, or
 taking low dose aspirin, or
 taking ACE inhibitors and diuretics, or any other medications that have significant interactions with Cox-2 inhibitors, or
 being prescribed medicine to prevent peptic ulcers developing, or
 soon going to have cardiac or vascular surgery;
OR does the client have:
 a history of asthma, urticaria or allergic reactions to NSAIDs or aspirin, or
 sub-optimal liver or renal function (indicated by tests) which makes it unsafe to use Cox-2 inhibitors, or
 high absolute risk potential for CVD or active CVS health conditions, or
 active GI disease, or
 a history that includes a previous MI or stroke?
No
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February 2010
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PART 3: CLIENTS WHO ARE ELIGIBLE FOR ACC CONTRIBUTION TO COST OF COX–2 INHIBITORS
ACC will contribute to the reasonable costs for one Cox–2 inhibitor prescription (for a one month supply) if you answer ‘Yes’ to ALL questions below.
1. Is the Cox-2 inhibitor being used to facilitate treatment of an ACC covered injury?
Yes
No
2. Do you confirm that NONE of the criteria in Part 2 apply?
Yes
No
3. Is the Cox-2 inhibitor being prescribed WITHOUT the co-prescription of any gastro protective agents?
Yes
No
4. Do all of the following apply?:
Yes
No

the client has trialled subsidised NSAIDs (+/- paracetamol) and has either not tolerated this OR has not had successful analgesia/relief (please state
name and dose of NSAID they have trialled)
and

use of other subsidised NSAIDs is contraindicated (please state reason for contraindication)
and

the client has a high risk of developing GI toxicity (please state reason for high risk):
PART 4: PRESCRIPTION DETAILS
Please state the following prescription details if they are not recorded in your PMS system (this information is for ACC audit purposes only).
Name and brand of Cox-2 inhibitor
Quantity Prescribed
Dose prescribed
Cost
PART 5: PRESCRIBER RESPONSIBILITIES

The Cox-2 inhibitor is prescribed for use at the usual dose range for pain and inflammation management.

The Cox-2 is prescribed for a duration of one month only with dispensing quantities of a one week supply then a three week supply (to ensure no
adverse events occur).

Use of the drug is regularly reviewed by the prescriber and reported to ACC by the specified review dates, prior to further subsidy being agreed
by ACC.

Organ function is regularly monitored for clients at high risk of developing adverse reactions.

The brand and dose form used is registered for use in New Zealand.

All adverse reactions are reported to the Centre for Adverse Reactions Monitoring, PO Box 913, Dunedin.

This completed/dated checklist is kept on the patient file, and will be made available for ACC clinical practice audits or viewing if requested.
Note:
ACC can consider requests for contribution towards a prescription for Cox-2 inhibitors for clients who do not meet the criteria set
out in Part 3 of this form. To request consideration for funding for these clients, you must send us this completed check-list and a
completed ACC1171 form (this is available on www.acc.co.nz/Publications/For Providers/Pharmaceuticals).
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PART 6: DECLARATION
This pharmaceutical is for the client’s covered injury, and is:

for restoring the client’s health to the maximum extent practicable

to facilitate treatment
 reasonably required.
I have discussed the treatment options with the client and advised why the recommendation is the appropriate pharmaceutical in this case.
I understand that ACC may request copies of the completed checklist or other claim-related information when reviewing eligibility for the funding of this
pharmaceutical for this client.
I have prescribed only one month of the Cox-2 inhibitor (dispensing one week then a further three weeks) as per the guidance of this checklist.
Prescriber’s signature:
Date:
Prescriber’s name/ACC Provider Number/Vocational Registration Type:
Address:
Phone:
Fax:
References:
Prescriber update; New Zealand Medicines and Medical Devices Safety Authority; Ministry of Health Vol 26 No. 1, June 2005;
http://www.medsafe.govt.nz/profs/PUarticles.asp
Prescriber update; New Zealand Medicines and Medical Devices Safety Authority; Ministry of Health Vol 26 No. 2, Dec 2005;
http://www.medsafe.govt.nz/profs/PUarticles.asp
The information collected by ACC on this form will be used to fulfil the requirements of the Accident Compensation Act 2001. In the collection,
use, and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy
Code 1994.
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Funding from ACC for pharmaceuticals – Information for
prescribers
ACC contributes to the cost of pharmaceuticals that are needed to treat a client who has had a personal injury.
We ask prescribers to discuss pharmaceutical options with the client and give us information about the
pharmaceuticals they are prescribing so we can make a decision about funding.
Pharmaceuticals definition
A pharmaceutical is defined in Section 6 of the
Accident Compensation Act 2001 to mean either:
 A prescription medicine, a restricted medicine,
or a pharmacy-only medicine, as listed in Parts
1, 2 and 3 of Schedule 1 of the Medicines
Regulations 1984
 A controlled drug as defined in the Misuse of
Drugs Act 1975.
Costs for prescribed items which do not meet this
definition are not normally reimbursed by ACC. If a
client needs long-term access to non-pharmaceutical
items, contact ACC so a case owner can assess the
need for these items.
ACC’s contribution to costs
ACC will consider contributing to the costs of
pharmaceuticals if they are:
 to facilitate the treatment, and
 reasonably required for rehabilitation, and
 are for a condition for which ACC has granted
cover, and
 not already paid for in contractual agreements
held with health and rehabilitation providers or
the Crown.
Who can request funding?
Note: Only specialist medical practitioners
practising within their scope of practice can request
funding for unapproved pharmaceuticals.
Prescribers should check http://www.acc.co.nz/forproviders/ (the ACC provider’s website) regularly
for updates on any specific prescribing and funding
information.
Requesting ACC funding for non-subsidised
pharmaceuticals
For new funding requests, complete the Request for
Funding from ACC for Non-Subsidised
Pharmaceuticals (ACC1171) or send in a letter
outlining the information required on the form.
Please explain to the client, that if the information
you submit is incomplete, ACC cannot make a
decision to contribute to the cost of pharmaceuticals
and you will be asked to complete the information
and resend the request for funding.
If a funding contribution is granted, it is timelimited and cost-capped.
ACC will regularly check that a client’s
rehabilitation outcomes are being achieved for any
pharmaceutical funding we contribute to. You will
need to give us regular updates on how
pharmaceutical usage is helping the client. Please
use the form ACC1172 – Evaluation of
Pharmaceutical Use to give us this information.
All prescribers who are:

treatment providers with prescribing rights, and
 prescribing within their scope of practice.
Where pharmaceutical funding is being sought
long-term, has been funded long-term, or is for
unique circumstances, ACC may require a medical
specialist to confirm the need for the
pharmaceutical.
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Please request funding before prescribing an item.
If you prescribe a non-subsidised pharmaceutical
before ACC gives funding approval, please explain
to the client that ACC may not contribute to the cost
of the item.
ACC does not contribute to the cost of you applying
for pharmaceutical funding.
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Prescriber responsibilities

You should:





advise the client that you will regularly send
their medicines information to ACC to help us
make funding decisions (this may include
information regarding non-ACC health
conditions)
follow any special authority or prescribing
guidelines developed by Pharmac and DHBs or
their best practice agencies
seek funding from Pharmac (special authority
funding) or DHBs (via various community
funding mechanisms) where available (ACC
makes a bulk payment to the Ministry of Health
to cover this pharmaceutical funding)
use the generic name when prescribing, eg
diclofenac tablets - not Voltaren tablets (ACC
may not contribute to the cost of branded
pharmaceuticals where equivalent generics
exist)
for new prescriptions or when changing
medicines, prescribe short courses of
pharmaceuticals to ensure adherence and
outcomes before prescribing any long-term
quantities (eg prescribe one week’s treatment
with two repeats, close control if necessary,
instead of three months all at once)



regularly evaluate the pharmaceutical use and
ensure best prescribing practice information is
followed and rehabilitation outcomes are being
achieved
regularly evaluate organ function (eg
gastrointestinal symptoms, liver, renal function,
etc) and monitor laboratory tests for clients at
high risk of developing adverse reactions
report adverse reactions to the Centre for
Adverse Reactions Monitoring, PO Box 913,
Dunedin
refer the client to ACC for active case
management if the pharmaceutical is to be used
long-term.
Prescriber checklists
ACC has developed the prescriber checklists, the:

ACC1173, ACC2530, and ACC2531.
These outline best practice prescribing guidance
and are available at ACC Publications
(www.acc.co.nz > Publications > For Providers >
Pharmaceuticals).
Refer to the checklists before asking ACC for costcontribution. ACC will not normally contribute to
the cost of the pharmaceuticals, where the guidance
has not been followed.
The information contained in this fact sheet is a guide only. ACC has made every attempt to ensure that it is accurate. However, in the event of any
dispute the Accident Compensation Act 2001 will take precedence. February 2010.
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