Download document - Herts Valleys CCG

Ocriplasmin for vitreomacular traction, NICE TA297, October 2013
Only fully completed forms will be accepted for consideration
The completed form must be sent by the hospital commissioning team to the High Cost Drugs Team at [email protected]
If the patient does not fulfil NICE criteria



The responsible commissioner will not normally fund any treatment where the patient does not meet the agreed criteria as outlined in this patient
specific funding application form.
Following a clinical trial, the responsibility for ongoing funding remains with the provider or pharmaceutical company. The commissioner will only
fund treatment that meets the commissioned pathway.
Applications can be made via the Individual Funding Requests process ONLY where the patient has exceptional clinical circumstances.
Please check the commissioner websites for contact details of the IFR team.
Payment by the commissioner will only be made if the completed form is received no later than 15 days after treatment
Patient NHS No.
Trust:
GP Name:
Patient Hospital
Number:
Consultant Making
Request:
Patient initials:
Patient Dob:
GP code / Practice
code:
/
/
GP Post code:
Criteria for initiation
Patient has a diagnosis of vitreomacular traction – only qualifies for treatment if answer is yes
Which eye is to be treated? As per SPC, treatment is not commissioned in both eyes concurrently, or within 7 days of
treatment in 1st eye
Yes /
Left eye
No
/ Right eye
The eye to be treated is ocriplasmin treatment naïve (i.e. patient has not received previous ocriplasmin in the requested
eye) – only qualifies for treatment if answer is yes
Yes /
No
An epiretinal membrane is not present – only qualifies for treatment if answer is yes
Yes /
No
Please state which one
of these conditions apply
(must be one to meet
NICE criteria)
The patient has stage II full-thickness macular hole with a diameter of 400 micrometres or
less AND severe symptoms
Yes /
No
The patient has stage II full-thickness macular hole with a diameter of 400 micrometres or
less (without severe symptoms)
Yes /
No
The patient has severe symptoms (but does not have a stage II full-thickness macular hole of
Yes /
No
Pharmacy and Medicines Optimisation Team
Herts Valleys Clinical Commissioning Group (HVCCG)
400 micrometres or less)
Please confirm that the commissioner will only be charged the actual acquisition cost of the drug to the provider at the
time of treatment. Any other drug charge to the commissioner will be challenged
Yes
Drug charge per
injection, inclusive of
VAT
£
What is the activity code being charged for administration?
Clinician’s Declaration
I confirm that I have discussed with the patient and that they understand and consent to their personal information being shared with
commissioning and commissioning support organisations for the purposes of processing this funding application and validating the subsequent
invoice. I have also recorded this discussion in the patient’s notes.
I confirm the risks and benefits of treatment have been fully discussed with the patient and documented.
I confirm that funding approval is subject to initiation and follow up of treatment response being undertaken by a specialist ophthalmology team.
I acknowledge and adhere to the cost effective use of this treatment as advocated in NICE TA 297, I understand that this may be subject to audit,
and I believe that within this Trust the above patient would be best managed using the treatment as requested above.
Name of supervising consultant:
Signature (electronic signature):
If this patient is being jointly managed by a second consultant, please
state name here:
Name:
Date:
Date:
/
/
Signature (or email confirmation) by Trust Chief Pharmacist (or nominated
deputy)
Name:
Signature:
Date:
/
/
NICE technology appraisal 297: Ocriplasmin for treating vitreomacular traction, October 2013
Ocriplasmin is recommended as an option for treating vitreomacular traction in adults, only if:
 an epiretinal membrane is not present
and
 they have a stage II full-thickness macular hole with a diameter of 400 micrometres or less and/or
 they have severe symptoms.
Pharmacy and Medicines Optimisation Team
Herts Valleys Clinical Commissioning Group (HVCCG)