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
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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: / Devices:AIDS/HIV antiretroviral Drugs / Bespoke Orthopaedic Prosthesis
Anti Fungals: / Spinal Cord Stimulators
- Amphotericin / Gliadel Wafers
- Caspofungin / Insulin Pumps and Pump Consumables
for home use – do not currently need prior approval if in line with NICE guidance
- Voriconazole
Anti-TNF Drugs including: / Deep Brain Stimulators
- Adalimumab / Vagal Nerve Stimulators
- Etanercept / Sacral Stimulators
- Infliximab / Aneurysm Coils
BETA Interferon / Procedures/Other:
Betaine / Gastric Banding and Bypass
Carnitine / PET scans (other than for level A evidence)
Cysteamine / Haemophilia Blood Products
Efalizumab / Hyperbaric oxygen treatment for non local PCTs
Enzyme Replacement Therapy / Low Priority Procedures (LPPs)
Hepatitis C Drugs: / Cosmetic Surgery including:
- Roferon / - abdominoplasty
- Viraferon / - blepharoplasty
- Pegylated Interferons / - breast reduction / augmentation
- Tribivirin / - face lift
- Ribavirin / - liposuction
- Lamivudine / - pinnaplasty (over 16 year olds)
Herceptin / - rhinoplasty
Intravenous/sub-cutaneous human
normal immunoglobulins / - tattoo removal
Benign skin lesions
Palivizumab / Circumcision
Pulmonary Hypertension Drugs: / Dental Implants
- Bosentan / Orthodontic Treatment (IOTN 1-3)
- Epoprostenol / Reversal of sterilisation
- Iloprost / Varicose Vein Removal (for cosmetic reasons)
Riluzole / Pathology free wisdom teeth removal
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) / (more detailed information on LPPs can be viewed at – 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
Please put ‘prior approval request’ in subject header
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