NWL CCG Use Only

Date Received:

Contact:

CCG:Ref:

REQUEST FOR CONTINUATION OF FUNDING FOR PbR EXCLUSION
F.A.O: / PbR Excluded Drugs Team
North West London Collaboration of Clinical Commissioning Groups
E-mail:
From:
Your designation:
Your contact details: / Tel:
E-mail:
Date (dd/mm/yyyy):

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 for processing this request for further funding and validating subsequent invoices.

Consent given: ☐Yes (please note, we will be unable to process this form if this box is not ticked)

I would like to request further funding for the following:

Indication: / Wet Age related Macular Degeneration
Drug name: / Ranibizumab☐ Aflibercept☐(please tick one)
Drug dose/frequency:
Patient NHS number: / [PatientNHSNum]
Hospital no: / [PatientHospNum]
Patient birth year: / [PatientBirthYear]
GP Practice Code: / [GPPracticeCode]
GP Practice Postcode: / [GPPostcode]

I herewith provide you with the information required for re-approval for a further 12 months treatment:

1. This request is for continued treatment of the same eye(s)* with same drug. / ☐Yes / ☐No
2. Please confirm which eye(s) is/are to be treated and their current visual acuity (BCVA) and lesion size
☐Left Eye – BCVA: Lesion size: ☐Right Eye – BCVA: Lesion size:
3. Visual acuity has continued to improve? / ☐Yes / ☐No
4. Visual acuity has not yet been stable for 3 consecutive months? / ☐Yes / ☐No
5. Lesion size has not deteriorated further? / ☐Yes / ☐No
6. Patient does not meet any of the criteria for discontinuing treatment as defined by Royal College of Ophthalmologists Sept 2013 (i.e. none of the discontinuation criteria described below apply)
Consider discontinuing treatment permanently if there is:
  • A hypersensitivity reaction to anti-VEGF is established or suspected
  • Reduction of BCVA in the treated eye to less than 15 letters (absolute) on 2 consecutive visits in the treated eye, attributable to AMD in the absence of other pathology
  • Reduction in BCVA of 30 letters or more compared to either baseline and/or best recorded level since baseline as this may indicate either poor treatment effect or adverse event or both
  • There is evidence of deterioration of the lesion morphology despite optimum treatment. Such evidence includes progressive increase in lesion size confirmed with FFA, worsening of OCT indicators of CNV disease activity or other evidence of disease activity in the form of significant new haemorrhage or exudates despite optimum therapy over 3 consecutive visits.
/ ☐Yes / ☐No
7. What is acquisition cost of drug including VAT (if applicable)? / £/ 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 in visual acuity
  • Treatment of the other eye
  • New treatment with another anti VEGF in the same eye.

I look forward to your response in due course.

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