Pharmaceutical Representative Visit Request Form

Derbyshire Medicines Management

PHARMACEUTICAL REPRESENTATIVE REQUEST FORM

This form is to be completed by representatives wishing to have their drug, appliance, device or service (relevant to the management of medicines) to be considered by the Derbyshire Medicines Management Pharmacists. Please complete one form for each product/service.Once completed this should be sent to Kate Stanley, Senior Administration Officer. Please email

NAME OF PRODUCT/SERVICE TO BE DISCUSSED
DRUG COMPANY: / DATE:
REPRESENTATIVE’S NAME
CONTACT DETAILS (e-mail/telephone number)

For a new drug/device or new form of an existing drug completesection A

For branded generics orbrandedversions of items already on the Derbyshire Formularycompletesection B

For service related offers (e.g. IT software) complete section C

Section A- new drug/device or new form of an existing drug

1. Licensed indications

1. Proposed place in Derbyshireclinical pathway (see relevant section on medicines management website )

1. Please provide supporting evidence of the drug/device

1. Price per 28 days at standard or average dose (or unit as appropriate)

1. Is the product currently available through national wholesalers?

Alliance, AAH, Phoenix
With sufficient supply to meet demand?
CCG checklist
If advanced budgetary notice, send to specialist commissioning pharmacist
Does the proposed scheme require a significant change in an existing clinical pathway (e.g. NICE/local guidance/best practice/formulary?)
Are the anticipated net (financial or improvement in quality/safety) rewards through the proposed scheme of sufficient value compared to other CCG priorities?
Could engaging with the proposed scheme encourage perverse prescribing contrary to CCG prescribing policy?
Is the drug/device replacing an existing drug/device in a clinical pathway that is equivalent or clinically superior/safe?
Will this negatively impact on patient care?
Other barriers to adoption (e.g. concerns over similar sounding products)
Are there any Equality and Diversity implications?
(Protected Characteristic: Age, Disability, Gender Re-assignment, Marriage and Civil Partnership, Pregnancy and Maternity, Race, Religion and Belief, Sex, Sexual Orientation)
How significant is this proposal? Normally considered in line with periodic BNF chapter & clinical guideline update

Recommendation

Arrange a visitYes No At a later date Further information required

Section B- Branded generics / Branded products

1. Generic drug name:

1. Strengths available:

1. Licensed indications:

1. Originator or current formulary product:

1. Are licenced indications of product the same as the originator brand or current formulary product?

1. Are all strengths of the originator product available? Yes/No (if no provide details)

1. For modified release products, please provide information to demonstrate bioavailability is equivalent to the originator product:

1. Drug Tariff category: A, C, M, Other

1. Is the product listed in the paper BNF? Yes / No

1. Is the product listed in the on line BNF? Yes / No

1. Is the product’s SPC currently on the EMC Yes / No

1. Is the product currently listed on SystmOne and Emis web ? Yes / No

1. Which national wholesalers currently stock the product?

1. What assurances can be given that demand can be met if a Derbyshire wide switch was implemented?

1. Price per 28 days at standard or average dose (or unit as appropriate):

1. Please provide information on all other branded generics and generics available including current drug tariff/MIMS prices

Drug name / DT / Mims price (28 days at standard or average dose or as appropriate)
Recommendation:
Forward to SPAT to consider:
Yes No At a later date Further information required
Section C – Service related offers
Recommendation
Forward to SPAT to consider:


Yes No At a later date Further information required