Request for pharmaceutical funding




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Complete this form to request pharmaceutical funding from ACC.

When you’ve finished, please either:



  • return this form to the client’s case manager at their local ACC branch, or

  • send it to the Pharmaceutical Reimbursement team at either:

    • PO Box 90341, Auckland Mail Centre (if you live in Waikato, Bay of Plenty, Auckland or Northland areas)

    • PO Box 408, Dunedin (if you live anywhere else)

Before requesting funding, please check if the pharmaceutical is listed in The Pharmaceutical Schedule (including the hospital formulary section). If it is listed, follow the special authority or restrictions in The Pharmaceutical Schedule. If it isn’t listed, or the special authority criteria aren’t met, then check whether or not Pharmac funds the pharmaceutical through its Named Patient Pharmaceutical Assessment (NPPA) process. See the Pharmac website ‘Tools and Resources’ section for more details.

1. Client details

Client name:      

Claim number:      

Date of birth:      

Date of injury:      

Address:      

Today’s date:      




2. Type of funding request (please tick relevant box or boxes)

 Initial. Please complete Parts A and D.

 Renewal. Please complete Parts B and D.

 Unapproved pharmaceutical. Please complete Parts C and D.

Part A – To be completed for initial funding requests only

3. Medicine information

Please confirm you have attached a list of medicines your client is currently taking. Without this information we might not be able to consider this funding request.

 Yes, the list is attached.



Complete the following table for each medicine you’re requesting funding for. Add extra pages if needed.

Medicine name and strength

Daily dose regime (eg one tid etc

How long has it been used for?

How long will it be used for

Pharmac subsidy

Indication for use – explain why it’s needed for the injury

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

List other pharmaceuticals you have trialled and their outcomes. Include the strength, dosage and duration of use for each pharmaceutical:

     



If this request includes non-subsidised pharmaceuticals, explain why subsidised alternatives are not effective or can’t be trialled:

     



Have you applied to Pharmac for special authority or Named Patient Pharmaceutical Assessment funding?

 Yes (Attach the Pharmac application and response)  No. Please explain why:      





Are the pharmaceutical(s) approved for use in New Zealand?

 Yes


 No – please ask a medical specialist to complete Part C

Will the pharmaceutical(s) be used for approved indications?

 Yes


 No – please ask a medical specialist to complete Part C




4. Injury information and rehabilitation goals

What is the current condition you are treating?

     




Outline the pathology of how the injury caused the current condition:

     



List the other health or non-injury conditions the client has that are contributing to the injury condition you are treating:

     




What are the expected rehabilitation outcomes? For example, return to work, being able to do everyday activities etc. You will need to report against these for funding renewals.

     



Part B – To be completed for funding renewals only

5. Rehabilitation outcomes

List the rehabilitation outcomes that have been achieved since your previous funding request, eg change in pain measurement scores, evidence of decreased home help requirements, evidence of increased hours at work etc:

     



What is the current condition you are treating?

     




List the non-injury conditions which contribute to the current condition:

     




Please confirm you have attached a list of medicines your client is currently taking. Without the information we might not be able to consider this funding request.

 Yes, the list is attached.




Complete the following table for each medicine you’re requesting funding for. Add extra pages if needed.

Medicine name and strength

Daily dose regime (eg one tid etc)

How long has it been used for?

How long will it be used for?

Pharmac subsidy

Indication for use – explain why it’s needed for the injury

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

     

     

     

     

 Yes  No

     

Has the medicine regime changed since the first funding request?

 No


 Yes. Outline the reasons for the change:      


Are you applying for any unapproved pharmaceuticals or for pharmaceuticals not approved for the indications you are treating, or submitting additional literature to support a previous unapproved pharmaceutical or indication in this renewal?

 Yes – please ask a medical specialist to complete Part C

 No – go to Part D


Part C – To be completed by a medical specialist for unapproved pharmaceutical funding requests

6. Unapproved pharmaceuticals, or pharmaceuticals being used for unapproved indications

Medical specialist name:      

Vocational registration type:      

Contact details:      

Date:      

What is the condition this pharmaceutical(s) is being used for?

     



Please list any literature you have attached to support this application.

     



Please identify whether this pharmaceutical is registered in the following regions and for what indication.

Address to check if the pharmaceutical is used in the corresponding region

Registered

What indication(s) is it approved for?

United Kingdom (email info@mhra.gsi.gov.uk)

 Yes  No

     

Australia (www.tga.gov.au/industry/artg.htm)

 Yes  No

     

United States (www.fda.gov/Drugs/InformationOnDrugs)

 Yes  No

     

New Zealand (www.medsafe.govt.nz/profs/datasheet/DSForm.asp)

 Yes  No

     

Europe – European Medicines Agency

(http://www.ema.europa.eu and click on the ‘Find medicine’ heading)



 Yes  No

     

Other – please specify:      


Part D – To be completed for all requests

7. Prescriber declaration

I have:

  • completed a medicine reconciliation for all medicines and products the client takes

  • checked all the medicines and products the patient is taking are safe and appropriate to use together

  • considered the rehabilitation outcomes from the pharmaceuticals and other interventions used to date

  • attached a list of medicines and products currently taken by the client.

I have let the client know:

  • about their rehabilitation plan

  • that I am sending the information about their medicines to ACC to seek pharmaceutical funding

  • that if this information is not provided, ACC maybe unable to fund the pharmaceutical

  • that if ACC agrees to fund the pharmaceutical, it may only be for a limited time and limited cost.

I agree to prescribe:

  • using generic medicine names, not brand names

  • subsidised pharmaceuticals, unless they’re unavailable

  • for a short duration to begin with, to ensure there are no adverse events and the client continues to take their medicine regularly.

Prescriber’s name:      

Vocational registration type:      

ACC provider number:      

Prescriber address:      

Phone:      

Prescriber’s signature:      

Date:      

When we collect, use and store information, we comply with the Privacy Act 1993 and the Health Information Privacy Code 1994. For further details see ACC’s privacy policy, available at www.acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001.
This information sheet explains to prescribers how ACC can help with the cost of pharmaceuticals for a client who has been injured.


What we mean by pharmaceutical


For ACC a pharmaceutical means either:

  • a prescription, restricted, or 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.

How we can help


We can help with the costs of some pharmaceuticals if a client needs them to manage an injury condition and they’re not already covered in another agreement with the Ministry of Health or a service provider.



We’re unable to:

  • pay you for applying to ACC for pharmaceutical funding

  • reimburse costs for prescribed items which don’t meet our definition of a pharmaceutical.

If a client needs long-term access to non-pharmaceutical items, for example food supplements, please contact us to see if we can help.


Scripts for our clients are eligible for A4 prescribing – please don’t code prescriptions as ‘nonsubsidised’ or ‘A3’ etc, even for overseas visitors who are injured in New Zealand.

Who can request funding


You can request funding for pharmaceuticals so long as you have prescribing rights and you’re prescribing within your field of work. Only specialist medical practitioners can request funding for unapproved pharmaceuticals.

What we need from you


When you’re prescribing pharmaceuticals we ask that you:

  • talk through all the options with your patient

  • check the Pharmaceutical Schedule listings on the Pharmac website to see if the pharmaceutical is listed. If it isn’t listed or doesn’t meet its funding criteria, yet it meets the Named Patient Pharmaceutical Assessment (NPPA) criteria then apply for the pharmaceutical through Pharmac via the NPPA system

  • explain to your patient that:

    • to support funding requests, you’ll need to send ACC their complete medicines information. We need this to make sure that the pharmaceuticals we fund are safe and appropriate and will help with your patient’s recovery.

    • if ACC is able to grant funding, it will be for a limited time only and costs will be capped

    • if you prescribe a non-subsidised pharmaceutical before ACC gives funding approval, then ACC may not be able to contribute to the cost of the item

  • use the generic name when prescribing, as we can only contribute the prescription co-payment fee when an generic equivalent exists




  • prescribe short courses of pharmaceuticals to ensure adherence and outcomes before prescribing any long-term quantities

  • report adverse reactions to the Centre for Adverse Reactions Monitoring, PO Box 913, Dunedin or online at https://nzphvc.otago.ac.nz/.

We’re here to help

You can keep up to date with our pharmaceutical funding information on our website under the ‘For providers’ heading.



ACC1171 July 2015 Page of 1



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