The Information in This Document Is CONFIDENTIAL to the Trust and Should Under NO Circumstances

Please Note: -

The information in this document is CONFIDENTIAL to the Trust and should under NO circumstances be shared with outside agencies.

• Sample material of drugs should not be accepted from representatives or used within the Trust.
• Requests should NOT be completed by pharmaceutical representatives.

• The requested drug will only be obtained after agreement from the Associate Medical Director (AMD) and Formulary Working Group (FWG). All Forms MUST be countersigned by the AMD (part II) otherwise they will be returned as incomplete.
• A budget must be set by the Directorate for the use of the drug.
• Any unused stock that is discarded will be costed to the requesting Consultants Directorate.
• Applicants will be given the opportunity to attend a Formulary Working Group meeting to further support their application. Meetings are held on the 3rd Tuesday of each month at GWH.

• Applicant details:

Name of consultant/clinician: Date:

Tel No: Pager No: E mail address:

• Declaration of conflict of interest:

Applicants are required to declare any potential conflicts of interest in accordance with thestandards of professional conduct. Eg sponsorship ,hospitality ,funding for equipment or staff.

• Reason for request:

New drug for formulary New use for existing formulary drug

New Form of existing formulary drug

Other Please give more details below:

• Drug details:

Drug non proprietary name:

Drug manufacturer and brand name:

Drug preparation and strength(s) required:

Licensed indication:

Indications for use in the formulary:

Likely dosing regime:

List preparations currently on the formulary used for the same indication:

• Cost of new drug:

Hospital Trust Community

a) Cost per patient/per month:

b) Estimated number of months treatment per year:

c) Number of patients to be prescribed this drug, per year:

• Reasons for request:(State claimed advantages over existing formulary preparations for this indication)

• Evidence:

New drug requests will only be considered if they provide evidence to support the preparation in terms of EFFICACY, SAFETY, CONVENIENCE and COSTin comparison to existing formulary preparations. Please attach your evidence to this document which should rely heavily on well-controlled published clinical trials. Please submit copies of key papers and a complete list of references. Requests submitted without evidence will be rejected.

• Type/cost of treatment or procedure it may replace:

Drug/Procedure:

Hospital Trust Community

Cost per treatment course:

or procedure(if applicable):

• Cost savings/cost increase from new drug introduction:

Will there be any anticipated changes in expenditure to the Trust? (give details):

Please estimate cost :

In which directorate will they be seen?...D and OPlanned CareUnscheduled CareWomens and Childrens

(please choose from dropdown list above)

• Colour coding/duration of treatment/ to be prescribed in hospital/primary care:

Signed ______

Print name:

Date:

This form MUSTbe forwarded to the Associate Medical Director (AMD) for completion of Part II.

Non completion by the AMD will result in automatic rejection of the request.

• Status of request:

Will funding be available from existing drug budget? YesNo

If Yes: Budget for Drug£/month. Is this for a limited period? Yes No

If Yes: months.

• Usage limited to:

Consultant(s) Signature onlySpecify named Consultant/s:

Consultant Team onlySpecify named team:

Named Speciality onlySpecify named Speciality:

All Directorate medical staff

Non Speciality Prescribing

Signed ______

Print name:

Date:

Please ensure all the above sections are completed before forwarding to

Dr Ravi Chinthapalli, Chair Trust Prescribing Committee & Formulary Working Group,

C/O Formulary Office, Pharmacy Office, 1st Floor, GWH.

This drug has been approved for inclusion in the 3Ts formulary

This drug has not been approved

Reason/details:

Signed (TPC/FWG Chair) ______

Print name:

Date:

1

April 2013