This is the text extract for Ethambutol 100 mg tablets - application information & form, browse documents here.

APPLICATION INFORMATION FOR ETHAMBUTOL 100 mg TABLETS

With the withdrawal of ethambutol 100 mg tablets from the market, an alternative brand will be funded through Exceptional Circumstances. We are aware that Health Support Limited has been importing ethambutol 100 mg tablets from the UK and has been supplying this brand to the market. As this product does not have consents for distribution from Medsafe, it is only available pursuant to Section 29 of the Medicines Act for patients where there is no suitable alternative. The purpose of the Exceptional Circumstance scheme is to provide fully funded pharmaceuticals for some individuals whose needs are not met under the Pharmaceutical Schedule. This scheme would not generally be available to those who do not meet the strict criteria for admittance to this scheme. However, the EC scheme will administer the funding of ethambutol 100 mg tablets for a small group of people. Approvals will be granted for a fixed period, generally of one year. Additional forms may be obtained from: PHARMAC Help Line (9-4) 0-800-66-00-50 or downloaded from www.pharmac.govt.nz

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Application Form for Ethambutol 100mg Tablets

Return completed to: Community Exceptional Circumstances Panel Co-ordinator PHARMAC PO Box 10-254 WELLINGTON Phone: 04-916 7553 Fax: 09-523 6870

Patient Details

Last Name: First Name: Address:

Details of Applying Physician

Last Name: First Name: Address:

Gender: Male/Female Date of Birth: NHI No: Phone: NZMC#

Are you a GP ❏ or Specialist ❏ ?

Medicine/treatment sought Chemical Name: Supplier: Ethambutol 100mg tablets Health Support Limited

Cost Cost will be reimbursed at Cost Brand and Source: Cost: $61.55 per 56 tablets

1. Dosage to be used: 2. Nominated Pharmacy:(if approval is given from where will the patient have the prescription dispensed?) Name: Address:

3. Entry Criteria: List indication for which funding for ethambutol is sought. Indication: 4. Consent:

Patient consent has been obtained for the use of a non-registered medicine being obtained under Section 29

❏

Please indicate that patient has been consulted.

Signature of Medical Practitioner: ___________________________________ Date of Request: _________________________________________________

S4-3-0 #89647