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Application information for renewal of candesartan tablets

The Special Authority for candesartan was changed on 1 July 2004. This altered Special Authority restricts the maximum funded doses as follows: Tab 4mg. No more than 1.5 tabs per day Tab 8mg. No more than 1.5 tabs per day Tab 16mg. No more than 1 tab per day Patients who were taking a higher dose prior to 1 July 2004 were able to remain on their higher dose and obtain funding for candesartan through the Exceptional Circumstances scheme. Patients were issued an authority number. The following form should be used when applying for renewal of candesartan funding of such a previously issued Exceptional Circumstances authority number. Note that patients commencing on higher doses after 1 July 2004 will not be funded through Exceptional Circumstances unless the usual Exceptional Circumstances criteria are met (please refer to the Pharmaceutical Schedule or the PHARMAC website for more information on Exceptional Circumstances). Approvals will be granted for a fixed period, generally one year. CONTACT Exceptional Circumstances Panel Co-ordinator PHARMAC PO Box 10-254 Wellington Phone: Fax: Email: 04-916-7553 09-523-6870 ecpanel@pharmac.govt.nz

P2-5-2 #81327

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Renewal application form for candesartan tablets

Return completed to: Exceptional Circumstances PHARMAC PO Box 10-254 Wellington Phone: 04-916-7553 Fax: 09-523-6870 Email: ecpanel@pharmac.govt.nz

Patient Details

Last Name: First Name: Address:

Details of Applying Practitioner

Last Name: First Name: Address:

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

Phone: Facsimile: Email: Are you a GP or Specialist ? NZMC#:

Medicine/treatment sought: Chemical Name: candesartan 1. Renewal Criteria:

Cost: Cost will be reimbursed at Subsidy price

Patient was on a dose of candesartan above 16 mg per day before 1 July 2004

(Approvals are granted to enable patients to continue on these higher doses. Approvals cannot be granted for patients commencing on a higher dose after this date.)

Current EC number

EXCP/

2.

Dosage: Dosage to be used and anticipated cost per year (please tick the appropriate amount or enter an amount if another dose is required): 20 mg (2.5 x 8 mg tablet per day) 24 mg (1.5 x 16 mg tablet per day) 32 mg (2 x 16 mg tablet per day) Other dose________________________

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3.

Nominated Pharmacy: (approval can only be granted if this is supplied) Name: Address: ______________________________________________________ ______________________________________________________

P2-5-2 #81327

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4.

Consent:

The patient has been consulted about this use of candesartan

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Signature of Medical Practitioner: __________________________________________ Address: _______________________________________________________________ Date of Request: ________________________________________________________

Practitioners Stamp:

P2-5-2 #81327