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APPLICATION INFORMATION FOR PROPYLTHIOURACIL

With the withdrawal of the Abbott brand of Propylthiouracil from the market, an alternative source of Propylthiouracil is available from Health Support Limited (HSL). As this product is being sourced from Australia, it is only available pursuant to Section 29 of the Medicines Act for patients where there is no suitable alternative, and it cannot be funded through the Pharmaceutical Schedule. 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 Exceptional Circumstance scheme will administer the funding of the generic Propylthiouracil for a small group of people who have trialed and are unable to tolerate the funded alternative Carbimazole, or patients for whom this medication is contraindicated. Exceptional Circumstances funding will not generally be available for patients who do not meet either of the above criteria. In circumstances where the patient is unable to pay for the medication, due to financial constraints, a disability allowance may be available from the Department of Work and Income. 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

APPLICATION FORM FOR PROPYLTHIOURACIL

Return completed to: Exceptional Circumstances Panel Co-ordinator PHARMAC PO Box 10-254 Wellington

Phone: Fax: Email:

04-916-7553 09-523-6870 ecpanel@pharmac.govt.nz

Prior to completing this application please read the attached notes on criteria for approval. Type the application or write clearly. Full name of patient: _____________________________________________________ Residential Address: _____________________________________________________ _____________________________________________________ Date of Birth: NHI: GP: Address: Specialist: Address: Patient Ethnicity: _______________________ Daytime Phone: _______________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ European q Maori q Pacific Nations q Other: __________

Medicine/treatment sought?

Chemical Name: Manufacturer: Pack size: Dosage to be used: Propylthiouracil HSL _____________________ Cost: __________________________ _____________________

Anticipated cost year quoted by nominated pharmacy : ___________________________ Nominated Pharmacy – (if approval is given from where will the supplies be obtained?) Name: Address: _____________________________________________________ _____________________________________________________

1. b)

Entry Criteria List treatment trialed and patient response to treatment. Where treatment has not been trialed but is contraindicated provide documentation of the reason for contraindication. Response/Contraindicated due to…

Treatment Carbimazole

2.

Consent

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

o

Please indicate that patient has been consulted.

Signature of Medical Practitioner: _________________________________________ Address: ______________________________________________________________ Date of Request: _______________________________________________________ Practitioners Stamp: