This is the text extract for Prednisolone sodium phosphate oral liquid - application information & form, browse documents here.

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APPLICATION INFORMATION FOR PREDNISOLONE

SODIUM PHOSPHATE ORAL LIQUID

With the withdrawal of the GSK’s brand of betamethasone (Betnesol) 0.5mg dispersable tablet from the market, an alternative oral corticosteroid is available for patients over 12 years of age from Aventis, prednisolone sodium phosphate (Redipred) oral liquid, 5mg per ml, 30ml. As this product does not have an indication for use as a mouthwash for oropharyngeal lesions, 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 Redipred for a small number of patients with certain disorders affecting the oral mucosa, that need to be treated with an oral corticosteroid. Applications are to be made by a relevant specialist. 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, of 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

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Application Form for Prednisolone sodium phosphate oral liquid

Return completed form 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. Patient Details: Full name of patient: _____________________________________________________ Residential Address: _____________________________________________________ _____________________________________________________ Date of Birth: NHI: Applying Physician: Full name: Address: _____________________________________________________ _____________________________________________________ _______________________ Daytime Phone: _______________ _____________________________________________________

Are you a GP o or Specialist

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Medicine/treatment sought?

Chemical Name: Manufacturer: Dosage to be used: Prednisolone sodium phosphate Aventis _____________________

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

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Entry Criteria List indication for which funding for prednisolone sodium phosphate is sought.

Indication

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Consent

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

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Please indicate that patient has been consulted.

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

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