This is the text extract for Liothyronine 20mcg tablets - application information & form, browse documents here.

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APPLICATION INFORMATION FOR LIOTHYRONINE 20MCG TABLETS

With the withdrawal of the GSK’s brand of liothyronine (Tertroxin) 20mcg tablets from the market, an alternative brand will be funded through Exceptional Circumstances. We are aware that Health Support Limited has been importing liothyronine (Goldshield) 20mcg tablets from the UK and have 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, 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 EC scheme will administer the funding of Tertroxin for a small group of people who are unable to tolerate the funded alternative. 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

P10-12-0 #75653

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Application Form for Liothyronine 20mcg Tablets

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

Phone: Fax:

04-916-7553 09-523-6870

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: _______________________ Daytime Phone: _______________ _____________________________________________________

Applying Physician: Full name: _____________________________________________________ Address: _____________________________________________________

Are you a GP o or Specialist

o

?

Medicine/treatment sought

Chemical Name: Manufacturer: Dosage to be used: liothyronine 20mcg tablets Goldshield _____________________

Anticipated cost year quoted by nominated pharmacy : ___________________________ Nominated Pharmacy – (if approval is given from where will the patient have the prescription dispensed?) Name: Address: _____________________________________________________ _____________________________________________________

P10-12-0 #75653

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1.

Entry Criteria List indication for which funding for liothyronine is sought.

Indication

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:

P10-12-0 #75653