Commissioning – HCD – Proformas

Electronic completion of the forms via Blueteq is the preferred method of submitting a High Cost Drug Funding Request. For Trusts who are not currently operating Blueteq. Please complete the relevant Proforma and return to the CCG (contact details on form).

BCCG Individual Funding Request Form Drugs Only July 2016

Abatacept or etanercept for treating JIA in adults only TA373

Adalimumab for Psoriasis

Adalimumab or Infliximab for Crohns Disease (EoE PAC policy)

Adalimumab or Infliximab for Crohns Disease (L&D hospital use only)

Adalimumab or Infliximab to recapture remission of Crohns Disease (L&D hospital use only)

Adalimumab or tocilizumab for treating JIA in adults only TA373

Adalimumab, Etanercept, Golimumab, Certolizumab pegol and Infliximab for Ankylosing Spondylitis & Non-radiological Axial Spondyloarthriti (TA383)

Adalimumab, Etanercept, Infliximab, Golimumab for Psoriatic Arthritis (TA199 and TA220)

Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Golimumab, Tocilizumab and Abatacept for Rheumatoid Arthritis (TA375)

Aflibercept for the treatment of Choroidal Neovascularisation

Aflibercept for treatment of Diabetic Macular Oedema

Aflibercept for Macular Oedema secondary to CRVO

Aflibercept for wet  Age-related Macular Degeneration (w AMD)

Aflibercept for macular oedema secondary to BRVO TA40

Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia in adults

Alitretinoin for severe Chronic Hand Eczema

Apremilast for adults with psoriasis NICE TA419

Apremilast for psoriatic arthritis TA433

Baricitinib for the treatment of severe Rheumatoid Arthritis

Bone Morphogenetic proteins (BMP) (EoE  PAC policy)

Botulinum Toxin A (excluding use for Hyperhidrosis)

Botulinum Toxin A for treatment of Hyperhidrosis

Botulinum Toxin B in Cervical Dystonia JPC Bulletin 223

Brodalumab for moderate to severe plaque psoriasis

Certolizumab pegol for Rheumatoid Arthritis after TNF inhibitor TA415

Certolizumab pegol for the treatment of active Psoriatic Arthritis

Collagenase clostridium histolyticum (CCH) for treating Dupuytren's contracture (TA459)

Dexamethasone Intravitreal Implant for the treatment of Diabetic Macular oedema

Dexamethasone Intravitreal Implant for treatment of Macular Oedema secondary to RVO

Dexamethasone Intravitreal implant for treating non-infectious uveitis (updated February 2018)

Dimethyl fumarate for the treatment of Severe Plaque Psoriasis

Dupilumab for moderate to severe atopic dermatitis

Eltrombopag for the Treatment of Chronic Immune Thrombocytopenic Purpura

Eltrombopag for the treatment of Thrombocytopenia in Chronic Hepatitis C

Etanercept for Psoriasis

Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia in adults

Freestyle Libre Flash Glucose Scanning System (FGS) - for adults - version 2 updated October 2018

Freestyle Libre Flash Glucose Scanning System (FGS) - for children and young people (age 4 up to 19 years) - version 2 updated October 2018

Flucinolone acetonide for Diabetic Macular oedema (DMO)

Gluten Free Foods

Guselkumab for the treatment of Severe Plaque Psoriasis

Infliximab, adalimumab, golimumab for moderate to severely active ulcerative colitis NICE TA329

Infliximab for the treatment of Psoriasis

Infliximab (INFLECTRA BRAND) for the treatment of Ulcerative Colitis

Infliximab (REMICADE BRAND) for the treatment of Ulcerative Colitis

Infliximab (REMSIMA BRAND) for the treatment of Ulcerative Colitis

Insulin pump <12 years

Insulin pump >12 years

Insulin pump renewal or replacement

Ixekizumab for the treatment of active Psoriatic Arthritis

Ixekizumab for the treatment of Severe Plaque Psoriasis

Ocriplasmin for the treatment of Vitreomacular Traction

Omalizumab for Chronic Spontaneous Urticaria (in patients > 12 years old)

Omalizumab for Relapsed Chronic Spontaneous Urticaria (following previous Omalizumab treatment)

PDT with verteporfin for chronic CSC

Ranibizumab for the treatment of Age related Macular Degeneration

Ranibizumab for the treatment of Diabetic Macular Oedema

Ranibizumab for the treatment of Macular Oedema secondary to RVO

Ranibizumab for the treatment of Pathological Myopic CNV

Riluzole for the treatment of ALS form of Motor Neurone Disease

Rituximab for the treatment of Idiopathic Thrombocytopenic Purpura (ITP)

Rituximab for the treatment of Refractory Vasculitis

Rituximab or TNF inhibitor or Abatacept for the treatment of Rheumatoid Arthritis after the failure of TNF therapy

Rituximab monotherapy as an alternative to TNF inhibitors for treatment of Rheumatoid Arthritis - Applicable to a Select Group of Patients Only

Romiplostim for the treatment of Idiopathic Thrombocytopenic Purpura

Sarilumab for the treatment of Severe Rheumatoid Arthritis

Secukinumab for the treatment of active Psoriatic Arthritis

Secukinumab for the treatment of moderate to severe Plaque Psoriasis

Secukinumab for ankylosing spondylitis after NSAIDs and TNF inhibitors TA407

Sequential use of a second biologic in the treatment of Psoriasis

Sequential use of Apremilast or Dimethyl Fumarate in the treatment of Psoriasis

Somatropin for treatment of Growth Failure in Children - Initiation of therapy form

Somatropin for treatment of Growth Failure in Children - Continuation of therapy form

Somatropin for treatment of Growth Failure in Adults (aged upto 25 years)

Somatropin for treatment of Growth Failure in Adults (aged over 25 years)

Teriparatide for the secondary prevention of postmenopausal osteoportic fragility fractures

Tocilizumab in combination with methotrexate or as monotherapy for Rheumatoid Arthritis

Tofacitinib for the treatment of severe Rheumatoid Arthritis

Tolvaptan for the treatment of Autosomal Dominent Polycystic Kidney disease

Tolvaptan (Samsca® Brand) tablets for the treatment of hyponatraemia secondary to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) in patients not requiring chemotherapy

Ustekinumab - dose frequency escalation of ustekinumab for the treatment of moderately to severely active Crohn's disease after previous treatment

Ustekinumab for the treatment of Psoriasis

Ustekinumab for the treatment of Psoriatic Arthritis

Vedolizumab for the treatment of moderate to severe Crohn's Disease

Vedolizumab for the treatment of moderate to severe Ulcerative Colitis

 

 

 

 

 

 

 

 

 

 

 

                                                                  

 

 

 

 

Bedfordshire Clinical Commissioning Group (BCCG): Beds.IFRrequests@nhs.net  (e-mail preferred method) or telephone 01494 555530. IFR team, South, Central and West CSU, Albert House, Queen Victoria Road, High Wycombe, HP11 1AG.

Luton Clinical Commissioning Group (LCCG) IFR team luton.itp@nhs.net (email is preferred route) , The Lodge, 4 George St West, Luton, Beds, LU1 2BJ



Last updated: 07/12/2018

Update due: 07/12/2019