Ixekizumab for treating moderate to severe plaque psoriasis, NICE TA442 (April 2017) Only fully completed forms will be accepted for consideration The completed form must be sent by the hospital commissioning team to the High Cost Drugs Team at: Herts Valleys CCG: East & North Herts CCG: If the patient does not fulfil NICE criteria The responsible commissioner will not normally fund any treatment where the patient does not meet the agreed criteria as outlined in this patient specific funding application form. Following a clinical trial, the responsibility for ongoing funding remains with the provider or pharmaceutical company. The commissioner will only fund treatment that meets the commissioned pathway. Applications can be made via the Individual Funding Requests process ONLY the patient has exceptional clinical circumstances. Please check the commissioner websites for contact details of the IFR team. Payment by the commissioner will only be made if the completed form is received no later than 15 days after INITIAL treatment commences Patient NHS No. Trust: GP Name: Patient Hospital Consultant Making GP code / Practice Number: Request: code: Patient initials: Patient Dob: / / GP Post code: Criteria for initiation Please confirm the disease is severe as defined by a total PASI of 10 or more and a DLQI of more than 10. Yes No Please provide PASI score: and DLQI score: and date measured: Please confirm the psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate, and PUVA (psoralen and long-wave ultraviolet radiation), or the person is intolerant to or has a Yes No contraindication to these treatments. Please specify which drugs the patient has previously received:
Ixekizumab for treating moderate to severe plaque psoriasis, NICE TA442 (April 2017) Only fully completed forms will be accepted for consideration The completed form must be sent by the hospital commissioning team to the High Cost Drugs Team at: Herts Valleys CCG: East & North Herts CCG: If the patient does not fulfil NICE criteria The responsible commissioner will not normally fund any treatment where the patient does not meet the agreed criteria as outlined in this patient specific funding application form. Following a clinical trial, the responsibility for ongoing funding remains with the provider or pharmaceutical company. The commissioner will only fund treatment that meets the commissioned pathway. Applications can be made via the Individual Funding Requests process ONLY the patient has exceptional clinical circumstances. Please check the commissioner websites for contact details of the IFR team. Payment by the commissioner will only be made if the completed form is received no later than 15 days after INITIAL treatment commences Patient NHS No. Trust: GP Name: Patient Hospital Number: Consultant Making Request: GP code / Practice code: Patient initials: Patient Dob: / / GP Post code: Criteria for initiation Please confirm the disease is severe as defined by a total PASI of 10 or more and a DLQI of more than 10. Please provide PASI score: and DLQI score: and date measured: Yes No Please confirm the psoriasis has failed to respond to standard systemic therapies including ciclosporin, methotrexate, and PUVA (psoralen and long-wave ultraviolet radiation), or the person is intolerant to or has a contraindication to these treatments. Please specify which drugs the patient has previously received: Yes No
Ixekizumab%20for%20psoriasis%20TA442%20proforma.docx