Retinal Vein Occlusion Initial Pbs Authority Application printable pdf download

Retinal Vein Occlusion

Initial PBS authority application

Supporting information

Purpose of this form

Authority prescription form

This form must be completed by the treating ophthalmologist.

Complete the appropriate authority prescription form and attach to

this application.

You must lodge this form for a patient starting initial Pharmaceutical

Benefits Scheme (PBS) subsidised treatment of visual impairment

The medical indication section of the authority prescription form

due to macular oedema secondary to Branched Retinal Vein

does not need to be completed when submitted with this application.

Occlusion (BRVO) or Central Retinal Vein Occlusion (CRVO).

Applications for initial treatment

Ranibizumab can be subsidised through the PBS for patients with

visual impairment due to macular oedema secondary to BRVO or

Applications can be for the initial treatment and 2 repeats. Where

CRVO treatment.

both eyes are being treated simultaneously, a quantity of 2 vials can

be requested on the same prescription.

Aflibercept can be subsidised through the PBS for patients with

visual impairment due to macular oedema secondary to CRVO

treatment.

Applications for continuing treatment

In the eye(s) proposed for treatment, patients must have a visual

After an application for an initial treatment has been approved,

impairment defined as Best-Corrected Visual Acuity (BCVA) score

application for continuing treatment for the same eye can be made

based on the Early Treatment Diabetic Retinopathy Study (ETDRS)

in writing or by phone. Call 1800 700 270 Monday to Friday,

chart administered at a distance 4 metres of:

between 8.00 am and 5.00 pm, Australian Eastern Standard Time.

•

for BRVO a score between 73 and 20 letters (approximate

Note: Call charges apply from mobile phones.

Snellen equivalent 20/40 to 20/400)

•

for CRVO a score between 73 and 24 letters (approximate

For more information

Snellen equivalent 20/40 to 20/320).

For more information, go to our website

Approval may only be given for 1 PBS subsidised agent at a time.

humanservices.gov.au/healthprofessionals or call 1800 700 270

The treatment must be the sole PBS subsidised therapy for this

www.

Monday to Friday, between 8.00 am and 5.00 pm, Australian Eastern

condition.

Standard Time.

All initial applications must be in writing and must include sufficient

Note: Call charges apply from mobile phones.

information to determine the patient’s eligibility according to the PBS

criteria.

Filling in this form

A copy of the fluorescein angiogram which diagnoses visual

•

Please use black or blue pen

impairment due to macular oedema secondary to Branched

•

Print in BLOCK LETTERS

Retinal Vein Occlusion (BRVO) or Central Retinal Vein Occlusion

✓

(CRVO) must be included. Where a fluorescein angiogram cannot

•

Mark boxes like this

with a

be performed due to a contraindication as listed in the Therapeutic

Goods Administration approved Product Information, details of the

Returning your form

contraindication must be provided. A copy of the report of an

Check that you have answered all the questions you need to answer

alternative method of diagnosis must be included in the application,

and that you have signed and dated this form.

for example, optical coherence tomography or red free photography.

Send the completed authority application form, completed appropriate

The information on this form is correct at the time of publishing and

authority prescription form and all relevant attachments to:

is subject to change.

Department of Human Services

Complex Drugs Programs

Emergency treatments only

Reply Paid 9826

To avoid delay in starting treatment, the initial application, angiogram

HOBART TAS 7001

report and a copy of the prescription can be faxed to the Australian

Government Department of Human Services on 1300 093 177. The

Department of Human Services will then call the prescriber between

8.00 am and 5.00 pm Monday to Friday, Australian Eastern Standard

Time. The original authority application form and angiogram must be

mailed to the Department of Human Services.

For Department of Veterans’ Affairs patients, call 1800 552 580.

Note: Call charges apply from mobile phones.

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PB154.1510

Retinal Vein Occlusion Initial Pbs Authority Application

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