Fast-Track Enrollment For The Oregon Health Plan

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Gastrointestinal stromal tumour – adjuvant
Initial PBS authority application
Supporting information
Purpose of this form
For more information
This form is completed by the prescriber. You must lodge this form
If you need assistance completing this form, or more information, go
for a patient starting initial Pharmaceutical Benefits Scheme (PBS)
to our website
humanservices.gov.au/healthprofessionals > PBS
www.
> Specialised drugs (PBS) A-I > Gastrointestinal stromal tumour
subsidised treatment with imatinib mesylate following complete
(GIST) – imatinib mesylate or call 1800 700 270 Monday to Friday,
resection of primary gastrointestinal stromal tumour and who is at
high risk of recurrence.
between 8.30 am and 5.00 pm Australian Eastern Standard Time.
Note: Call charges apply from mobile phones.
All applications must be in writing and must include sufficient
information to determine the patient’s eligibility according to the PBS
criteria.
Filling in this form
For all initial applications, supply a copy of pathology reports
Please use black or blue pen
confirming:
Print in BLOCK LETTERS
the diagnosis of a gastrointestinal stromal tumour
7
Mark boxes like this
with a
or
the presence of CD117 on immunohistochemical staining
the size and mitotic rate of the tumour
Returning your form
the date of tumour resection, which must not be more than
Check that you have answered all the questions you need to answer
3 months prior to the date of this application.
and that you have signed and dated this form.
Patients who are eligible to receive imatinib mesylate must not
Send the completed authority application form, all relevant
exceed 400mg per day for a period of 36 months in total.
attachments and a completed Authority Prescription form to:
Department of Human Services
Acknowledgements
Prior written approval of specialised drugs
Reply Paid 9826
The patient’s and the prescriber’s acknowledgements must be
HOBART TAS 7001
signed in the presence of a witness (over 18 years of age).
Authority Prescription form
A completed Authority Prescription form must be attached to this
form.
The medical indication section of the Authority Prescription form
does not need to be completed when submitted with this form.
Phone approvals
Under no circumstance will phone approvals be granted for complete
authority applications or for treatment that would otherwise extend
the treatment period.
Applications for continuing treatment
Applications for continuing treatment may be made in writing or may
be obtained by calling the Australian Government Department of
Human Services on 1800 700 270 Monday to Friday, between
8.00 am and 5.00 pm Australian Eastern Standard Time.
Note: Call charges apply from mobile phones.
Send to:
Department of Human Services
Prior written approval of specialised drugs
Reply Paid 9826
HOBART TAS 7001
1 of 3
PB057.1312 (formerly 8011)

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