Great Western Hospitals NHS Foundation Trust
NEW DRUG REQUEST for addition to the 3Ts Formulary.
Directorate : ...
(please choose from dropdown list above)
Please Note:  The information in this document is CONFIDENTIAL to the Trust and should under NO
circumstances be shared with outside agencies.
 Sample material of drugs should not be accepted from representatives or used within
the Trust.
 Requests should NOT be completed by pharmaceutical representatives.
 The requested drug will only be obtained after agreement from the Associate Medical
Director (AMD) and Formulary Working Group (FWG). All Forms MUST be
countersigned by the AMD (part II) otherwise they will be returned as incomplete.
 A budget must be set by the Directorate for the use of the drug.
 Any unused stock that is discarded will be costed to the requesting Consultants
Directorate.
 Applicants will be given the opportunity to attend a Formulary Working Group
meeting to further support their application. Meetings are held on the 3rd Tuesday of
each month at GWH.
Part I. To be completed by requesting Consultant/Clinician.
Please complete this new drug request form electronically (grey sections), save
locally, print, sign and ensure part II is completed by the relevant AMD.
Then post to: Dr Ravi Chinthapalli, Chair Trust Prescribing Committee & Formulary
Working Group, C/O Formulary Office, Pharmacy Department, 1st Floor, GWH.

Applicant details:
Name of consultant/clinician:
Tel No:
Pager No:
Date:
E mail address:

Declaration of conflict of interest:
Applicants are required to declare any potential conflicts of interest in accordance with the
standards of professional conduct. Eg sponsorship ,hospitality ,funding for equipment or staff.

Reason for request:
New drug for formulary
New use for existing formulary drug
New Form of existing formulary drug
Other
Please give more details below:

Drug details:
Drug non proprietary name:
Drug manufacturer and brand name:
Drug preparation and strength(s) required:
Licensed indication:
Indications for use in the formulary:
Likely dosing regime:
List preparations currently on the formulary used for the same indication:
April 2013
1

Cost of new drug:
Hospital Trust
a) Cost per patient/per month:
b) Estimated number of months treatment per year:
c) Number of patients to be prescribed this drug, per year:

Community
Reasons for request: (State claimed advantages over existing formulary preparations for
this indication)

Evidence:
New drug requests will only be considered if they provide evidence to support the preparation in
terms of EFFICACY, SAFETY, CONVENIENCE and COST in comparison to existing formulary
preparations. Please attach your evidence to this document which should rely heavily on wellcontrolled published clinical trials. Please submit copies of key papers and a complete list of
references. Requests submitted without evidence will be rejected.

Type/cost of treatment or procedure it may replace:
Drug/Procedure:
Hospital Trust
Community
Cost per treatment course:
or procedure(if applicable):

Cost savings/cost increase from new drug introduction:
Will there be any anticipated changes in expenditure to the Trust? (give details):
Please estimate cost :
In which directorate will they be seen? ...
(please choose from dropdown list above)

Colour coding/duration of treatment/ to be prescribed in hospital/primary care:
Anticipated length of treatment (in weeks)
Hospital Care
Primary Care
Hospital use only (RED)
N/A
Hospital care initiation only (AMBER)
Treatment under GP care (BLUE/GREEN)
N/A
Signed __________________________________________________________
Print name:
Date:
April 2013
2
This form MUST be forwarded to the Associate Medical Director (AMD) for completion of
Part II.
Non completion by the AMD will result in automatic rejection of the request.
Part II. To be completed by Associate Medical Director (AMD)

Status of request:
Will funding be available from existing drug budget? Yes
No
If Yes: Budget for Drug £
/month. Is this for a limited period? Yes
If Yes:
months.

Usage limited to:
Consultant(s) Signature only
Specify named Consultant/s:
Consultant Team only
Specify named team:
Named Speciality only
Specify named Speciality:
All Directorate medical staff
Non Speciality Prescribing
No
Signed __________________________________________________________
Print name:
Date:
Please ensure all the above sections are completed before forwarding to
Dr Ravi Chinthapalli, Chair Trust Prescribing Committee & Formulary Working Group,
C/O Formulary Office, Pharmacy Office, 1st Floor, GWH.
Part III. To be completed by Formulary Working Group (FWG)
This drug has been approved for inclusion in the 3Ts formulary
This drug has not been approved
Reason/details:
Signed (TPC/FWG Chair) ____________________________________________________
Print name:
Date:
April 2013
3