Maraviroc (Celsentri®)
Highly Specialised Drugs Program Declaration Form*
| Patient's Name: | ____________________________________ |
| Medical Record Number: | ____________________________________ |
| Medicare Number: | ____________________________________ |
I certify that the above patient meets the Pharmaceutical Benefits Advisory Committee's criteria for funding under Section 100 of the National Health Act, 1953.
Criteria
In combination with other antiretrovirals, for the treatment of an antiretroviral experienced patient infected with only CCR5-tropic HIV-1 and:
(a) evidence of HIV replication (viral load greater than 5,000 copies per mL); and/or
(b) CD4 cell counts of less than 500 per cubic millimetre.
A patient must have virological failure of previous treatment with, or have resistance to, 3 different antiretroviral regimens, including regimens with:
(i) at least 1 non-nucleoside reverse transcriptase inhibitor; and
(ii) at least 1 nucleoside reverse transcriptase inhibitor; and
(iii) at least 2 protease inhibitors.
Specialist/ Authorised Prescriber
| Signature: | ____________________________________ |
| Name: | ____________________________________ |
| Date: | ____________________________________ |
Additional information to be provided by authorised general practitioners only:
| Provider Number: | ____________________________________ |
| Practice Address: | ____________________________________ |
| Telephone Number: | ____________________________________ |
*To be completed by the specialist or authorised prescriber initiating drug treatment, and retained by the hospital Pharmacy Department.
April 2010