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PNF FORM NO. 3. LETTER OF REQUEST AND PROPOSAL FORM FOR EXEMPTION
LETTER OF REQUEST
Date
Chief
Pharmaceutical Division
Department of Health
SUBJECT: Proposal to EXEMPT the medicine from E.O. No. 49 s. 1993 that states that only
medicines listed in the PNF shall be procured by government entities.
The (Philippine Heart Center) is requesting for the EXEMPTION of the following medicine
(Ceftriaxone+SulbactamZeftrax-S) from E.O. No. 49 s.1993.
Please find attached two (2) hard and soft copies each of the following documents:
Respectfully yours,
PROPONENT’S NAME
Chair, Pharmacy and Therapeutics Committee
Name of Health Facility
Indicate email address, telephone and facsimile number
PNF FORM NO. 3:
Instruction: Please gather data on the price of the proposed medicine from the pharmaceutical
company. For the comparator drug, please refer to the Drug Price Reference Index (DPRI).
b. Intervention costs:
(management of adverse
drug reaction treatment)
Formula: D + E
EXPECTED NUMBER OF
PATIENTS WHO WILL USE
THE DRUG (G)
Possible references:
Burden of Disease
If no local epidemiological
study, current volume of use
in the Philippines based on
market data
ESTIMATED BUDGET
IMPACT
Formula: F x G