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Directions:

Use this form to request an addition, deletion or re-evaluation of a specific drug. Send completed form to Community Health Plan Medical Affairs Committee, 1000 S. Fremont Avenue, Bldg. A-9 East, 2nd Fl, Unit #4, Alhambra, CA 91803-1323, Attn: Medical Director. Please provide justification for formulary consideration. If you have any questions or need more information, please call (626) 299-5539.

Your Name:

ONLY COMPLETED REQUESTS WILL BE PROCESSED Telephone & Fax:

Affiliation/IPA

COMMUNITY HEALTH PLAN

MEDICAL AFFAIRS COMMITTEE FORMULARY DRUG REVIEW REQUEST

Address:

Exhibit B

Drug Generic Name:

Drug Trade Name/Strength(s)/Dosage forms/Mfg.

Your recommendation (choose one): Delete Drug Add drug without restrictions/guidelines

IF YOU RECOMMEND DELETION, reason: New evidence drug is unsafe An equivalent drug on formulary is more effective

Add drug with restrictions/guidelines-please indicate restriction/guidelines

An equivalent drug on formulary is less expensive Attach supporting documentation Specify preferred drug:

IF YOU RECOMMEND AN ADDITION, PROVIDE EVIDENCE BASED DOCUMENTATION TO SUPPORT THE FOLLOWING CRITERIA:

NEED- specify unique qualities of drug not shared by other formulary drugs EFFECTIVENESS- drug is substantially more effective than similar drugs on formulary consider- efficacy,

adverse effects and applicable pharmacokinetic properties. SAFETY PROFILE- drug is substantially safer than similar drugs on formulary FINANCIAL IMPACT- drug is substantially less costly than similar drugs on formulary

Declaration and Signature:

I have no financial interest in this drug or the pharmaceutical company which manufacturers, distributes, or sells it. Or I will fully disclose any conflict of interest or potential conflict of interest with this request.

Physicians Signature:

Date:

License #:

Physicians Name (please print):

Reviewed by:

VERSION 03/2004

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