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.
ONLY COMPLETED REQUESTS WILL BE PROCESSED Telephone & Fax:
COMMUNITY HEALTH PLAN
MEDICAL AFFAIRS COMMITTEE FORMULARY DRUG REVIEW REQUEST
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 Name (please print):