PHARMACY AND THERAPEUTICS COMMITTEE

Please print clearly. Prescriber’s Name: Specialty: Address: State brand/generic names, dosage, strength and manufacturer, if known, of the drug you are suggesting for formulary addition:

Addition to Formulary Request Form 
PHARMACY AND THERAPEUTICS COMMITTEE
Addition to Formulary Request Form

Please print clearly. Prescriber's Name:
Address:

Specialty:

State brand/generic names, dosage, strength and manufacturer, if known, of the drug you are suggesting for formulary addition:

What formulary agents, if any, are available in the same therapeutic class or for the same indication? Please list.

Indicate the advantage of the recommended agent over the current formulary options.*

Are you affiliated with this drug's manufacturer? If yes, how?

*Submit supporting literature citations with the request. (A minimum of two documenting journal articles is requested.)

Prescriber's Signature:

Date:

Please submit completed form and supporting documentation to EmblemHealth by fax to Clinical Pharmacy at 1-877-300-9695, by email to clinicalpharmacy@emblemhealth.com or by mail to EmblemHealth, Attn: Clinical Pharmacy Department, 441 Ninth Avenue, New York, NY 10001. If you have any questions, please call 1-877-362-5670.

Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
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