Anthem Blue Cross Blue Shield Health Insurance  
Formulary Addition Request

Please note, all required fields (indicated by an *) must be completed and will be verified for authenticity.

 Required field.

  1. Name of requestor:
 
  2. Address of requestor:
 
  3. Requestor's specialty or area of practice:
 
  4. Trade name of requested drug:
 
  5. Generic name of requested drug:
 
  6. Dosage form(s) available for requested drug:
 
  7. Strengths available for requested drug:
 
  8. List comparable drug(s):
 
 
  9. Describe clinical situations and/or reasons which support the requested change:
 
 
  10. Cite complete references and/or clinical literature which supports the addition of this agent to the drug list/formulary:
 
 
  11. List the anticipated frequency of use of requested drug in your practice:
 
 
  12. Disclose any potential conflicts of interest:
    I receive research support from the manufacturer of the product Yes    No
    I have a consulting agreement with the manufacturer of the product Yes    No
    I, my spouse, or a dependent, have a financial interest in the manufacturer of the product Yes    No

Please Note: Due to privacy concerns, this feature will only display information about you and minor dependents on your policy. Minor dependent information can ONLY be viewed by the subscriber. It will NOT display any information about other individuals under your policy.

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Anthem Blue Cross and Blue Shield

is the trade name for the following: In Connecticut: Anthem Health Plans, Inc. In Colorado, Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HMO Missouri, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi) and Compcare Health Services Insurance Corporation (Compcare). Independent licensees of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri, Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use.

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