Drug List Addition / Clinical Criteria Change Request Form

Please complete all required fields to submit your request

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

Your Info

Drug Info

Clinical Criteria

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Your Information

* 1. Full Name of requestor:

* 2. Are you a Member, Prescriber or Other:

If Other please specify:

3. Requestor's specialty or area of practice:

* 4. Address of requestor:
Street, City, State, Zip Code

* 5. Phone number:

* 6. Email Address:

* 7. Please disclose any potential conflicts of interest:

I, my spouse, or a dependent, have a financial interest (i.e. shareholder, equity) or employment relationship with the manufacturer:

Yes

I have served as a consultant, advisor, speaker, or researcher with the manufacturer:

Yes

Drug Information

Name of drug being requested:

Clinical rationale for requested drug:

Drug List (if known):
Essential Drug List or National Drug List for example

Line of Business (if known):
Commercial, Medicare or Medicaid

Drug Name/Therapeutic Class:

Clinical Criteria Information

Clinical Guideline # (if known):

Brief description of requested change in clinical criteria:

Provide evidence (e.g. cite peer-reviewed, published literature) to support the addition of a drug or a change in clinical criteria:

Thank you for your inquiry.

The medications on our drug lists are thoroughly reviewed by our Pharmacy and Therapeutics (P&T) Committee. The P&T Committee includes practicing physicians, pharmacists, and clinicians from leading academic medical centers and clinical practices with expertise in evidence-based medicine. All major clinical specialties are represented. The P&T Committee meets regularly to review which drugs should be added, removed or moved to the benefit tiers. Their decisions help us create drug lists that reflect the latest clinical evidence and the most effective treatment options available. Your inquiry will be shared with the P&T Committee at its next scheduled meeting.