Get Formulary Addition Request Form

Completing the Formulary Addition Request Form online is essential for initiating a review of a non-formulary drug. This guide provides detailed instructions to ensure all components of the form are filled out accurately and effectively.

Follow the steps to complete your request for formulary review.

1. Press the ‘Get Form’ button to access the Formulary Addition Request Form and open it in your preferred online editor.
2. In the 'Requestor Information' section, provide your name, date, email, phone number, specialty, fax number, mailing address, and your network affiliation with SCFHP.
3. Fill out the 'Drug Information' section by entering the brand name and generic name of the drug you are requesting to review. Specify the dosage form and strength of the drug.
4. Detail the FDA-approved indications for use, and describe any additional indications for which the drug is being used or studied.
5. Indicate whether there is a similar drug on the SCFHP formulary by selecting 'Yes' or 'No'. If applicable, specify the name of the similar medication.
6. Provide a rationale for including the drug in the formulary, listing your reasons in the designated space.
7. Answer the questions regarding the drug's efficacy, toxicity, expected patient usage, and cost-effectiveness compared to formulary drugs.
8. Attach supporting documentation, including a bibliography and copies of two pivotal studies showing the drug's superiority over others.
9. Disclose any potential conflicts of interest by selecting 'Yes' or 'No' and providing details if applicable.
10. Add any additional comments you feel are relevant to the request.
11. Sign the form and date it at the bottom.
12. Submit your completed request to the Santa Clara Family Health Plan Pharmacy Department either by mail or by faxing it to the specified number.

Complete your Formulary Addition Request Form online to initiate an essential review process.