Provider Request: Add a Drug to the PHP Formulary

Request Addition of a Drug to the Presbyterian Health Plan Formulary

Please complete all lines of this form

Generic Name:
Trade name(s) and manufacturer(s)
List the therapeutic indication(s) for which you would use the requested drug:
Usual dosage regimen
Usual length of therapy:
Approximate daily cost of drug therapy:
What is the anticipated monthly use of the drug (i.e., number of patients):
What have you been using in the absence of this drug?
List comparable drug products currently on the PHP Formulary:
List the potential advantages of the drug being requested for Formulary:
Which of the current formulary drugs can be deleted if this drug is added?
Please describe any relationship that you have with the drug manufacturer (sponsored speaker, investigator in clinical trials):
Please cite published literature which demonstrates in controlled, comparative studies a therapeutic advantage for the product requested versus products currently on the formulary. If such studies are unavailable, please provide a copy of the literature which has convinced you to prescribe this drug.
Your name:
Phone Number:
Specialty:
E-mail:

Once all material for the request for addition of a drug to the Presbyterian Health Plan Formulary has been received, your request will be placed on the next available agenda for the Pharmacy and Therapeutics Committee. The Committee meets quarterly. You are welcome to present your request to the Pharmacy and Therapeutics Committee, although your attendance is not mandatory. You will be notified after the committee has made a recommendation on your request.

You can also print this form, then mail or fax to:

Pharmacy Services
Presbyterian Health Plan
2301 Buena Vista SE
Albuquerque, NM 87106
Fax (505) 923-5540

Provider Request: Add a Drug to the PHP Formulary

Request Addition of a Drug to the Presbyterian Health Plan Formulary

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