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Add Drug to Hospital Formulary Request

Request Addition of a Drug to the Presbyterian Hospital Formulary

This form is for Presbyterian physicians and practitioners to request additions to Presbyterian Hospital's formulary. There is a separate form to request an addition to the Presbyterian Health Plan formulary

(All fields are required, except Comments)

Generic Name
Trade name
List the therapeutic indication(s) for which you would use the requested drug
Usual dosage regimen
Usual length of therapy
What is the anticipated monthly use of the drug (i.e, number of patients)

List the potential advantages of the drug being requested for Formulary

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.
Which of the current formulary drugs can be deleted if this drug is added?
Please describe any relationship that you have with any drug manufacturers (Sponsored speaker, investigator in clinical trials)
Your name
Phone Number
Specialty
E-mail

Comments (optional)

Once all material for the request for addition of a drug to the Presbyterian Hospital Formulary has been received, your request will be placed on the next available agenda for the Pharmacy and Therapeutics Committee.

The Committee meets bi-monthly on the third Wednesday at 1230.

You will be contacted in advance of the meeting by a Pharmacy Clinical Services representative to discuss your request, which you are required to present to the Pharmacy and Therapeutic Committee.

You will be notified after the committee has made a recommendation on your request.

If you prefer to send this form, you may print, fill out and send it to:

Rachel Hroncich, PharmD
Presbyterian Hospital Pharmacy
PO Box 26666
Albuquerque, NM 87125-6666
Phone: 841-1686
Fax 724-6024