Request for Non-Formulary Drug

REQUEST FOR NON-FORMULARY DRUG

The objective of the Formulary is to promote the rational and safe use of effective drugs in patients. Only drugs accepted into the Formulary are stocked in the Pharmacy.

The Pharmacy and Therapeutics Committee will review and evaluate the Request considering the need for the drug, alternatives for the therapy, documented clinical studies, toxicity, usage, possible single component therapy for combined products and expense. To be considered, it is ESSENTIAL that all questions on the application form be completely answered.

Please provide the following information:

*Indicates Required Field
*Date *Physician's Name *Physician's Service
*Phone or Beeper #
1a. * Drug Generic Name 1b. *Drug Trade Name
2. *Dosage form and strength(s)
3. *State specific pharmacological action of drug and therapeutic need or rationale for requesting this drug
4.*Advantage over comparable drugs in the Formulary
(equivalents or close equivalents)
5. *Could current medication be deleted?
Please be aware that there may be a delay obtaining this non-formulary agent, and that all such requests will be handled as promptly as possible.



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