OCHSNER HEALTH NETWORK (OHN)
REQUEST FOR HOSPITAL FORMULARY OR ADDITION TO
A CLINIC DEPARTMENT DRUG LIST

Instructions:
The Ochsner Health System Pharmacy and Therapeutics Committee makes formulary decisions based on published data from controlled clinical trials. The committee considers the efficacy, safety, approved indication(s), tolerability, and cost/reimbursement of a medication when determining its formulary status.

Please fill out this form completely. This form consists of three parts: Part A: Additions to the Formulary or Changes in Restriction, Part B: Deletions from the Formulary, and Part C: Conflict of Interest Disclosure. You must be an attending-level physician to request a change to the formulary.

Please select your institution, as this will determine to whom this form's contents will be sent via email.
-- Select -- BAPH - Baptist BRMH - Baton Rouge KNMH - Kenner NMCH - North Shore NOMH - New Orleans / Jefferson Highway STAH - St. Anne WBMH - West Bank

Part A - Additions to Formulary or Changes in Restriction

Generic Name:
Trade Name:
Manufacturer:
Dosage form(s) and strength(s) requested for addition:
Is a change in restriction required? Yes   No
Why is the medication superior to or significantly better than current formulary agents?
Improved Safety Profile   Improved Efficacy   More Convenient Dosing Regimen
Less Prone to Med Errors   Additional Indications   More Cost Effective

Based on the above information, please provide the literature citations to support formulary addition or change in restriction.


What FDA approved and/or off label indications do you intend to use this medication to prevent or treat?


Please provide any additional information you think pertinent to assist the Pharmacy and Therapeutics Committee in evaluating this agent for formulary addition or change in restriction.


Will this medication require any specialized financial reimbursement requirements?
(e.g., preapproval from the insurer, obtained from a speciality pharmacy) Yes   No   Unknown

Is there a drug similar to this currently stocked in pharmacy? Yes   No
If yes, are you proposing this drug as a replacement? Yes   No
What medication(s) may be deleted from formulary?
Availability:
How should this drug be offered?
Available to all providers   Restricted to a service   Restricted to a treatment protocol   Not for primary care use

What is the anticipated usage rate?
In how many patients do you expect this drug to be used during the next six months?
Were you involved in the clinical trials for the medications? Yes   No
Did a pharmaceutical representative prompt this request? Yes   No

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Part B - Deletions from the Formulary

Generic Name:
Trade Name:
Manufacturer:
Dosage form(s) and strength(s) requested for deletion:
Please provide justification for the deletion of this product from formulary:

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Part C - Conflict of Interest Disclosure

Note: This information is shared with Ochsner Health System Pharmacy and Therapeutics Committee members and is considered when evaluating your request. A potential conflict of interest does not preclude a person from requesting a medication for formulary addition or a change in restriction. The Committee appreciates that physicians with an area of expertise often receive research grants or other support from industry. The Committee considers it important to disclose these relationships to eliminate any concerns regarding potential conflicts of interest.

Please provide the following information to the best of your knowledge:

Companies involved in the development, production and distribution of the requested medication:


Do you, or an immediate member of your family, have a proprietary interest in any of these companies listed?
Yes   No

If yes, which companies?
Please check all that apply:
Own stock in one of the above companies (excluding mutual funds)
Serve on the board of directors for one of these companies
Expect to receive (or currently receive) royalties from one of these companies
     Other:

Have you received any financial support in the last 12 months from the companies listed? Yes   No

Please check all that apply:
Received more than $5000 in research funding
Received support for presenting continuing education or professional education programs supported by the company
     (Defined as more than 1 lecture for the same company in a 12 month period)
Received an educational grant of more than $5000
received more than $500 in travel support, personal gifts, compensation, or rewards in the past 12 months
     Other:

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Requestor's name and specialty:
Phone or Email:

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