Formulary Inclusion Request

Formulary Inclusion Request

Request Evaluation of a Medication for Formulary Inclusion
- To initiate an evaluation of a medication for formulary inclusion, the requestor must complete the below form.
- After submission of this form, you and your department chair will be contacted by a representative from the P&T Committee to verify the request and outline the evaluation process and your role and discuss scheduling.
- P&T Committee meetings are held the 4th Thursday of each month from noon-1:30pm via Zoom. You will receive a calendar invite for the P&T meeting well in advance of the meeting and will be sent a reminder along with the prepared monograph for the requested medication about a week before the meeting.
For more information, please contact Kelly Hinerth (pinson@uw.edu).
Requestor Information
Name*

First NameLast Name
Email*
example@uw.edu
Cell Phone Number
For meeting reminders
Practice Location(s)*

HarborviewMontlake CampusNorthwest CampusFred Hutch
Division/ Department*
Division/ Department Chair*
Division/ Department Chair's Email*
A copy of this submission will be sent to this email.
Requested Medication
Generic Name*
Trade Name and Manufacturer*
FDA Approved Indications*
Drugs currently on formulary used for the same indication(s)
Intended Therapeutic Applications*
Can any of the above agents be deleted from the formulary?

YesNo
What agents can be removed from the formulary?

Estimated Monthly Usage by Site

	HMC	ML	NW	FHCC
Estimated Monthly Usage

Rationale for the Request*

Fills a therapeutic voidTherapeutically superior to drug(s) currently on formularyTherapeutically equivalent, but anticipate improved tolerabilityTherapuetically equivalent but less expensiveOther
Please elaborate on your rationale*
Disclosures
Medical staff members who initiate a request for addition of a drug to the UW Medicine Drug Formulary must disclose potential conflicts of interest. This information is shared with the Committee members prior to considering your request. Disclosure of a potential conflict of interest issue does not disqualify you from requesting a drug. The Committee recognizes that many members of the Medical Staff have relationships with pharmaceutical companies and have received research grants or other support from companies; however, the Committee feels that full honest disclosure of these relationships is necessary to achieve a balanced decision-making process.
In the past 2 years have you had a proprietary interest or received any financial support from the company(ies) involved in developing, producing and/or distributing the requested drug or therapeutically similar drugs?*

YesNo
Please list the companies you have proprietary interest with below
Type of proprietary interest/ financial support

Own stock in one of the above companies (excluding mutual funds)Serve on the board of directors for one of the above companiesExpect to receive (or currently receive) royalties from one of the above companiesReceived support for presenting continuing medical education or other professional education programs supported by the companyReceived an educational grant or funding for support staff or equipmentReceived travel supportReceived honorarium or member of speakers bureauReceived consulting fees or served on an advisory boardOther
By signing below, you attest that the information in this form is accurate and complete to the best of your knowledge. Approval for requests will also be sought from the requestor's division/department chair.
Signature*

Powered by Jotform SignClear
Should be Empty:

Formulary Inclusion Request

Requestor Information

Requested Medication

Disclosures