Healthcare Formulary Comments

HEALTHCARE FORMULARY COMMENTS

Use this form to submit clinical comments, coverage concerns, or a request for formulary review or exception for a specific medication. Complete all applicable sections and attach supporting clinical documentation. Information provided will be used for clinical review and quality assurance and will be protected in accordance with applicable privacy laws.

Patient Information

Patient Name:

Insurance / Plan Information

Prescribing Provider / Submitter

Medication Details

Medication Name:

Clinical Justification

Indication / Diagnosis:

Prior therapies tried, responses, and dates:

Clinical rationale and evidence supporting use for this patient (include pertinent labs, weight-based dosing, contraindications to alternatives):

Potential patient impact if access is restricted (clinical deterioration, hospitalizations, adverse events, inability to tolerate alternatives):

Requested Action

Please indicate the requested administrative action (select all that apply):

Supporting Documentation

Please indicate which documents are attached for clinical review:

Authorization and Acknowledgement

By signing below, I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize the release and review of medical records and other health information necessary to evaluate this formulary comment or exception request. I understand that submission of this form does not guarantee a change in formulary status or coverage and that the reviewer may request additional documentation. This authorization remains in effect until the authorization expiration date below unless earlier revoked in writing.

I understand I may withdraw this authorization in writing; however, withdrawal will not affect actions taken prior to receipt of the revocation. Protected health information obtained in connection with this review may be used for quality improvement and formulary management activities as permitted by law.

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