KAISER PERMANENTE Drug Formulary Addition and Deletion Request Instructions

June 16, 2024
KAISER PERMANENTE

KAISER PERMANENTE Drug Formulary Addition and Deletion Request

Product Information

Specifications

  • Product Name: KPMAS Pharmacy and Therapeutics Committee Formulary Addition/Deletion Request
  • Revised: December 2022

Product Usage Instructions

Requestor Information

To submit a formulary addition or deletion request, please provide the following information:

  • Requestor Name
  • Requestor Address
  • Requestor Phone Number

Request Type

Indicate the type of request by circling one of the options:

  • Member
  • Physician
  • Pharmacist
  • Other Healthcare Professional

Formulary Change Type

Circle one of the options to specify if the request is for an addition or deletion:

  • Addition
  • Deletion

Formulary Type

Circle one of the options to specify if the request is for the Commercial or Medicare Part D formulary:

  • Commercial
  • Medicare Part D formulary (separate formulary drug list for members 65 years of age and over with Medicare Part D benefits)

Medication Details

Provide information about the medication for which a change is being requested:

  1. Generic Name of the Drug
  2. Brand Name of the Drug
  3. Drug Strength(s)
  4. Dosage Forms
  5. Specify if the request is for a specific brand name
  6. If yes, identify the brand name

Reason for Formulary Change Request

Describe the reason for the formulary change request:

[Reason for the formulary change request]

Supporting Studies

List any studies that support the addition/deletion of this agent to/from the current formulary:

[List of supporting studies]

Signature and Date

Sign and date the form to complete the request.

Frequently Asked Questions (FAQ)

Q: How often can a re-review be considered for a drug?

A: If the committee has made a decision on a drug, a re-review will not be considered for at least six months.

Drug Formulary Addition and Deletion Request Kaiser Foundation Health Plan of Mid-Atlantic States Formulary Addition/Deletion Request

Instructions

  • Use the Addition/Deletion request form to request a review for addition or deletion of a medication to the Kaiser Permanente Mid-Atlantic States drug formulary. The Kaiser Permanente of Mid-Atlantic States (KPMAS) Pharmacy and Therapeutics Committee will consider requests at any time submitted by KPMAS health plan members, Mid-Atlantic Permanente Medical Group and Affiliated providers, and KPMAS pharmacists for the addition or deletion of a medication to the formulary.

  • To request that a medication be added or deleted from the formulary, please fill out the request form on page 2 of this document. Once completed you may mail the completed form to:
    Regional Pharmacy &Therapeutics Committee Co-Chair, Clinical Pharmacy 4000 Garden City Drive Hyattsville, MD 20785 Attn: James Chai Wang or Send via email to James Chai Wang at james.c1.wang@kp.org

  • The KPMAS Pharmacy and Therapeutics Committee will evaluate the request. If the committee has made a decision on a drug, a re-review will not be considered for at least six months.
    Revised December 2022

Kaiser Foundation Health Plan of Mid-Atlantic States
Formulary Addition/Deletion Request

KAISER-PERMANENTE-Drug-Formulary-Addition-and-Deletion-Request-
FIG-2

Revised December 2022

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