KAISER PERMANENTE Drug Formulary Addition and Deletion Request Instructions
- June 16, 2024
- KAISER PERMANENTE
Table of Contents
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:
- Generic Name of the Drug
- Brand Name of the Drug
- Drug Strength(s)
- Dosage Forms
- Specify if the request is for a specific brand name
- 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
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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.
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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
Revised December 2022
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