Request for Formulary Consideration

Request for Formulary Consideration

Medical Centers at the University of California San Francisco

UCSF Formulary Addition Request

The Pharmacy &Therapeutics (P&T) Committee is a medical staff committee that formulates policies regarding the evaluation, selection, diagnostic and therapeutic use, and monitoring of medications and medication-associated products and devices. Pediatric-medication requests will be first presented to the Pediatric Medication Review Committee (PMRC) for cross bay collaboration between BCH-SF and BCH-Oakland.

A thorough evidence-based review will be initiated, as well as safety, effectiveness, cost, and utilization analysis. You will be contacted once the review is completed and will be notified when the medication will be placed on the PMRC or P&T Committee agenda. As the requester, you will serve as the champion for the formulary addition request. You will also be expected to attend the P&T Committee meeting at UCSF where the merits of the drug will be discussed.

Date*

Requestor name (First, Last) and degrees*

Title/position*

Please indicate your department/service area*

Please indicate your main practice site*

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Email address*

Phone number*

Please indicate the generic name of the drug being requested*

Please indicate the brand name of the drug being requested*

Requested use is for what age group(s)?*

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Intended location of use*

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Manufacturer*

Please list the manufacturer of the drug being requested (if applicable)

FDA-labeled indications*

Administration route*

If this medication is available to be administered via different routes, which route(s) of administration is being requested to be added to the formulary (e.g., transdermal patch, IV, oral)?

Dosing differences*

If applicable, how is the request for the drug to be administered and/or dosed different from the FDA-approved dosing and/or administration? If not applicable, insert N/A.

Is this a unique molecular entity/first in its class?*

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For which indications will the agent be used at UCSF?*

Include information on how the agent will be used, if same as FDA-approved used, indicate "Same as FDA approved"

Describe the role in therapy of this agent in the management of these indications:*

Are there any therapeutic alternatives on the formulary? Please indicate Yes or No.*

You can link to the UCSF e-formulary: https://online.lexi.com/lco/action/home

If yes, please list

Could any drug products be removed from the UCSF formulary if this drug addition is approved?*

Please list any drugs that could be considered for removal.

Is this medication more or less costly than the current standard of care?*

Please describe any information you have related to cost, and it if it higher, please justify why this additional cost is important to consider.

Please list any any relevant publications that support the use of this therapy.*

Should this drug be restricted by indication or by service?*

If yes, please explain.

UCSF Health is committed to maximizing medication value while improving clinical outcomes, supporting internal operations, maximizing the patient experience while ensuring safe medication use. In doing so, the inpatient use of outpatient medications will be carefully reviewed for 'site of care' considerations based on the patient's immediate clinical care needs. Where appropriate, continued administration of select medications may be deferred to the outpatient setting, post-discharge. If inpatient administration is desired, please indicate why this medication must be administered during an inpatient admission.*

Indicate N/A if not applicable.

Please provide the anticipated number of patients at UCSF who will be treated annually with this agent in the INPATIENT setting:*

Enter "0" if none.

How many doses do you anticipate each patient will receive while in the INPATIENT setting?*

Enter "0" if none.

Please provide the anticipated number of patients at UCSF who will be treated annually with this agent in the OUTPATIENT/AMBULATORY CARE/INFUSION CENTER setting:*

Enter "0" if none.

If this medication is primarily used in the OUTPATIENT/AMBULATORY CARE/INFUSION CENTER setting, and the patient is admitted, can the medication be held until the patient is discharged?*

Conflict of Interest and Financial Disclosure

Requests for addition of a medication of therapy to the UCSF Formulary are official University actions and subject to the University of California's Conflict of Interest policies. Therefore, medical staff members who initiate requests are required to disclose whether or not they have any financial interest in the company which manufacturers the recommended drug. This form is designed to enable the Committee to be aware of any financial interests when it considers Formulary addition requests; it does not preclude medical staff members with such interests from making additional requests and will not necessarily preclude approval of the requested drug for addition to the formulary. This information will become part of the Committee's records and will be accessible to Committee members only.

In the past 24 months, have you served on a task force, focus group, or speaker's bureau from a nongovernamental entity related to the medication or therapy being requested?*

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In the past 24 months, have you or your Department/Division(s) received research funds or other financial support from the manufacturer of this medication or therapy?*

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In the past 24 months, have you or any close relatives received any form of loan, gift, salary, honoraria, or compensation for consulting services from the manufacturer?*

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Please add details of your conflict of interest *

Have you or any close relative maintained any other financial interest (e.g., stock, stock options, stock grants) in the medication or therapy's manufacturer?*

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Please indicate the amount:*

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Thank you

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