This form will be used when the user; either a physician or a pharmacist is requesting a specific drug to be removed from the pharmacy formulary. The form is part of the main policy “Pharmacy formulary system policy” and this attachment serves as an example of the form, make sure to change the header and footer to better suit your organization design style, and add the proper dates of creation, modification and due to review date.
| HOSPITAL NAME – PHARMACY AND THERAPEUTICS COMMITTEE REQUEST FOR DELETION OF A DRUG FROM THE FORMULARY |
|---|
| Date of the request: __ /__ /____ |
| This is to request that ____________________________________ to be deleted from the formulary. |
| Reasons(s) for the request: (Check the number which is applicable) 1. The drug is no longer considered effective. 2. The drug is no longer available. 3. Another drug, specifically ________________________ is considered more effective or as effective with fewer side effects. The following is a brief comparison of the two drugs: …………………………………………………………………………………………………………………………………………………………………………………………………… 4. Another drug, specifically ________________________ is considered more effective or as effective but less expensive. |
| Requester name: |
| ID / signature: |
| Pharmacy department remarks: |
| Action by pharmacy and therapeutic committee: on __ /__ /____ 1) It is recommended by the P&T committee that the drug will be deleted for the reasons stated above. 2) It is recommended that the drug be retained on the formulary: comment: ………………………………………………………………………………………………………………………………………………………………………… |
| …………………………………………….. Pharmacy administration: | ………………………………………………………. Chairperson of P&T committee: |
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