The following form will work when a physician needs to use a certain formulary drug for a usage other than the approved use like unapproved indication or route of administration. 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.
EDIT: This form can be used as off label use form.
| HOSPITAL NAME – PHARMACY AND THERAPEUTICS COMMITTEE REQUEST FOR USE OF FORMULARY DRUG FOR AN UNAPPROVED INDICATION FORM |
|---|
| Information related to the requested drug |
| Drug generic name: Suggested brand name: Dosage form: Strength: Pharmacological classification: Therapeutic use / approved clinical indications: |
| Intended use: (unapproved indications) 1) 2) 3) |
| Are there therapeutic alternatives the hospital formulary which were used and failed? If yes, please list …………………………………………………………………… |
| How is this drug superior to existing formulary drug? Attach references/text book. |
Requested physician:
Signature / stamp:
Date:
Department head:
Specialty:
Signature / stamp:
Date:
P&T committee use only
Evaluation completed by:
Date:
Scheduled for P&T Committee meeting dated: … /… / ….
Committee action: …………………………………………………………………………………………………
P&T committee chairperson:
1) Approve
2) Disapprove
Signature / stamp:
Date:
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