Request for Formulary Topic Review

This form is intended for use by all IHS healthcare providers to request a drug or drug class be considered for review by the IHS National Pharmacy & Therapeutics Committee for inclusion on the National Core Formulary. Please complete all requested information and submit your information using the electronic form below. Thank you!

Contact Information:

Full Name
Email Address

Phone Number
Organization

Discipline
Area
Facility

Request Information: Generic Name / Class Name
Current NCF medication(s) which this product could replace (if applicable)
Document advantages over current formulary products. Please include references.
Would this drug/class be used by a substantial proportion of patients? Explain.
Is this drug/class a core component of current standards of care? (Alternatively, can you provide appropriate care for a majority of patients without using this drug?) Explain.
Will general availability of the drug/class enhance portability of the pharmacy care benefit to IHS patients?
Please disclose any real or perceived conflicts of interest that you have from your association with the manufacturer of this product (e.g., company stock, company speaker's bureau, etc.):