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Drugs and Therapeutics Committee
REQUEST FOR ADDITION TO THE FORMULARY
This form will not be considered until fully completed and supported by published evidence of efficacy and superiority over existing products
Name of Consultant or GP:
Date:
Extension or phone number:
Guidance on completing this form:
Please type
One drug per form
Additions to the formulary should represent a significant advance over previous therapy
If the new drug is a close equivalent of an existing product please indicate (at 2.2) which product could be deleted as a result of your request
If there are major cost implications, the form should be approved by your Head of Service before consideration by the Drugs and Therapeutics Committee
Help with completion of the form may be requested from the Clinical Effectiveness Pharmacist on extension 4881 or E-Mail
Please provide the following information to enable the committee to evaluate this drug:
1. Product
1.1 Name, form and strength
1.2 Indication(s)
1.3 Mode of action
2. Usage
2.1 What will it replace?
2.2 Can an existing drug be deleted from the formulary as a result of your request?
2.3 Approximate number of patients to be treated per year
2.4 Likely duration of treatment
3. Criteria for use and any restrictions on use
4. Cost
4.1 Cost per patient per 28 days or course
4.2 Cost of treatment it would replace (per patient per 28 days or course)
4.3 Any cost savings due to therapy?
No
All submissions to the Drugs and Therapeutics Committee should be supported by the Head of Service. Confirmation should be given that costs can be managed within existing primary and secondary care resources. Please attach details of any sponsorship that has been offered by the Pharmaceutical company promoting the drug
Signature of Consultant/ GP making submission ......................................................
Signature of Head of Service supporting submission ..........................................
Date:
Please return to:
Peter Davies
Clinical Effectiveness Pharmacist
Pharmacy Department
Salisbury District Hospital
Summary of considerations with regards the introduction of the product including a risk assessment of the product
Summary completed by
To be completed by the Drugs and Therapeutics Committee
Limits/conditions to approval
Approved Not approved
Signed on behalf of the committee
Date
h:\personal\word\peter\drugs and therapeutics commitee\newdrug\newdrugfsep09.doc