Formulary Medication Request Form Instructions Use this form to request the addition or deletion of a drug from the BWC Formulary. BWC reviews requests at the next meeting of the Pharmacy & Therapeutics Committee. The committee meets on a quarterly basis. The committee will only review forms submitted and signed by a HPP certified prescriber. You must complete all sections of page two. BWC will return requests submitted with incomplete documentation without P&T Committee review. Please furnish published literature, which demonstrates in controlled, comparative studies a superior therapeutic currently on the Formulary. If such studies are unavailable, please furnish a copy of the literature, which has convinced you to prescribe this drug. You may submit completed form and supporting documentation in one of two ways listed below. Mail: Pharmacy Program Director Ohio Bureau of Workers Compensation st 30 W. Spring St., 21 Floor Columbus, OH 43215 Email: Attention Director of Pharmacy at Pharmacy.benefits@BWC.state.oh.us Requester contact information First name MI Last Professional title M.D. D.O. Medical specialty D.D.S. D.P.M. NPI number Certified HPP Provider Yes No (BWC will not consider formulary addition requests from Non-HPP certified providers.) Office e-mail address Office street address Suite, floor, etc. City State Nine-digit ZIP code Office telephone number ( ) Office fax number Please furnish published literature, which demonstrates in controlled, comparative studies, a superior therapeutic advantage of this product versus comparable products currently on the formulary. If such studies are unavailable, please furnish a copy of the literature that convinced you to prescribe this drug. Signature of requester Signature date Specialty BWC-3935 (10/19/2012) MEDCO-35 American LegalNet, Inc. www.FormsWorkFlow.com Formulary Medication Request Form Drug information Generic/trade name of drug Dosage form Specific pharmacological action/therapeutic use or indication Anticipated monthly usage (i.e., number of patients) Comparable products currently on the BWC formulary Advantage over comparable products on the BWC formulary Which formulary product(s) could this drug replace? Is this a request for an emergent or compassionate use condition? Yes If yes, please provide complete clinical documentation of the situation below. No BWC-3935 (10/19/2012) MEDCO-35 American LegalNet, Inc. www.FormsWorkFlow.com