Johns Hopkins Aramco Healthcare | Drugs & Therapeutics Committee

Formulary Addition Request Form

(Please read the instructions on the reverse side before filling the form)

I. Requested drug details:

Generic Name
Trade name(s)
Dosage Form(s)
Strength(s)
Manufacturer(s) (If
Known)

II. Description of use:

Approved uses
(FDA or EMEA approved
uses)
Off label uses
(If Applicable)

III. Justification for formulary addition:

Will this addition replace a current formulary drug? If so, what drug(s)?

How is this drug superior to existing formulary drugs?

References

IV. Other Information

Should the usage of this drug be restricted to certain specialty services or administration locations?
If so, Please specify.

Anticipated usage rate if this drug is added to the formulary. Please specify a monthly estimate
number of cases with an average daily dose

V. Requestor Information
Requested By Signature Date

Chief of Signature Date

Service

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 Johns Hopkins Aramco Healthcare | Drugs & Therapeutics Committee

Instructions for Completion of the sections

Section II.

 This section should include how the requestor anticipates the use of the requested drug
in SAMSO. Printed referenced information or the drug package insert maybe attached to
support the requested use of the drug.

Section III.

 Replacement of existing drugs and superiority over existing drugs are two important
areas for Committee consideration. In order to control the growth of the formulary, it is
preferred that each addition be balanced by a deletion when practical. In any case, the
Committee must be provided with a published scientific journal article (not an
advertisement) demonstrating the efficacy of the new drug.

 Formulary addition requests should have non-company sponsored literature, and a

summary of the literature attached for member review.

Section IV.

 Restricted use of a drug is possible if it is felt that a drug should only be used by certain
members of the Medical Staff. This would mean that Pharmacy would not honor orders
for the drug by non-approved specialties.

 Usage rate of the new drug is essential to prevent ordering an excessive quantity that
may not be required. For Example: A statement such as “two ampoules per patient visit
and ten patients per month” is necessary.

Section V.

 The requesting physician should get the signature of service chief before submitting the
completed form to the Chief Pharmacist. The requesting physician will be notified of the
date and time of the Committee meeting to consider the request and may be invited to
attend to lend support.

 The requestor will also be notified of the Committee's action and will be notified when
the medication is actually on hand ready to be used.

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