Formulary Change Request Form

Formulary Change Request

The requesting physician must complete this form in full.

Recommendation of change

Required field

Trade Name: Generic Name:
Dosage Form:     Dosage Strength:

Intended Therapeutic Application(s):
Reason why this medication should be included on the OptumRx Formulary:
Please provide at least three literature studies (of which two should be peer-reviewed studies) to support the recommendation:

Should other medications currently included in the formulary be replaced by this recommended addition:
YES If yes, which one(s)?
Clinical concerns with the current guideline:
Please disclose any "conflicts of interest" which may influence the interests of OptumRx and/or patients served by OptumRx with respect to your recommendations for the above mentioned guideline:


Reviewer Information

First Name:
Last Name:
Address Line1:
Address Line2:
Zip code:
Phone: - -
Fax: - -
Email Address: