Empire Blue Cross  
Drug List Addition / Clinical Guideline Change Request Form

Please note, all required fields (indicated by an *) must be completed and will be verified for authenticity.

General Request Information

 Required field.

  1. Full Name of requestor:
 
 


2. Are you a Member, Prescriber or
Other
 

If other please Specify

 

3. Requestor's specialty or area of practice:

 
 


4. Address of requestor:
Street, City, State, Zip Code

 


5. Phone Number

 


6. Email Address

 


7. Please disclose any potential conflicts of interest:
    I, my spouse, or a dependent, have a financial interest (i.e. shareholder, equity in a company, commissions) or of any organizational nature (i.e. employee, president, board member, owner, partner) in the manufacturer
of the requested product.

Yes    No
    I, have served as a consultant, advisor, speaker, or researcher with the manufacturer of the requested product. Yes    No
 
 

Drug List Addition

  8. Name of drug being requested
 
  9. Clinical rationale for requested drug
 
  10. Drug List (if known): Essential Drug List or National Drug List for example

  11. Line of Business (if known): Commercial, Medicare or Medicaid

 
  12. Drug Name/Therapeutic Class

 

Changes to Clinical Criteria

  13. Clinical Guideline # (if known)

 
  14. Brief description of requested change to clinical criteria
 
 
  15. Provide evidence (e.g. cite peer-reviewed, published literature) to support the addition of a drug or a change in clinical criteria

 
 

Thank you for your inquiry.

The medications on our drug lists are thoroughly reviewed by our Pharmacy and Therapeutics (P&T) Committee. The P&T Committee includes practicing physicians, pharmacists, and clinicians from leading academic medical centers with expertise in evidence-based medicine. All major clinical specialties are represented. The P&T Committee meets regularly to review which drugs should be added, removed or have changes to the benefit tiers. Their decisions help us create drug lists that improve health outcomes for our members. Your comments are appreciated and we value your input. Your inquiry will be shared with the P&T Committee at its next scheduled meeting.



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