Empire Blue Cross  
Formulary Addition Request

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

 Required field.

  1. Name of requestor:
  2. Address of requestor:
  3. Requestor's specialty or area of practice:
  4. Trade name of requested drug:
  5. Generic name of requested drug:
  6. Dosage form(s) available for requested drug:
  7. Strengths available for requested drug:
  8. List comparable drug(s):
  9. Describe clinical situations and/or reasons which support the requested change:
  10. Cite complete references and/or clinical literature which supports the addition of this agent to the drug list/formulary:
  11. List the anticipated frequency of use of requested drug in your practice:
  12. Disclose any potential conflicts of interest:
    I receive research support from the manufacturer of the product Yes    No
    I have a consulting agreement with the manufacturer of the product Yes    No
    I, my spouse, or a dependent, have a financial interest in the manufacturer of the product Yes    No

Please Note: Due to privacy concerns, this feature will only display information about you and minor dependents on your policy. Minor dependent information can ONLY be viewed by the subscriber. It will NOT display any information about other individuals under your policy.


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