REQUEST FOR ADDITION TO MAP & MAP BASIC FORMULARY

Do not submit Protected Health Information (PHI) on this request form.

Complete the form below, or download a PDF, complete, and return.

Request Date

MM slash DD slash YYYY
Name of Requesting Provider:

First

Last
Phone
Email
Drug Trade & Generic Name
Strength(s) and dosage form(s) (e.g. tablets, liquid, etc.)
Conditions to be treated or intended use
Current formulary medications available to treat above conditions?
Advantage of requested product over currently available formulary product(s). Please submit any literature supporting this with submission using the FIle Upload link below.
Please list any conflicts of interests, financial or otherwise, you have with this request
File Upload
Drop files here or

Max. file size: 80 MB.

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