Anthem Blue Cross Health Insurance  
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.


®Registered marks Blue Cross and Blue Shield Association
©2005 copyright of Anthem Insurance Companies, Inc.

Health insurance

for individuals, families & employers. Find Anthem Blue Cross health and medical insurance information for visitors, members, individuals & families, employers, brokers & producers. Learn about group health insurance plans, family & individual insurance options, health insurance savings accounts, obtain a health insurance quote.

Anthem Blue Cross

is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association..

Investor relations – information on WellPoint, Inc., formerly Anthem, Inc.