This document provides a template for writing formulary monographs or class reviews. It includes sections for background information on the drug or class, indications, pharmacokinetics, efficacy evidence from clinical trials, guidelines, safety, dosing and administration, availability and cost, utilization and cost assessment, conclusions, and recommendations for formulary status across different care settings. The recommendations section indicates whether the drug or medications within the class should be formulary, restricted, limited use, or non-formulary at various venues. It may also include recommendations for therapeutic substitutions.

1. Save written manuscript and PowerPoint presentation using
the title format below:
<Generic (Brand)> Formulary Monograph <Month YYYY>
or
<Medication Class> Formulary Class Review <Month YYYY>

2. Event title/location if applicable
Pharmacy and Therapeutics CCG
Pharmacy and Therapeutics CCG
Formulary Review:
Generic (Brand)/(CLASS)
Name
Title
Banner Pharmacy Services
Date (Month YYYY)

3. Background
• Drug Name
• Reason for formulary review
• Formal request
• Cost savings opportunity identified
• New to market
• Alternatives/Agents currently on formulary

4. Indications
• FDA approval: Date
• Major indications
• including key off label indications

5. Pharmacokinetics
• Table of ADME
• Bullet key parameters that need to be highlighted

6. Efficacy
Trial Study Design Intervention Primary
Outcome
Results
Trial 1
Trial 2

7. Guidelines
• Summarize recommendations from pertinent guidelines if available

8. Safety
• Contraindications
• Warnings

9. Dosing and Administration
• Dose
• Preparation/Administration

10. Availability and Cost
• Product Availability- if multiple product, make separate slide
• Product cost

11. Utilization and Cost Assessment
• Pharmacoeconomic assessment, including cost of alternatives
• System usage, including other options
• Banner impact

12. Conclusion
• Summarize findings

13. Recommendation (Formulary Monograph)
• Formulary Recommendation: (address each venue of care with X in 1 of 3 options)
• If recommendation to add to formulary with restrictions, outline criteria below
• Criteria
Venue Formulary
Formulary
Restricted
Non-Formulary
Limited Use
Non-Formulary
Acute Care Inpatient
Hospital-based Outpatient
Ambulatory Clinic/Urgent Care

14. Recommendation (Class Review)
• Formulary Recommendation: (address each venue of care with X in 1 of 3 options)
• If multiple medications included on formulary, indicate which is preferred
Acute Care Inpatient
Acute Care
Outpatient
Ambulatory Clinic/
Urgent Care
Medication Formulary
Formulary
Restricted
Non-Formulary
Limited Use
Non-Formulary Outpatient Infusion Formulary Non-Formulary

15. Recommendation (if applicable)
• Implement a therapeutic substitution
• Outline conversion
Therapeutic Class
Ordered Medication Dispensed Medication
Medication A (and dose if pertinent) To Medication C (and dose if pertinent)
Medication B (and dose if pertinent) To Medication C (and dose if pertinent)
Exclusions: