Submission Form for Addition of New Drug to the SDAP Formulary

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The Colorado State Drug Assistance Program's (SDAP) Medical Advisory Committee (MAC) will review drug requests as scheduling of the MAC permits, and the MAC may elect to withhold review and decision of newly marketed drugs pending FDA approval, price negotiations, and CDPHE cost analysis.

Complete the form to the best of your ability.

The current SDAP formulary can be found here: https://drive.google.com/file/d/1kFoQZfYDgkBsaJBubiF7xIROm8zL6fZu/view

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Who is making this request? *

Community Member

Physician

Pharmacist

Other Healthcare Professional

This request to add a new drug is intended: *

For people living with HIV (served by ADAP)

For people at the risk of acquiring HIV (served by PHIP)

Pflichtfrage

Drug Generic Name

Drug Brand/Trade Name

Drug Strength(s)

Dosage Form

Oral (pill, tablet, capsule, syrup, power, liquid, power, paste, film, etc)

Ophthalmic

Inhalation (aerosol, inhaler, nebulizer, vaporizer, etc)

Parenteral (intradermal, subcutaneous, intramuscular, intraosseous, intraperitoneal, intravenous, etc)

Topical (cream, gel, lotion, skin patch, vaginal rings, etc)

Suppository (vaginal, rectal, urethral, nasal, etc)

Sonstiges:

Auswahl löschen

Is a specific brand necessary?

Yes

Auswahl löschen

If yes, please list the manufacturer:

Weiter

Alle Eingaben löschen

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Dieses Formular wurde bei State.co.us Executive Branch erstellt.

Sieht dieses Formular verdächtig aus? Bericht

Formulare