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Group #: ____________    Evaluator: _________________

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EXCEEDS EXPECTATIONS MEETS EXPECTATIONS UNSATISFACTORY

Formulary Selection

Includes of all of the formulary requirements

Includes majority of the formulary requirements 

Includes less than half of the formulary requirements

Review of the Literature

 • Includes clinical trials that cover all of the indications

 • Accurately completes Clinical Review Chart

 • Includes 5–7 of the requested indications

 • On the Clinical Review Chart, 2–3 items are not documented correctly

 • Includes <4 of the requested indications from clinical trials

 • On the Clinical Review Chart, >3 items are not documented correctly

Equivalency Chart

Accurately and completely filled out

Includes 1–2 inaccurate or incomplete sections

Greater than 3 items are inaccurate or incomplete

Rationale and Recommendations

 • Presents rationale for selected medications clearly and completely

 • Formulary document is complete

 

 • Presentation does not provide rationale, and clinical justification is difficult to determine

 • Formulary document is incomplete

*Rubric was created by Dr. Timothy Gladwell.

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