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Group #: ____________    Evaluator: _________________

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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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