FormularyDecisions : Registration

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Company Information

Company:

Organization Covered Lives:

Organization Geographical Coverage (i.e. State):

User Information

User id (email address):

Using your employer-provided email address for registration helps us ensure that Registered Users are, in fact, health care decision makers.

First Name:

Last Name:

Role:
Select all that apply


	Prepare product reviews/recommendations for P&T Committee

	P&T Committee member

	Rebate/contracting

	Student in rotation

	Pharmacist resident or fellow

Other (please specify):

Position:

Business Title:

Covered Lives That You (and / or Your Team) are Responsible for:

Geographical Coverage That You (and / or Your Team) are Responsible for (i.e. State):

Line of Business:


	Commercial

	Managed Medicaid

	Medicare Advantage (MAPD)

	Medicare Part D/PDP

	Health Insurance Exchange

	Self-funded Employer

Other (please specify):

LinkedIn URL

How did you hear about FormularyDecisions?

Address:

City:

State:

Country:

ZIP Code:

Phone:

Password (?)
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Professional Details

As part of the registration process, please describe your direct involvement in making formulary and/or benefit design decisions. Please note: If you are a health care decision maker, but do not hold a professional license (as required below), you may still describe your position as a decision maker and your request for registration will be considered during the verification process. Thank you!

Professional Degree:
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Professional License:

Name on License:

State of License:

State License #:

License Expiration Date:

Subject to Sunshine Act

Select this option if you are subject to Sunshine Act Reporting requirements. Your pertinent details will only be shared with the manufacturer for items that are subject to Sunshine Act reporting. Content subject to Sunshine Act Reporting will be indicated with

within FormularyDecisions.

Please describe your direct involvement in making formulary and/or benefit design decisions:

Verifying your status as a health care decision maker will be required in order for you to access select content and services. Your professional information will only be used for verification purposes.

Please check this box to verify that you are a health care decision maker.