Douglas A. Ducey, Governor
Jami Snyder, Director
801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 •
602-417-4000 •
www.azahcccs.gov
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Conflict of Interest Disclosure Form
As detailed in the Committee Operational Policy, Committee members and public individuals
external to the Committee who provide verbal or written public comment to the Committee shall
not:
a. Be employed by, subcontract with, or directly or indirectly represent a pharmaceutical
manufacturer,
b. Be employed by, subcontract with, or directly or indirectly represent a pharmacy benefits
management (PBM) company,
c. Receive payments or compensation from the pharmaceutical industry in excess of the
physician mean general payment amount for the most recent year as specified on
openpaymentsdata.cms.gov.
Thus, any individual who meets a., b. or c is not eligible for serving on the Committee or
providing external public comment to the Committee.
Please initial the following:
____I am not employed by, subcontract with, or directly or indirectly represent a pharmaceutical
manufacturer
____I am not employed by, subcontract with, or directly or indirectly represent a pharmacy
benefits management (PBM) company
___I do not receive payments or compensation from the pharmaceutical industry in excess of the
physician mean general payment amount of $3,307.06 (2017 openpaymentsdata.cms.gov)
The purpose of this Conflict of Interest Disclosure form is to require the individual completing
the form to affirmatively identify any potential conflicts of interest of that individual with respect
to matters coming before the Pharmacy and Therapeutics Committee (Committee) to ensure that
information considered by the Committee is evaluated in an impartial manner.
The following individuals shall disclose any financial relationship, affiliation, or other
relationship with any organization that may have a direct or indirect interest in business that may
be considered by the Committee:
1) Committee members prior to serving on the Committee and at other timeframes described in
the Committee Operational Policy; and
2) Individuals external to the Committee interested in providing verbal or written public
comment to the Committee prior to providing comment to the Committee.
A financial relationship may include, but is not limited to: being employed by, being on retainer,
having research or honoraria paid by, or receiving other forms of remuneration from any organization
that may have a direct or indirect interest in business that may be considered by the Committee.
An affiliation other than one that is financial in nature may include holding a position on an
advisory committee or some other role or benefit to a supporting organization.
The existence of such financial relationships or affiliation does not necessarily constitute a
