AHCCCS P&T Committee Application - 2/2020
Conflict of Interest Disclosure
As detailed in the Committee Operational Policy ACOM 111, 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 the CMSO Open Payments
website at 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; and
I do not receive payments or compensation from the pharmaceutical industry in excess of the
physician mean general payment amount for the most recent year specified on the CMSO Open
Payments website at 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 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.
