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Pharmacy and Therapeutics Committee Procedure

This appendix includes two policy and procedure operational statements. The first is specifically written to centralize the formulary decision process for a multihospital health system: a Formulary Committee. The second, and closely related, operational statement is written as a model to function as the traditional Pharmacy and Therapeutics Committee for a Hospital’s Medical Staff. Both operational statements describe the functions of their related committees based on a certain degree of autonomy. Their membership is ultimately chosen by an administrative leader as a means to best isolate the committee from organizational as well as economic influences. The decision process for each operational statement is intended to create predictability and transparency. To implement this set of operational statements, each Executive Committee of the hospitals in a multihospital system would pass the following resolution:

The Medical Staff of Alpha Hospital agrees to delegate its Pharmacy and Therapeutic Committee responsibilities to ALPHAOMEGA HEALTH based on the policy and procedures for a “Hospital Formulary System” and a “Hospital Pharmacy and Therapeutics Committee.”

The two operational statements can also be combined to reflect the traditional functions of a single hospital, medical staff-based pharmacy, and therapeutics committee. Also, there may be other arrangements where the two operational statements could provide the organizational environment for a closed health system, a pharmacy benefits manager, or one of the new organizational structures created by Federal Legislation in 2004 for the new financing of drug coverage in the United States.



To maintain a HOSPITAL FORMULARY and a Formulary Committee for all ALPHAOMEGA HEALTH Hospitals as a means to enhance the quality of health care for all patients served by ALPHAOMEGA HEALTH


  1. The Formulary Committee of ALPHAOMEGA HEALTH will periodically evaluate its performance as a means to improve its ability to support the Vision and Mission of ALPHAOMEGA HEALTH.

  2. ALPHAOMEGA HEALTH will maintain one Formulary Committee and a Pharmacy and Therapeutics Committee (P&T COMMITTEE) at each ALPHAOMEGA HEALTH Hospital to implement this POLICY in accord with the applicable Medical Staff Bylaws and this POLICY.

  3. The Formulary Committee of ALPHAOMEGA HEALTH will maintain a standard format for a HOSPITAL FORMULARY that is based on the provisions of this POLICY.

  4. The Formulary Committee will develop and continually revise a list of therapeutic products, a HOSPITAL FORMULARY, that reflects the current clinical judgment of the Medical Staff of ALPHAOMEGA HEALTH Hospitals regarding the selection of the best therapeutic products for the health care of hospitalized patients. The Formulary Committee will evaluate the various alternative therapeutic products available and develop the HOSPITAL FORMULARY based on an evaluation of each therapeutic product’s indications, effectiveness, risks, patient safety, and overall impact on health care costs.

  5. The Formulary Committee will collaborate with the P&T Committee at each ALPHA OMEGA HEALTH ...

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