Establishment of a children's Drugs and Therapeutics Committee to ensure evidence-based and cost-effective medical treatment for children.

The prevalence of undocumented medical treatments among children is a significant issue, as well as many EU countries lack access to newly developed children-friendly medicines. Consequently, there is a pressing need for supplementary resources that can facilitate informed decision-making regarding children's medication. We therefore aim to describe the process of establishing a children's Drug and Therapeutics Committee (cDTC), as well as the preparing and implementation of recommendations for children in the capital region of Denmark. Following the guidelines outlined by the World Health Organization, we established a cDTC, and recommendations for paediatric medication practice were constructed from assessments of medication use patterns among children in the capital region between 2019 and 2021. The recommendations were meticulously crafted based on evaluation of the current marketing authorization landscape and existing best available evidence. In 2019, the capital region established the first cDTC supported by expert councils and an editorial board. A total of 2429 purchase item numbers covering 1 222 846 defined daily doses and 592 088 purchased packages covering 10 200 000 defined daily doses were identified in the secondary and primary sectors, respectively. Three comprehensive lists covering recommendations for newborns and children were published between 2021 and 2020 totaling 331 recommended pharmaceutical products. The recommendations primarily intended for use in the secondary healthcare sector were implemented through the revision of 38 paediatric- and six neonatal product ranges throughout capital region. In conclusion, recommendation lists for children governed by a cDTC provide a rational auxiliary tool that can be immediately implemented in the clinic.

Navigating high-cost medicines: summary of the Guiding Principles for the governance of high-cost medicines in Australian hospitals.

High-cost medicines (HCMs) can be clinically impactful for individual patients but are also subject to variable funding mechanisms. Public hospitals and health services are often asked to fund HCMs, but inconsistent processes frequently create large variations in care. CATAG (Council of Australian Therapeutic Advisory Groups) is the Australian peak national advisory body for the quality use of medicines in hospitals and health services, with all states and territories collaborating to support Drug and Therapeutics Committees (DTCs). CATAG has developed national Guiding Principles to assist DTCs to effectively govern HCMs. An established process for the development of CATAG Guiding Principles was undertaken to develop these Guiding Principles. This includes the formation of an Expert Advisory Group (EAG) comprising individuals with recognised expertise, development of draft principles and stakeholder consultation from within the CATAG membership and externally. All feedback was discussed, and changes were agreed upon. The final version was approved by the EAG and CATAG members. This document represents a summary of the seven Guiding Principles developed, covering the areas of governance, application and assessment, communication, training and resourcing. Although many outstanding priorities still exist, including the development of national coordination regarding HCM assessment, these Guiding Principles offer a basis to navigate this complex area.

Knowledge support for environmental information on pharmaceuticals: experiences among Swedish Drug and Therapeutics Committees.

BACKGROUND: Two publicly available Swedish knowledge support systems, "Pharmaceuticals and Environment" on Janusinfo.se and Fass.se, provide environmental information on pharmaceuticals. Janusinfo is provided by the public healthcare system in Stockholm and Fass is provided by the pharmaceutical industry. The objectives of this study were to investigate the experiences among Swedish Drug and Therapeutics Committees (DTCs) with using the databases, retrieve development proposals for these, and investigate the DTCs' challenges with working with pharmaceuticals in the environment. METHODS: A cross-sectional survey with 21 questions, both closed and open-ended, was distributed electronically in March 2022 to Sweden's 21 DTCs. Descriptive statistics and inductive categorization were used for the analysis. RESULTS: A total of 132 respondents from 18 regions filled out the survey. The average regional response rate was 42%. The DTCs used the knowledge supports to consider environmental aspects of pharmaceuticals in their formularies and in education. Respondents were more familiar with Janusinfo compared to Fass but appreciated the availability of both. The DTCs especially valued the concrete proposals for certain active pharmaceutical ingredients on Janusinfo. Respondents requested that all medicinal products have environmental information on Fass. Challenges included lack of data, lack of transparency from the pharmaceutical industry and difficulties considering the environmental aspect of pharmaceuticals in their healthcare practice. Respondents wanted more knowledge, clear messages, and legislation to support their work to reduce the negative environmental impact of pharmaceuticals. CONCLUSIONS: This study demonstrates that knowledge supports for environmental information on pharmaceuticals are valuable for the DTCs in Sweden, but the respondents experienced challenges in their work in this field. The study can provide insights to those in other countries interested in considering environmental aspects in their formulary decision-making.

Evaluating the effectiveness of drug and therapeutics committees (DTCs) in controlling irrational drug use: A retrospective analysis.

WHAT IS KNOWN AND OBJECTIVE: This study aimed to explore methods to optimize the function of Drug and Therapeutics Committees (DTCs) in controlling irrational drug use. Clinical pharmacologists contribute their specific knowledge and skills to DTCs and help guide rational therapeutics. The DTC is the highest organization of hospital pharmacy management. METHODS: From January 2016 to August 2021, the DTC promoted the optimization of clinical drug treatment schemes and reduced unreasonable drug use by improving the organizational framework, clarifying the division of functions, regularly monitoring drug use, organizing expert comments, scientific decision-making and functional intervention. During this time, we statistically analysed typical management cases, irrational drug use and drug cost to evaluate the effectiveness of the DTC's management. RESULTS AND DISCUSSION: The DTC's intervention led to a significant reduction in prescribing errors (65.98%, p < 0.05); the intervention acceptance rate increased by 16.37%; and the rate of problem resolution increased by 45.84% (p < 0.05). The level of drug treatment was improved, and the proportion of patients' drug expenses was reduced. WHAT IS NEW AND CONCLUSION: The DTC carried out a series of continuous improvement work that played a significant normative role in clinical drug use. Giving more power to the DTCs can significantly improve the level of drug treatment and reduce unreasonable drug use, which reduces unnecessary drug expenses.

"There are ways drug companies will get into DTC decisions": How Australian drug and therapeutics committees address pharmaceutical industry influence.

AIMS: One tool for protecting quality use of medicines in hospitals is a drug and therapeutics committee (DTC) that oversees medicines availability. Pharmaceutical industry marketing to prescribers is associated with less appropriate prescribing and increased costs. There is little data on decision-making practices of DTCs so it is unknown whether or how they might be vulnerable to pharmaceutical industry influence. This project explores DTC decision-making with a focus on how pharmaceutical industry influence on access and use of medicines is identified and managed. METHODS: We used a qualitative methodology with individual interviews of 29 participants who were current or recent members of public hospital DTCs across New South Wales, Australia. Participants included medical, pharmacy and nursing staff and 1 citizen. Committees were linked to specific hospitals or regions, and some were affiliated with paediatric, neonatal, rural or mental health services. RESULTS: Drug committee processes for oversight of medicines in public hospitals are vulnerable to pharmaceutical industry influence at several points. Applications for formulary additions are sometimes initiated and completed by company representatives. Conflict of interest disclosures among applicants and committee members may be incomplete. In some institutions, medicines are available from pharmaceutical companies without committee review, including through free samples and industry-supported medicines access programmes. Participants noticed the presence and impact of pharmaceutical company marketing activities to local clinicians, resulting in increased prescriber demand for products. CONCLUSION: Improved DTC practices and review of hospital policies concerning pharmaceutical marketing activities might preserve the independence of evidence-based decision-making for safe, cost-effective prescribing.

Managing conflicts of interest in pharmacy and therapeutics committees: A proposal for multicentre formulary development.

WHAT IS KNOWN AND OBJECTIVE: While many countries have central agencies responsible for formulary development, within the United States, each hospital, health care system, or insurance provider has their own pharmacy and therapeutic committee, leading to both inefficiencies and inequalities across formularies. The number and variety of processes within pharmacy and therapeutic committees also increases the likelihood that conflicts of interest will influence the development of formularies. We sought to determine how such influences could be reduced by reviewing international evidence related to the presence and harms of conflicts of interest in formulary development. METHODS: Several approaches have been taken to reduce the influence of conflicts of interest in pharmacy and therapeutics committee processes, including include disclosure, recusal, exclusion, universal consideration and dual committees. The feasibility of each of these approaches is considered in the context of the United States. RESULTS AND DISCUSSION: A proposal is drawn from the discussion of various approaches to conflicts of interest in pharmacy and therapeutics committees: multicenter formulary development. WHAT IS NEW AND CONCLUSION: Multicentre formulary development, where resources are pooled across institutions, may lead to a reduction in the influence of conflicts of interest in pharmacy and therapeutics committee processes in the United States, increasing the chances of including the most safe, efficacious and cost-effective drugs on formularies.

Effect of phentolamine mesylate on regression of lidocaine-epinephrine epidural anaesthesia in sheep.

OBJECTIVE: To determine the impact of epidural phentolamine on the duration of anaesthesia following epidural injection of lidocaine-epinephrine. STUDY DESIGN: Blinded randomized experimental study. ANIMALS: A group of 12 adult ewes weighing 25.7 ± 2.3 kg and aged 8-9 months. METHODS: All sheep were administered epidural lidocaine (approximately 4 mg kg-1) and epinephrine (5 µg mL-1). Of these, six sheep were randomized into three epidural treatments, separated by 1 week, administered 30 minutes after lidocaine-epinephrine: SAL: normal saline, PHE1: phentolamine (1 mg) and PHE2: phentolamine (2 mg). The other six sheep were administered only epidural lidocaine-epinephrine: treatment LIDEP. Each injection was corrected to 5 mL using 0.9% saline. Noxious stimuli were pinpricks with a hypodermic needle and skin pinch with haemostatic forceps to determine the onset and duration of sensory and motor block. Heart rate, noninvasive mean arterial pressure (MAP), respiratory rate and rectal temperature were recorded. RESULTS: The onset times were not different among treatments. Duration of sensory block was significantly shorter in SAL (57.5 ± 6.2 minutes), PHE1 (60.7 ± 9.0 minutes) and PHE2 (62.0 ± 6.7 minutes) than in LIDEP (81.7 ± 13.4 minutes) (p < 0.05). Duration of motor blockade was significantly shorter in PHE1 (59.4 ± 5.4 minutes) and PHE2 (54.3 ± 4.0 minutes) than in SAL (84.8 ± 7.0 minutes) and LIDEP (91.5 ± 18.2 minutes) (p < 0.01). MAP in PHE2 was decreased at 10 minutes after administration of phentolamine (p < 0.05). CONCLUSION AND CLINICAL RELEVANCE: Epidural administration of 5 mL normal saline after epidural injection of lidocaine-epinephrine reduced the duration of sensory but not motor block in sheep. Epidural administration of phentolamine diluted to the final volume of 5 mL diminished both the duration of sensory and motor block in sheep administered epidural lidocaine-epinephrine.

Closing in on the Reservoir: Proactive Case Detection in High-Risk Groups as a Strategy to Detect Plasmodium falciparum Asymptomatic Carriers in Cambodia.

Background: In the frame of elimination strategies of Plasmodium falciparum (Pf), active case detection has been recommended as complementary approach to the existing passive case detection programs. We trialed a polymerase chain reaction (PCR)-based active detection strategy targeting asymptomatic individuals, named proactive case detection (PACD), with the aim of assessing its feasibility, the extra yield of Pf infections, and the at-risk population for Pf carriage status. Methods: A pilot of PACD was conducted in 3 villages in Chey Saen district (Preah Vihear province, Cambodia), from December 2015 to March 2016. Voluntary screening and treatment, following health promotion sensitization, was used as mobilization strategy. Results: A total of 2802 persons were tested, representing 54% of the population. PACD (n = 30) and the respective reactive case detection (RACD) (n = 3) identified 33 Pf carriers, approximately twice as many as the Pf infections (n = 17) diagnosed in passive case detection and respective RACD, by health centers and village malaria workers using PCR, in the same villages/period. Final positivity rate was 1.07% (30/2802). People spending nighttime in forests and plantations were found to be at increased risk for Pf infection (odds ratio [OR], 3.4 [95% CI, 1.6-7.2], P = .002 and OR, 2.3 [95% CI, 1.1-4.9], P = .03, respectively). Conclusions: We demonstrated the usefulness of the PACD component in identifying Pf asymptomatic carriers. Social mobilization and promotion led to good attendance of specific risk groups, identified to be, in the Cambodian context, individuals spending nighttime in forest and plantations.

Primary care physicians report high trust in and usefulness of the Stockholm drug and therapeutic committee's list of recommended essential medicines (the 'Wise List').

PURPOSE: Inappropriate use of medicines causes increased morbidity, mortality, adverse drug reactions, therapeutic failures and drug resistance as well as wastes valuable resources. Evidence-based cost-effective treatment recommendations of essential medicines are a way of avoiding these. We assessed primary care prescribers' knowledge about and perceptions of an essential medicines formulary, as well as the reasons for adhering to the recommendations. METHODS: We conducted a web based questionnaire survey targeting all physicians working in the primary healthcare of the Stockholm healthcare region (2.3 million inhabitants), regarding the knowledge of, attitudes to and usefulness of the essential medicines formulary of the Stockholm Drug and Therapeutics Committee, the so-called Wise List. RESULTS: Of the 1862 physicians reached by our e-mail invitations, 526 (28%) participated in the survey. All but one respondent knew of the formulary, and 72% used it at least once a week when prescribing. The main reason for using the formulary was evidence-based prescribing; 97% trusted the guidelines, and almost all (98%) found the content easy to understand. At the same time, many prescribers thought that the annual changes of some recommendations were too frequent, and some felt that a national formulary would increase its trustworthiness. CONCLUSIONS: We found that the essential medicines formulary was widely used and trusted by the prescribers. The high uptake of the treatment recommendations could be due to the Stockholm Drug and Therapeutics Committee's transparent process for developing recommendations involving respected experts and clinicians using strict criteria for handling potential conflicts of interest, feedback to prescribers, continuous medical education and minor financial incentives.

Opinion paper: scientific, philosophical and legal consideration of doping in sports.

The term doping is generally used to indicate practices based on the use of performance-enhancing drugs (PEDs) or the abuse of medical therapies. Mostly analysed by doctors and officials, doping nevertheless also requires a philosophical consideration to avoid being simplistically portrayed as an isolated practice. To do this, we need to pay attention to the contradictions and paradoxes in the modern approach to doping in sport. In this context, doping is not only relevant to the health of an individual involved in the violation of World Anti-Doping Agency (WADA) criteria, but it actually represents a double-edged phenomenon containing ethical and legal points of view. Several philosophical items affect the ethics of doping. While, indeed, through a deontological vision it is easy to morally condemn an athlete who takes the decision to turn to doping, the same condemnation becomes difficult when the practice of doping is compared with the strong social demand of winners in every field of life. This point must be considered to prevent doping from becoming accepted as a daily practice to excel at all costs and regarded not only as normal but as a necessity for those participating in sport at both an amateur and professional level. Furthermore, a complete discussion on doping has to consider not only the philosophy of performance-enhancing drug abuse, but also the widespread practice of an inappropriate and excessive intake of certain dietary supplements with the unique and obsessive purpose (similar to doping) of increasing physical or mental performance. Based on the above, the aim of this paper is to provide a critical opinion of the doping problem and its related practices and analyze possible solutions considering issues that go beyond the impact of doping on health and reflect on whether it is right or not that an athlete does all he can to improve his performance.

Patients' knowledge and attitudes to the Wise List - a drug formulary from the Stockholm Drug and Therapeutic committee.

BACKGROUND: Involving patients in decisions about their pharmacotherapy is crucial for a satisfactory treatment outcome. Information and opinions about medicines are available from a variety of sources. The Wise List is the drug formulary of recommended essential medicines for the Stockholm healthcare region and is issued by the Drug and Therapeutics Committee (DTC). To inform the public about treatment for common diseases and the concept of recommended medicines, a patient edition of the Wise List was developed. The aim of this study was to explore patients' knowledge, needs and attitudes to the Wise List, DTC and information about medicines in general. METHODS: To examine patient knowledge about recommended medicines a survey (n = 312) was carried out at four large primary healthcare centres in Stockholm, Sweden. To further elucidate the patients' needs of the information on recommended medicines and medicines in general, three focus group discussions (FGDs) were performed. RESULTS: Of the respondents 57% did not recognise the Wise List, 26% recognised but did not use it and 17% used it. A total of 63% reported that they search for information about medicines. The most common information source was "asking their doctor" (36%) followed by searching the internet (31%). The FGDs revealed that the patients were not interested in medicines in general, only in the medicines they use themselves. They did not understand the aim of the Wise List or how they could benefit from information about recommended medicines. The patients expressed a wish to access all information they need about their own care as well as public healthcare information at one location. CONCLUSION: The intended aim of the DTC with providing information to the public was not achieved as the patients have difficulties to understand the information and how they should use it. The patients were not interested in medicines in general, they wanted information tailored to their specific needs. The findings highlight the importance of creating tools for patients in collaboration with them and evaluate the concept continuously.

MULTI-CRITERIA DECISION ANALYSIS AS A DECISION-SUPPORT TOOL FOR DRUG EVALUATION: A PILOT STUDY IN A PHARMACY AND THERAPEUTICS COMMITTEE SETTING.

OBJECTIVES: The aim of this study was to develop and to assess a specific Multi-Criteria Decision Analysis (MCDA) framework to evaluate new drugs in an hospital pharmacy and therapeutics committee (P&TC) setting. METHODS: A pilot criteria framework was developed based on the EVIDEM (Evidence and Value: Impact on DEcisionMaking) framework, together with other relevant criteria, and assessed by a group of P&TC's members. The weighting of included criteria was done using a 5-point weighting technique. Two drugs were chosen by evaluation: an orphan-drug for Gaucher disease, and a nonorphan drug for the treatment of inflammatory bowel disease. Evidence matrices were developed, and value contribution of each drug was evaluated by P&TC's members. An agreed final framework was obtained through a discussion between the P&TC's members. RESULTS: After criteria assessment, the pilot framework included eight quantitative criteria: "disease severity," "unmet needs," "comparative efficacy/effectiveness," "comparative safety/tolerability," "comparative patient-reported outcomes," "comparative cost consequences-cost of treatment," "comparative cost consequences-other medical costs," and "quality of evidence"; and one contextual criterion: "opportunity costs and affordability." The most valued criteria were: "comparative safety/tolerability," "disease severity," and "comparative efficacy/effectiveness." When assessing the drugs most valued characteristics of the MCDA were the possibility that all team may contribute to drug assessment by means of scoring the matrices and the discussion to reach a consensus in drug positioning and value decision making. CONCLUSIONS: The reflective MCDA would integrate quantitative and qualitative criteria relevant for a P&TC setting, allowing reflective discussions based on the criteria weighting score.

INTEGRATING HEALTH TECHNOLOGY ASSESSMENT PRINCIPLES IN FORMULARY MANAGEMENT.

OBJECTIVES: Effective formulary management in healthcare institutions safeguards rational drug use and optimizes health outcomes. We implemented a formulary management program integrating the principles of health technology assessment (HTA) to improve the safe, appropriate, and cost-effective use of medicine in Singapore. METHODS: A 3-year formulary management program was initiated in 2011 in five public healthcare institutions. This program was managed by a project team comprising HTA researchers. The project team worked with institutional pharmacy and therapeutics (P&T) committees to: (i) develop tools for formulary drug review and decision making; (ii) enhance the HTA knowledge and skills of formulary pharmacists and members of P&T committees; (iii) devise a prioritization framework to overcome resource constraints and time pressure; and (iv) conceptualize and implement a framework to review existing formulary. RESULTS: Tools that facilitate drug request submission, drug review, and decision making were developed for formulary drug inclusion. A systematic framework to review existing formulary was also developed and tested in selected institutions. A competency development plan was rolled out over 2 years to enhance formulary pharmacists' proficiency in systematic literature search and review, meta-analysis, and pharmacoeconomic evaluation. The plan comprised training workshops and on-the-job knowledge transfer between the project team and institutional formulary pharmacists through collaborating on selected drug reviews. A resource guide that consolidated the tools and templates was published to encourage the adoption of best practices in formulary management. CONCLUSIONS: Based on the concepts of HTA, we implemented an evidence-based approach to optimize formulary management.

A Survey of Antimicrobial Stewardship Programs in Korea, 2015.

The study was conducted to evaluate the Antibiotic Stewardship Program (ASP) in Korean hospitals compared with the previous two surveys in 2006 and 2012. The information on ASPs was collected through an online-based survey sent by e-mail to 192 infectious diseases specialists in 101 Korean hospitals in September 2015. Fifty-four hospitals (53.5%, 54/101) responded to the online survey. One infectious diseases specialist was employed in 30 (55.6%) of the 54 hospitals, and they were in charge of ASPs in hospitals with the program. Fifty of the 54 hospitals (92.6%) had ASPs and the same number of hospitals was conducting a preauthorization-of-antibiotics-use program. Although most hospitals adopted preauthorization strategies for more antibiotics in 2015 than in 2012 (median 14 in 2015; 13 in 2012), a limited number of antibiotics were under control. The number of per oral and parenteral antibiotics available in hospitals in 2015 decreased compared to 2006 and 2012. The number of hospitals performing a retrospective or prospective qualitative drug use evaluation of antibiotic use increased from 2006 to 2015. Manpower in charge of antibiotic stewardship in most hospitals was still very limited and ASPs heavily depended on preauthorization-of-antibiotics-use programs in this survey. In conclusion, there leaves much to be desired in ASPs in Korea in 2015.

[Indicators for drug selection in health systems: an integrative review]. / Indicadores da seleção de medicamentos em sistemas de saúde: uma revisão integrativa.

OBJECTIVE: To produce a panel of the main drug selection indicators by performing an integrative literature review. METHODS: After the elaboration of a review protocol, searches were conducted in LILACS, MEDLINE, Embase, and SciELO databases. The following search terms were used: "indicators"; "criteria"; "drug selection"; "pharmacy and therapeutics committee"; and "medication form"; with the applicable variations in English and Spanish. Sixteen original articles published between January 1996 and March 2012 were retrieved and reviewed to compose a panel of indicators. RESULTS: Forty-five quantitative and qualitative indicators were identified. These indicators were grouped according to conceptual similarities in three categories: 1) assessment of pharmacy and therapeutics committee structure; 2) evaluation of the general processes of drug selection; and 3) evaluation of the results of drug selection. CONCLUSIONS: The indicators identified reveal relative uniformity in the established patterns for drug selection. The group of indicators established in this study should serve as reference for the development and consolidation of drug selection in public health services.

Leveraging hospital formularies for improved prescribing.

Hospital formularies, guided by the Pharmacy and Therapeutics Committee, exist to optimize medication use by identifying and designating drugs of choice to guide rational prescribing, ultimately reducing patient risk and costs and improving patient outcomes. Guidelines and a framework exist to guide critical evaluations of medications for formulary listing; however, there may be opportunities to improve and standardize how a formulary change could be instituted in Canadian hospitals. A formulary change at an Ontario hospital revealed that there are some key challenges to the formulary change process including the importance of a robust project plan, appropriate resources, healthcare staff education, and acceptance.

The role of medicines and therapeutics committees structure in supporting optimal antibacterial use in hospitals in Uganda: A mixed method study.

Although the roles of Medicines and therapeutic committees (MTCs) have been expanding, there is limited information on the role of their structure in optimal antibacterial use in hospitals, especially in low-and-middle-income countries. Our study explored the structure and role of MTC in supporting antibacterial use in regional referral, general hospitals and tertiary private not-for-profit (PNFP) hospitals in Uganda. We conducted an explanatory sequential mixed-method approach with triangulation to explore the structure and functional role of MTCs from August 2019 to February 2020 in hospitals in Uganda. Quantitative data was collected using an interviewer-administered questionnaire among chairpersons or secretaries of MTCs and was analysed using descriptive statistics. We conducted key informant interviews using an interview guide among long-term serving members of MTCs to collect qualitative data which triangulated the quantitative data. The study revealed that sixteen hospitals had successfully established MTCs with an average duration of the MTCs' existence of 5.6 (+2.7) years. The membership of the MTCs varied between 7 and 14, with a median value of 10, and the majority of members in MTCs were pharmacists (15 out of 16) and clinical specialists (13 out of 16). The most frequent subcommittees of the 16 hospitals MTC were supply chain (n = 14), antimicrobial stewardship (n = 13), and infection control (n = 12). Majority (14 out of 16) of the MTCs supported availability and access of antibacterial use by selecting and evaluating antibacterials agents for their formulary lists using established criteria. Additionally, 15 out 16 MTCs conducted antimicrobial stewardship activities to support optimal antimicrobial use. In our study, MTC membership and subcommittees were critical structural components that aided the selection and evaluation antibacterials on hospital formulary lists and they supported optimal antibacterial use through implementing various antimicrobial stewardship activities. There is a need for the Ministry of Health to conduct more training on operationalising MTCs structures in all hospitals.

A primer on formulary structures and strategies.

Formularies are a tool for managing costs, optimizing patient access, and improving overall health outcomes. The general goal of formularies is to provide access to appropriate therapy while promoting effective resource utilization, which allows the managed care pharmacy organization to operate sustainably. Traditional formulary strategies have included open and closed formularies as well as tiered formularies. However, other formulary structures have emerged in support of the focus on product value. The formulary development process is primarily driven by the pharmacy and therapeutics (P&T) committee and value committee within an organization. Key considerations such as member population, regional differences, regulatory/compliance implications, and benefit design strategies may influence payers to create a customized formulary to provide additional value to their members while managing costs. With the rise of high-cost and specialty products, formularies continue to serve as an important tool for managed care pharmacy organizations. Ongoing trends, such as biosimilars, prescription digital therapeutics, and addressing health equity, will shape future strategy and management of formularies.