Pharmacy and Therapeutics committees have been around for ages in the provider community – they are the “link between medicine and pharmacy”. In the managed care world, P&T committees take on a somewhat different role, establishing formularies, reviewing medical device reimbursement (at some health plans), contributing to coverage determinations and benefit design.
Mostly, they provide the health plan or insurer with an expert opinion on most things pharmacy-related. Without a P&T Committee, these decisions often are left to a medical director, or worse, claims adjuster (in the P&C world), individuals who are not equiped to make educated decisions about pharmaceuticals.
Smaller payers and property/casualty insurers and TPAs rarely have the size needed to pay for and staff a full P&T committee. In these cases, the payer’s PBM can often provide input and advice to the payer’s medical director.
While this may seem like a lot of work, consider the potential impact on cost and appropriateness. For example, the State of Washington’s P&T committee for workers comp has outright refused to cover Actiq and Lyrica, two of the top ten drugs in WC. The cost savings are enormous, and the science behind the decision is very solid.
Lest you think you’re safe just relying on the FDA, remember the COX-2 disaster and who knows how many other unpublished and as-yet-unknown debacles.
