By Illuma Advisors
•
June 30, 2025
As the pharmacy benefit landscape evolves, an emerging challenge is gaining attention: supporting clinical rigor and governance in formulary decisions when traditional Pharmacy Benefit Managers (PBMs) increasingly restrict customization. For organizations seeking to maintain or expand control over their formulary strategies, the need for independent Pharmacy & Therapeutics (P&T) committees has never been more critical. Market Shifts: A Decrease in Customization Support from PBMs Historically, large PBMs offered some degree of customization for downstream clients—health plans, employer groups, and regional payers. However, over the past several years, a strategic shift has occurred. PBMs are increasingly signaling that they will no longer support custom formularies unless clients assume full ownership, including governance via an independent P&T committee. This shift has created a growing demand for third-party partners capable of offering the clinical and operational infrastructure necessary to support independent formulary oversight. For many organizations, developing this infrastructure internally is cost-prohibitive and operationally burdensome. Yet, the alternative—accepting a one-size-fits-all national formulary—often results in clinical misalignment, member dissatisfaction, and financial inefficiencies. Why P&T Committees Still Matter P&T Committees are more than regulatory artifacts; they are essential to evidence-based, patient-centered benefit design. When properly structured, an independent P&T committee ensures that: Formulary decisions are clinically grounded , balancing safety, efficacy, and comparative effectiveness. Utilization management strategies are clinically appropriate , nuanced, and aligned with organizational goals. Emerging therapies and pipeline products are proactively reviewed , with consideration of the clinical impact within the existing therapies for the disease state(s). It is particularly relevant today, as new chemical entities, biosimilars, and expanded indications are rapidly emerging across various therapeutic areas. Structural and Governance Considerations To operate independently, a P&T committee must include: A multidisciplinary panel of licensed and practicing physicians and pharmacists with relevant specialties Transparent processes and documentation to meet regulatory and accreditor expectations (e.g., URAC, CMS) Conflict of interest management , especially when advising on high-cost therapies The ability to convene regularly , with infrastructure to handle ad hoc reviews in a responsive manner Illuma Advisors provides this framework to clients who want to retain clinical control while outsourcing the operational burden. We develop, maintain, and brand materials to meet state licensure requirements and ensure procedural transparency. A Model That Supports Strategic Customization Illuma Advisors developed our P&T services in direct response to these exact market needs. The committee meets six times yearly and comprises clinicians from diverse geographical backgrounds and multiple specialties. Our work is grounded in a commitment to clinical excellence and real-world experience in managed care. Importantly, we view P&T not as a compliance obligation—but as a strategic lever. Our team brings expertise in formulary development, indication-based reviews, utilization management (UM) criteria, and integrating clinical policy with business strategy. Conclusion As PBMs continue to narrow the scope of support for custom formularies, the demand for independent, clinically sound P&T services will only grow. For organizations seeking to preserve clinical integrity while navigating an increasingly complex pharmaceutical market, partnering with experienced advisors may be the most pragmatic—and strategic—path forward.
