How we evaluate care options

Why we take a whole-person approach


We believe that a whole-person approach to care, one that uses evidence-based medicine and considers the full impact of a given care decision, is instrumental to improving members’ health. It also ensures that members have access to the drugs they need while still controlling pharmacy costs.


Our pharmacy and therapeutics committee (P&T), uses evidence-based medicine principles to carefully evaluate the clinical science and published literature to guide decisions on clinical policies.


We make sure the right pharmacy treatments are used at the right time, and in a way where members can get the most from their drugs. This allows us to:


  • Maximize clinical benefit.

  • Avoid clinically inferior drugs.

  • Minimize patient exposure to unnecessary health risk

  • Reduce waste.

The CarelonRx P&T Committee


All clinical criteria are developed to help guide clinically appropriate use of drugs and therapies and are reviewed and approved by the CarelonRx Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent and external committee that includes practicing physicians, pharmacists, and clinicians from leading academic medical centers and clinical practices with expertise in evidence-based medicine. All major clinical specialties are represented.


The P&T Committee normally meets four times a year to review evidence related to the safety and efficacy of drugs, biologics, and devices.


The P&T reviews include, but are not limited to:


  • FDA-approved indications. 

  • Information provided in major peer-reviewed publications.

  • Recommendations by recognized experts or leading medical centers.

  • Treatment guidelines. 

Once efficacy, safety, health outcomes, and comparisons to other drugs are known, the clinical value is determined for each drug and is used to inform drug list status, tiering, prior authorization, and step therapy decisions.


View our clinical criteria. If you have questions or feedback, please email us.

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