At CarelonRx, every therapy on our drug list is there for a reason.
We use a thorough, evidence-based process to help ensure the drugs we cover deliver meaningful results for the people who use them — your plan members. This meticulous approach isn’t just about medications; it’s about making confident, clinically informed decisions that benefit both patient outcomes and your organization’s bottom line. With a clinician-led strategy and a member-first mindset, our drug list is thoughtfully curated to promote effectiveness, safety, and value, from pipeline to prescription.
How pipeline monitoring shapes a smarter drug list
CarelonRx clinicians actively monitor drugs long before they receive Food and Drug Administration (FDA) approval. This early surveillance enables a proactive strategic evaluation throughout the entire drug lifecycle. Rather than waiting for FDA approval, we begin assessing the clinical potential and cost-of-care implications as early as possible.
Why this step is essential to our strategy:
- Early intelligence fuels clinical foresight. It gives us visibility into how pivotal trials are designed and how well study populations align with our member demographics.
- We build smarter clinical strategies. This foresight enables better forecasting of how a new drug might affect treatment patterns and adoption across your population.
- We prepare for cost implications. Early reviews help us estimate future total cost-of-care impacts — both pharmacy and medical — so we’re ready with informed planning and strategy.
What comes next:
Once clinical trial data becomes available, our team performs a deep-dive clinical assessment to evaluate trial quality and compare outcomes to existing treatments.
How we evaluate evidence for drug list decisions
To determine a drug’s value, our clinical pharmacists — trained in evidence-based medicine — conduct rigorous evaluations of all available data and relevant literature. Using the PICO framework (Population, Intervention, Comparison, Outcomes), we assess comparability, quality, and clinical impact.
Here’s how our evidence review ensures we select high-value therapies:
Randomized clinical trials (RCTs):
These are the gold standard for understanding a drug’s safety and effectiveness.
Why it matters: RCTs with proper design (like blinding and randomization) provide the most accurate data on potential benefits and harms.Systematic reviews and meta-analyses:
When available, we use these to assess the broader body of evidence.
Why it matters: They allow us to compare therapies within a drug class and understand their impact on meaningful clinical outcomes. However, newer drugs may lack this level of analysis.FDA medical and statistical reviews:
We evaluate these reviews to uncover study limitations that might not be evident in published literature.
Why it matters: This gives us additional context to anticipate real-world performance.Evidence-based treatment guidelines:
These are evaluated for trustworthiness and relevance.
Why it matters: Guidelines offer insight into current standards of care and how drugs are used in broader practice.Broad literature searches:
We look for safety concerns and rare side effects that may not appear in early clinical trials.
Why it matters: Post-marketing studies and FDA reviews help us evaluate real-world safety signals that could affect your members.What comes next:
Once all the available evidence is analyzed, the Pharmacy & Therapeutics (P&T) evidence review process begins, setting the stage for formulary decisions.
How our formulary process prioritizes value and member impact
At CarelonRx, our P&T process is more than a committee — it’s a proprietary system rooted in independence, evidence, and member-first thinking. Every decision is intentionally designed to promote access to therapies that improve health, while at the same time, help plan sponsors manage costs.
Our drug list is shaped through the following key steps:
An independent, diverse P&T committee:
Our committee is composed of physicians and pharmacists who are experienced, geographically diverse, and free from significant conflicts of interest.Subspecialty committees for complex areas:
Specialized groups focus on hematology/oncology, behavioral health, and policy review — ensuring informed, nuanced decision-making.High-value therapy promotion:
We prioritize therapies with demonstrated efficacy, safety, and cost-effectiveness to support your members’ health and control long-term healthcare expenses.Systematic value assessment:
Each recommendation undergoes an additional layer of review focused on tiering, utilization, member/provider impact, and more.Continuous monitoring of evidence:
We update formulary decisions as new evidence emerges to maintain optimal care standards. Drugs are reviewed at least annually, ensuring our lists remain aligned with current data and real-world experience.
Through our formulary development methodology, CarelonRx allows clinical evidence and outcomes data to help make formulary decisions that support our P&T goal: to positively impact health outcomes, lower total cost of care, and improve the member and provider experience.
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