Chapter 1 – Health Care Governance and Administration

1.2.11 CCHCS Systemwide Pharmacy and Therapeutics Committee

• Procedure Overview

  • The California Correctional Health Care Services (CCHCS) Systemwide Pharmacy and Therapeutics (P&T) Committee shall:

    • Provide overall direction to Pharmacy Services at all California Department of Corrections and Rehabilitation (CDCR) institutions.

    • Report to the statewide Quality Management Committee (QMC).

    • Oversee subcommittees including, but not limited to, the Systemwide Medication Management Subcommittee and Drug Utilization Review Subcommittee.

  • Institutions shall have a Medication Management Subcommittee that reports to the local QMC to oversee medication management practices including local medication storage, distribution, administration and utilization locally; however, changes to approved, standardized pharmacy policies and procedures, the standard practice model, and the CCHCS Drug Formulary must be approved by the Systemwide P&T Committee.  Recommended changes to policy, procedure, or the formulary shall be submitted to the Regional Deputy Medical Executive (DME) and Statewide Chief of Pharmacy Services for consideration by the Systemwide P&T Committee as appropriate.

• Purpose

  • To ensure the safe, rational, evidenced-based, cost-effective, standardized use of therapeutic drugs and develop policies and procedures related to medication management within the CDCR.

• Procedure

  • Membership

    • The chairperson is appointed by the Deputy Director, Medical Services, for a two-year term (eligible for reappointment) and shall be responsible for the Systemwide P&T Committee meeting.

    • The chairperson shall assist the Deputy Director, Medical Services, in selecting the other members of the Systemwide P&T Committee and determining terms of service.

    • Voting members shall include the following, or the members shall assign a designee with decision-making authority similar to the member that is unable to attend:

      • Deputy Director, Medical Services or designee at the executive level

      • Headquarters Deputy Medical Executive chairperson

      • Two Headquarters Physicians at the executive or management level

      • Four Institutional or Regional Physicians at the executive or management level

      • Deputy Director, Nursing Services or designee

      • One Headquarters Chief Nurse Executive

      • Deputy Director, Mental Health Services (if psychiatrist) or designated psychiatrist at the executive or management level

      • Statewide Chief Psychiatrist or designee

      • Statewide Chief Telepsychiatrist or designee

      • One Psychiatric Inpatient Program Chief Psychiatrist or designee

      • Deputy Director, Dental Services or designee

      • Statewide Chief, Pharmacy Services or designee

      • Two Pharmacy Services Managers

      • One Deputy Medical Executive, Quality Management or designee

    • The Systemwide P&T Committee shall maintain a list of permanent designees for voting members. Designees for voting members of the Systemwide P&T Committee are permitted. Prior notification to the chairperson at least three working days in advance is requested when a designee shall attend for a voting member.  All designees must sign a confidentiality statement pursuant to Section (c)(3)(D).

    • Non-voting members shall include:

      • Deputy Director, Fiscal Services, or designee, at the Assistant Deputy Director level

      • An attorney from the CCHCS Office of Legal Affairs (COLA), to be designated by COLA’s Director and Chief Counsel

      • Pharmaceutical Program Manager and Pharmaceutical Consultant II, Department of General Services

      • Support staff

    • Guests for Systemwide P&T Committee meetings are permitted.  Prior notification to the chairperson at least three working days in advance is requested.  All guests must sign conflict of interest and confidentiality forms pursuant to Section (c)(3)(D) and understand that their attendance is as an observer and comments during the meeting are at the discretion of the chairperson.

  • Duties

    • The Systemwide P&T Committee is responsible for overseeing policies and procedures related to all aspects of medication use within CCHCS including, but not limited to:

    • Maintaining a formulary of medications, including standardizing the strengths and dosage forms for medications used across institutions.

    • Reviewing procurement and medication selection processes to promote cost-effective formulary management.

    • Conducting regular therapeutic category reviews for formulary selection.

    • Ensuring that pharmacy services address the health care and security needs of the institution.

    • Reviewing and monitoring medication usage and therapeutic use of medications within the CDCR.

    • Evaluating medication use and promoting safe medication practices.

    • Evaluating medication therapies and providing input to the development of disease management guidelines.

    • Reviewing and approving proposed changes to pharmacy policies. The Systemwide Medication Management Subcommittee shall be consulted for policymaking on any matters related to medication management processes.

  • Meetings

    • The Systemwide P&T Committee shall meet at least quarterly or as often as necessary to carry out its responsibilities.

    • Meetings via teleconference shall be made available to members of the Systemwide P&T Committee.

    • A record of the proceedings shall be kept which records committee activities, recommendations, and attendance.

    • Confidentiality/Non-Conflict

      • The proceedings and records of the Systemwide P&T Committee shall be kept confidential and protected from discovery to the extent permitted by law.

      • Any attendees shall provide a completed copy of a Conflict of Interest Form and a Confidentiality and Non-Disclosure Agreement.  Completed copies of each document shall be maintained with the Systemwide P&T Committee records.  Members may not have any financial or business relationships with entities doing business with the State of California.

      • If any attendee has an interest that may affect or be perceived to affect the member’s independence of judgment, the member shall recuse themself from the voting process for the drug class or other agenda items concerned.  This recusal includes, but is not limited to, refraining from deliberation or debate, making recommendations, volunteering advice, and participating in the decision-making process in any way.

    • Voting

      • Each voting member shall have one vote.  A quorum is designated as 50 percent of voting members, excluding vacancies and abstentions.

      • Action on a motion requires the total number of votes to be equal to or greater than a quorum.

      • The Systemwide P&T Committee may use electronic voting to address issues when it is determined that waiting until the next scheduled meeting is suboptimal.  Electronic voting may be used to resolve an existing agenda item or to address an urgent or emergent new agenda item.

      • An abstention is considered a non-vote, and thus does not accrue to the total number of votes.

  • Subcommittees

    • The Systemwide P&T Committee may charter standing subcommittees and establish ad hoc workgroups to plan and develop new or modify existing programs. The charter for each subcommittee shall be reviewed and updated as often as needed but no less than every two years. Standing subcommittees include, but are not limited to:

    • Systemwide Medication Management Subcommittee

      • The Systemwide Medication Management Subcommittee is a multidisciplinary group that works to ensure medication practices support the safety of the individuals served and improve the quality of care by developing and modifying processes as they relate to planning, procurement, ordering, preparing and dispensing, distribution, storage, and administering medications with the goal to reduce any potential harm that could be caused by medications.

    • Drug Utilization Review Subcommittee

      • The Drug Utilization Review Subcommittee shall:

      • Review prescription drug utilization and costs and identify clinical criteria, decision support, and methods for managing prescription drug cost and optimizing prescribing practices.

      • Develop and provide evidence-based recommendations to the Systemwide P&T Committee with respect to formulary selection, electronic health record system (EHRS) medication catalog availability, and use criteria or prior authorization criteria, if needed.

    • 340B Oversight Subcommittee

      • The 340B Oversight Subcommittee assists in monitoring, directing, and overseeing the CCHCS’ implementation of its 340B Program. The 340B Oversight Subcommittee’s reporting provides direction and ongoing surveillance of the organization’s 340B Program for compliance with policy and federal rules.

    • Nutrition Subcommittee

      • The Nutrition Subcommittee shall meet on an ad hoc basis when required to develop and provide evidence-based recommendations to the Systemwide P&T Committee with respect to enteral and parenteral nutrition and nutritional supplements that are deemed necessary to make available in the CCHCS Drug Formulary or make available in the EHRS medication catalog as a non-formulary item.

• References

  • California Civil Code, Division 1, Part 2.6, Chapter 1, Section 56 et seq.

  • California Evidence Code, Division 9, Chapter 3, Section 1157

  • California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 5, Article 2, Section 3413 (b)

  • California Code of Regulations, Title 22, Division 5, Chapter 3, Article 5, Section 72525, Required Committees

  • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 5, Section 79781, Required Committees

  • California Government Code, Title 2, Division 5, Part 2.6, Chapter 2.5, Article 10, Section 19990

  • California Government Code, Title 9, Chapter 7, Article 1, Section 87100 et seq.

  • California Penal Code, Section 5024.2

  • Health Care Department Operations Manual, Chapter 1, Article 2, Section 1.2.4, Quality Management Program, Statewide Governance

  • Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.12, Outpatient Dietary Intervention

  • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.5, CCHCS Drug Formulary

  • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.10, CCHCS Pharmacy Policy and Procedure Manual Review, Revisions, and Additions

• Revision History

  • Effective: 03/2007
    Revised: 10/22/2025