In order to investigate hospital formulary development in Japan, we constructed a set of questions concerning decision-making processes of the pharmacy and therapeutics committee (P&TC) in formulary development, the status of pharmacotherapy provided by the hospital, implementation of economic evaluation, and other issues. The questions used in the 2010 survey were based on those used in 2000 and 2005, with minor modifications. Of 145 questionnaires sent to pharmacy directors in university hospitals and hospitals that are members of the Japanese Society of Pharmacoepidemiology (JSPE), 80 were returned. Hospital formularies listed on average 746 oral drugs, 295 topical preparations, and 565 injection preparations. Pharmacies spent 198 hours/year/hospital to prepare for P&TCs, which were held 8.1 times/year. Increases in the rate of hospitals implementing critical pathways (89% [2005] to 95% [2010]), rate of including generic drugs in hospital formulary (6% [2005] to 10% [2010]), and rate of hospitals considering clinical guidelines in formulary development (25% [2005] to 56% [2010]) indicate that the hospitals have become more sensitive to cost and evidence. Less than half of the hospitals that perform cost analysis in formulary development considered also patient outcome or cost-effectiveness. Compared to hospitals that do not perform any type of pharmacoeconomic analysis for formulary development [20 (25%)], the hospitals that do [58 (73%)] appeared to be more sensitive to drug price and tended to group-purchase drugs. The anticipated changes in health policy to allocate monetary resources rationally and also to promote drug safety are likely to affect P&TC policies in the future, probably with more consideration on regulatory costs, patient outcome, and pharmacoeconomic analyses.