Formulary coverage is commonly treated as a practical endpoint of pharmacotherapy allocation, yet coverage alone does not establish comparative clinical benefit, acceptable treatment burden, preference concordance, affordability, or feasible treatment use. This analysis develops an evidence-bounded framework for distinguishing these domains and reconciling them without reducing patient value to a single coverage or economic signal. A targeted conceptual health-policy analysis was conducted across value assessment, health technology assessment, patient-preference methods, treatment-burden measurement, formulary policy, affordability, and real-world medication access. Evidence was used to define constructs, identify level-of-analysis boundaries, characterize discordant signals, and derive a proposed allocation architecture. Empirical findings were retained within their reported populations and policy contexts. The analysis separates five decision domains: comparative clinical benefit, treatment burden, patient preferences, budget impact, and real-world access. Coverage is positioned as an administrative state that can enable treatment but cannot independently establish patient value. The proposed architecture treats discordance among domains as information requiring explanation rather than as error requiring forced convergence. It also distinguishes payer affordability from patient affordability and nominal coverage from treatment feasibility. Patient-centered pharmacotherapy allocation requires reconciliation across clinical, patient, economic, and access evidence. The proposed architecture is not a validated score or policy rule; its usefulness depends on transparent domain-specific evidence, explicit uncertainty, local health-system context, and prospective evaluation of whether allocation decisions improve access without obscuring clinical appropriateness or patient heterogeneity.
