Implementation of a National Value-Based Insurance Drug Formulary in the Saudi Private Health Sector

OBJECTIVES: Saudi Arabia’s Council of Health Insurance (CHI) oversees service providers in the private sector, manages the National Platform for Health and Insurance Exchange Service (NPHIES) program, and identifies insurance beneficiaries. CHI established a national insurance drug value-based formulary (VBF) to standardize practices and assure health equity. The objectives of this article are to describe (1) the governance framework, a key component of VBF, and (2) the first year’s implementation results.

METHODS: The established governance comprised of a process, policies, and standard operating procedures described the dynamic engagement of four multilayered committees. This ensured multisectoral stakeholder representation, informed decision-making, and accountability supporting evidence-based review and rational use of medicines. The process described two workstreams: Topics Review and Continuous Monitoring. The former entailed indication identification and prioritization, review of clinical and economic guidelines, and final review and approval of the outcome. The latter was informed by horizon scanning of newly registered drugs and published guidelines, pharmacovigilance, formulary complaints from stakeholders, drug utilization trend, and user’s adherence.

RESULTS: 200 indications across 14 therapeutic areas were reviewed resulting in the following drug-indication pairs adjustments: 5700+ drug additions to relevant indications, 3300+ prescribing edits modifications, and 380+ delistings. Twelve monitoring reports described spending and utilization as per the prescribing edits, generics/biosimilars uptake, and specialty drugs prescribing patterns. Two dynamic analytical tools were developed, validated, and approved for future applications; the Prioritization Toolkit and Monitoring Dashboard. The Toolkit employs advanced algorithms to systematically prioritize indications for review based on detailed financial and clinical metrics derived from stakeholders’ value criteria. The metrics-related real-world data was extracted from NPHIES. The centralized Dashboard enables continuous monitoring as well as trends identification of drug usage, costs, and adherence.

CONCLUSIONS: This governance framework successfully supported national-level health innovation uptake while optimizing expenditure. Its regular update is essential for VBF maintenance.