Presentation (CTI)

OBJECTIVES: Daman Drug Formulary (DDF) evolved as a tiered mechanism that balances evidence-based clinical and economic values, financial sustainability, and equitable patient access to rationalize pharmaceutical coverage and control costs in the Saudi private healthcare sector. This study aimed to explore how generic substitution and the Council of Health Insurance (CHI) DDF policies shaped formulary decision-making in Saudi Arabia’s private healthcare sector, and to identify the behavioral, structural, and regulatory factors influencing implementation, medication access, and health system value.
METHODS: Qualitative semi-structured interviews were conducted. Purposeful sampling targeted individuals with direct formulary or policy decision-making authority including regulators, policy-makers, private insurers, healthcare providers, pharmacy and therapeutics committees, physicians, pharmacists, and pharmaceutical industry representatives. A validated topic guide, developed from the literature, was used to guide the discussion. Interviews explored medication listing processes, co-payment design, formulary tiering, and generic substitution practices following DDF implementation. All interviews were audio-recorded and transcribed verbatim. Data were analyzed using reflexive thematic analysis. Two researchers independently coded the data to enhance trustworthiness.
RESULTS: Twelve interviews were completed, with data saturation reached by the ninth interview and confirmed in subsequent transcripts, with no new themes emerging. Five themes emerged from the analysis: misalignment of co-payment structures, constrained insurer autonomy, the dual impact of standardization, behavioral and trust barriers, and prioritization of short-term cost savings.
CONCLUSIONS: CHI policies have strengthened formulary equity and rationalized prescribing. Nevertheless, co-payment design inconsistencies, restricted insurer decision-making authority, and underdeveloped data infrastructure continue to limit policy effectiveness. Policy reforms, including revision of co-payment ceilings, expansion of insurer-led tiering authority, and the development of a national e-prescription infrastructure, are recommended to advance value-based healthcare in line with Saudi Vision 2030. Such reforms would enhance policy uptake among all stakeholders and improve the long-term sustainability of pharmaceutical access in the private sector.