• Users Online: 94
  • Print this page
  • Email this page

 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 4  |  Page : 105-106

Insurance drug formulary contribution to patient-centered care in the Kingdom of Saudi Arabia

Consultant clinical pharmacist, Riyadh, Saudi Arabia

Date of Submission12-Dec-2022
Date of Acceptance12-Dec-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Nada A Al-Agil
Consultant clinical pharmacist
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjcp.sjcp_26_22

Rights and Permissions

How to cite this article:
Al-Agil NA. Insurance drug formulary contribution to patient-centered care in the Kingdom of Saudi Arabia. Saudi J Clin Pharm 2022;1:105-6

How to cite this URL:
Al-Agil NA. Insurance drug formulary contribution to patient-centered care in the Kingdom of Saudi Arabia. Saudi J Clin Pharm [serial online] 2022 [cited 2023 Feb 2];1:105-6. Available from: http://www.sjcp.org/text.asp?2022/1/4/105/366504

Formulary concept has been tracked as early as 1800s, and they have grown in importance as both drug selection and cost-control tools over the past three decades. The development of formularies in the late 1980s was driven by a structural change in the drug industry.[1],[2] While formularies gained importance as a tool for payers and regulators to use in selection of the most cost-effective medications among these treatment options. According to the value of formularies in the provision of value-based service, which is in line with the Cooperative Health Insurance (CHI) vision and mission to improve the health of beneficiaries through a regulatory environment that enables stakeholders to promote equity, transparency, and value-based care. CHI has identified key strategic programs under five themes revolving mainly around being beneficiary-centric, an enabler, value-driven, progressive, and improved adoption of digital excellence.[3],[4],[5]

Reform of the Essential Benefit Package (EBP) is one of the top strategic programs in which CHI is launched, and which is focusing on limiting, adding benefits, and launching a few key services aiming at optimizing the overall beneficiary’s experience. With medications representing approximately 20% of the value of the overall claim under private insurance, the enhancements made on the EBP needed to be coupled with the development of a well-governed evidence-based Insurance drug formulary (IDF), which shall promote the use of cost-effective medications, thus leaving a room for possible additional benefits on the EBP level.

The IDF is an evidence-based, disease-focused formulary that provides a drug list necessary to treat a particular disease. The concept of the formulary was based on benchmarking to several regional and national countries’ practices, including the United States, United Kingdom, Netherlands, United Arab Emirates, Ireland, Australia, and Singapore. Yeung et al. evaluated the impact of a value-based formulary (VBF) on adherence and patient and health plan expenditures in three chronic disease states: diabetes, hypertension, and hyperlipidemia. They found that for the diabetes cohort, member and overall expenditures decreased.[6] As for the hypertension cohort, there was a cost shift from member to plan, while there was no statistically significant effects on hyperlipidemia cohort expenditures or on medication adherence in any of the three disease cohorts. The study concluded that a VBF can ensure access to high-value medications while maintaining affordability.[6] In another study by Yeung et al. on the impact of a VBF on medication utilization, health services utilization, and expenditures, they found after VBF implementation, member medication expenditures increased by $2 per member per month (PMPM) (95% CI, $1 to $3) or 9%, whereas health plan medication expenditures decreased by $10 PMPM (CI, $18 to $2) or 16%, resulting in a net decrease of $8 PMPM (CI, $15 to $2) or 10%, which translates to a net savings of $1.1 million. Utilization of medications moved into lower copayment tiers and increased by 1.95 days’ supply (CI, 1.29 to 2.62) or 17%. Total medication utilization, health services utilization, and non-medication expenditures did not change.[7]

The IDF is meant to achieve treatment standardization, equity among treated patients, cost containment with introduction of therapeutically equivalent but cheaper treatment options, and ultimately improving governance in the private healthcare insurance sector. In addition to promoting adherence to clinical guidelines, IDF promotes cost savings through the partial or full replacement of brands with generics along with offering flexibility for patients to select brands while imposing additional cost-sharing measures in accordance with their respective insurance policies.

Clinical pharmacists’ role in medication management is paramount, starting with their impact on formulary management initiatives, coordinating Pharmacy and therapeutic committees’ tasks, and making recommendations based on sound clinical and pharmacoeconomic evidence. Pharmacists have additional roles, guidance to physicians in choosing medication wisely, adherence to health insurance regulations related to medication selection that assure patient access to care, and clinical pharmacist involvement in building clinical pathways based on sound clinical evidence. As well as working with insurance companies to build pharmacy management programs incorporating and prescribing edit “decision support alerts” that promote value-based health care. The pharmacist’s role in continuous monitoring and analysis of prescribing patterns that would be part of updating policies related to medication utilization and clinical pathways meeting the update in clinical evidence is essential for both value-based outcomes. Moreover, pharmacists play a significant role in Change management and patient education related to medication utilization, pharmaceutical and generic alternatives that meet their healthcare needs, and insurance plan premiums.

In summary, with the introduction of the IDF into the KSA private health care system, many unmet needs are being addressed. The changes will help create a regulatory environment for the private healthcare market in KSA which is at par with international reference markets.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

  References Top

Walser BL, Ross-Degnan D, Soumerai SB Do open formularies increase access to clinically useful drugs?. Health Affairs 1996;15:95-109.  Back to cited text no. 1
Summers KH, Szeinbach SL Formularies: The role of pharmacy-and-therapeutics (P&T) committees. Clin Therapeut 1993;15:433-41; discussion 432.   Back to cited text no. 2
Tyler LS, Cole SW, May JR, Millares M, Valentino MA, Vermeulen LC Jr, et al; ASHP Expert Panel on Formulary Management. ASHP guidelines on the pharmacy and therapeutics committee and the formulary system. Am J Health Syst Pharm 2008;65:1272-83.  Back to cited text no. 3
Concepts in Managed Care Pharmacy | AMCP.org. Available from: https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy. [Last accessed on 2019 Jul 18].  Back to cited text no. 4
Goldberg R Managing the pharmacy benefit: The formulary system. J Manag Care Pharm 1997;3:565-73.  Back to cited text no. 5
Yeung K, Basu A, Marcum ZA, Watkins JB, Sullivan SD Impact of a value-based formulary in three chronic disease cohorts. Am J Manag Care 2017;23:S46-53.  Back to cited text no. 6
Yeung K, Basu A, Hansen RN, Watkins JB, Sullivan SD Impact of a value-based formulary on medication utilization, health services utilization, and expenditures. Med Care 2017;55:191-8.  Back to cited text no. 7


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article

 Article Access Statistics
    PDF Downloaded85    
    Comments [Add]    

Recommend this journal