Decision Instrument · Pharmacy Cost Governance · Payer or Provider
PBM Governance Diagnostic
A 25-question structured assessment evaluating your organisation pharmacy benefit management capability across formulary management, prescribing intelligence, network contracting, specialty drug governance, and analytical infrastructure. Designed for payers and providers managing pharmacy spending in the post-CHI-289 environment.
5 domains
25 questions
Approximately 15 minutes
Payer or provider perspective
Self-assessment version. Available as a facilitated Full Diagnostic with independent formulary review, prescribing pattern analysis, and a board-ready PBM capability roadmap.
Several questions have payer-specific and provider-specific variants reflecting different PBM responsibilities at each side of the transaction.
Section 1 of 50% complete
Section 1 of 5
Formulary Management
Evaluates whether your organisation manages drug coverage decisions through a structured formulary process: defining what is covered, at which tier, with which clinical criteria, beyond simply adopting the CHI essential benefit package.
Does your organisation maintain a structured formulary with explicit tiering: differentiating preferred generics, branded products, specialty drugs, and excluded drugs with documented selection criteria beyond the CHI essential benefit package?
Strong - 3 pointsA multi-tier formulary exists with documented selection criteria, applied beyond CHI minimums, with annual review and budget impact assessment for each tier.
Partial - 2 pointsSome tiering exists but selection criteria are not formally documented or are limited to CHI default categories.
Weak - 0 pointsThe CHI essential benefit package is adopted without organisation-specific tiering or selection criteria.
Question 2
Are prior authorisation protocols defined for high-cost drug categories: specialty oncology, biologics, advanced cardiovascular therapies: with documented clinical criteria and a structured review process?
Strong - 3 pointsPrior authorisation protocols are documented for all high-cost categories with clinical criteria reviewed annually against published evidence and decision turnaround tracked.
Partial - 2 pointsPrior authorisation is required for some high-cost drugs but criteria are not consistently documented or reviewed.
Weak - 0 pointsNo structured prior authorisation protocols. Approval decisions are made case-by-case without documented criteria.
Question 3
Does your organisation have a documented therapeutic substitution policy: enabling pharmacists or clinicians to substitute equivalent agents within a therapeutic class based on cost-effectiveness criteria, with appropriate prescriber notification?
Strong - 3 pointsA therapeutic substitution policy exists with documented evidence base, prescriber notification protocol, and substitution rate monitoring as a programme metric.
Partial - 2 pointsGeneric substitution is permitted but therapeutic class substitution within branded products is not formally addressed.
Weak - 0 pointsNo therapeutic substitution policy exists. Substitution decisions occur ad hoc at the dispensing point.
Question 4
Is there an annual formulary review cycle with documented budget impact assessment: producing a forward projection of pharmacy spend by therapeutic area before formulary changes are implemented?
Strong - 3 pointsAnnual formulary review with documented budget impact assessment, forward spend projections by therapeutic area, and board-level approval of material changes.
Partial - 2 pointsSome review occurs but budget impact assessment is informal or not produced before changes take effect.
Does your organisation have a dedicated specialty drug management programme: addressing oncology, biologics, rare disease, and other high-cost categories with separate clinical pathways and outcome measurement?
Strong - 3 pointsA specialty drug programme exists with dedicated clinical pathways, outcome measurement, and case management for the highest-cost categories. Outcomes-based contracting is used where available.
Partial - 2 pointsSpecialty drugs are managed through standard formulary processes without a dedicated programme or outcome measurement.
Weak - 0 pointsNo specialty drug management programme. High-cost drugs are processed through standard claims adjudication.
Section 2 of 5
Prescribing Intelligence
Tests whether your organisation analyses prescribing patterns at the prescriber, drug class, and patient level: extracting actionable intelligence from NPHIES drug data rather than processing claims passively.
Does your organisation actively monitor prescribing patterns at the prescriber level: identifying outlier prescribers whose patterns drive disproportionate cost or deviate from established clinical guidelines?
Does your organisation actively monitor prescribing patterns at the prescriber level within your facility: identifying outlier prescribers whose patterns drive disproportionate cost or deviate from formulary expectations?
Strong - 3 pointsPrescriber-level prescribing patterns are monitored monthly, outliers are identified using defined statistical thresholds, and structured intervention protocols exist for confirmed outliers.
Partial - 2 pointsPrescribing patterns are reviewed periodically but without structured outlier detection methodology or intervention protocols.
Weak - 0 pointsNo prescriber-level prescribing analytics. Drug spending is monitored at aggregate level only.
Question 7
Does your organisation produce regular therapeutic class spending analysis: tracking cost-per-member-per-month or cost-per-admission by drug class, with comparison to market benchmarks where available?
Strong - 3 pointsTherapeutic class analysis is produced monthly with PMPM or cost-per-admission tracking, market benchmark comparison, and trend identification feeding formulary and clinical pathway decisions.
Partial - 2 pointsSome therapeutic class analysis is conducted but is not regular, lacks benchmarks, or is not connected to formulary and clinical decisions.
Weak - 0 pointsNo structured therapeutic class spending analysis.
Question 8
Does your organisation measure adherence and persistence for chronic disease therapies: identifying patients with poor adherence to evidence-based regimens for diabetes, cardiovascular disease, and other high-burden conditions?
Strong - 3 pointsAdherence is measured systematically using NPHIES refill data for defined chronic disease cohorts, with active intervention programmes targeting low-adherence patients.
Partial - 2 pointsAdherence is monitored at population level but without patient-level identification or active intervention programmes.
Weak - 0 pointsNo adherence or persistence measurement.
Question 9
Is polypharmacy actively identified at the patient level: flagging patients with concurrent prescriptions from multiple prescribers, drug-drug interaction risk, or inappropriate prescribing patterns for elderly populations?
Strong - 3 pointsPolypharmacy detection is operational using NPHIES medication history with structured pharmacist review of flagged patients and prescriber notification.
Partial - 2 pointsSome polypharmacy review occurs but is reactive or not driven by structured analytical detection.
Weak - 0 pointsNo polypharmacy detection or pharmacist-led review programme.
Question 10
Has your organisation built or commissioned NPHIES-based drug analytics: using SFDA codes, dispensing patterns, and longitudinal medication history to generate intelligence beyond what NPHIES claim adjudication produces?
Strong - 3 pointsNPHIES drug data feeds into an analytical environment producing scheduled and on-demand intelligence used by formulary, clinical, and contracting functions.
Partial - 2 pointsNPHIES drug data is analysed for specific projects but is not part of a continuous analytical capability.
Weak - 0 pointsNPHIES drug data is used only for claims adjudication. No analytical layer exists.
Section 3 of 5
Network Contracting & Generic Substitution
Evaluates whether your pharmacy network contracts and generic substitution practices are configured to maximise the savings the CHI-289 generic substitution policy makes available: not simply leaving substitution to default behaviour at the pharmacy counter.
Are pharmacy network contracts differentiated by performance: rewarding pharmacies with higher generic dispensing rates, better adherence support, or specialty drug capability with preferential reimbursement or volume placement?
Does your hospital pharmacy maintain differentiated supplier relationships: securing preferential pricing on high-volume generics and managing branded supply contracts based on dispensed volume and clinical pathway alignment?
Strong - 3 pointsPerformance-differentiated contracts exist with documented metrics. Generic dispensing rate and outcome measures drive reimbursement or supply terms.
Partial - 2 pointsSome differentiation exists but is not based on documented performance metrics or applied consistently.
Weak - 0 pointsContracts are uniform across the network. No performance differentiation in pricing or volume placement.
Question 12
Does your organisation actively measure and report generic dispensing rate as a programme metric: with documented improvement targets and trend analysis against the CHI-289 baseline?
Strong - 3 pointsGeneric dispensing rate is monitored monthly with documented targets, trend analysis, and intervention when targets are missed.
Partial - 2 pointsGeneric rate is tracked but without formal targets or systematic intervention.
Weak - 0 pointsGeneric dispensing rate is not monitored as a programme metric.
Question 13
Has your organisation quantified the unrealised generic substitution savings within its own claims book: identifying specific therapeutic areas where additional substitution potential remains based on NPHIES data analysis?
Strong - 3 pointsUnrealised substitution savings have been quantified at therapeutic area level with action plans for the highest-potential categories.
Partial - 2 pointsThe opportunity is recognised in principle but has not been quantified for the organisation specific book.
Weak - 0 pointsNo quantification of unrealised generic savings. Substitution rate is what it is.
Question 14
Does your network include differentiated arrangements for retail pharmacies, hospital pharmacies, and specialty pharmacies: recognising that each has distinct cost dynamics, volume patterns, and clinical roles?
Strong - 3 pointsPharmacy network is segmented by type with distinct contracting terms, performance expectations, and clinical pathway integration for each segment.
Partial - 2 pointsPharmacy types are recognised but not contracted on materially different terms.
Weak - 0 pointsPharmacy network operates on uniform contracts across all pharmacy types.
Question 15
Are mail-order or 90-day fill arrangements available for chronic disease therapies: capturing the cost reduction and adherence benefits of bulk supply for stable medication regimens?
Strong - 3 pointsMail-order or 90-day fill is available for defined chronic disease therapies with adherence outcome measurement and patient enrolment programmes.
Partial - 2 pointsExtended supply options exist but are not actively promoted or linked to adherence measurement.
Weak - 0 pointsNo mail-order or 90-day fill arrangements.
Section 4 of 5
Specialty Drug Governance
Tests whether your organisation manages specialty drugs (oncology, biologics, rare disease, advanced therapies) as a distinct discipline: with separate clinical pathways, outcome measurement, and cost containment strategies appropriate to high-cost, high-acuity therapeutic areas.
Has your organisation modelled specialty drug spending trajectory through 2028: projecting growth in oncology, biologics, and rare disease categories based on current claims patterns, pipeline drug approvals, and beneficiary risk profile?
Strong - 3 pointsA formal specialty spend projection model exists with quantified growth scenarios, pipeline drug impact assessment, and budget integration.
Partial - 2 pointsSpecialty drug growth is acknowledged but a quantified forward projection has not been produced.
Weak - 0 pointsNo specialty drug spending projection. Forward planning relies on historical trends only.
Question 17
Are clinical pathways defined for the highest-cost therapeutic areas (oncology, autoimmune, rare disease): specifying treatment sequencing, response measurement, and discontinuation criteria for non-responders?
Strong - 3 pointsClinical pathways exist for the major high-cost therapeutic areas with documented sequencing, response criteria, and discontinuation protocols. Pathway adherence is monitored.
Partial - 2 pointsClinical guidelines are referenced but specific organisational pathways with response and discontinuation criteria are not documented.
Weak - 0 pointsNo defined clinical pathways for high-cost therapeutic areas.
Question 18
Has your organisation engaged with NUPCO or directly with manufacturers on outcomes-based contracting for specialty drugs: aligning reimbursement to documented clinical effectiveness rather than fixed pricing?
Strong - 3 pointsOutcomes-based contracts are in place for at least one high-cost specialty category with defined outcome measures, data capture protocols, and reimbursement adjustment mechanisms.
Partial - 2 pointsOutcomes-based contracting is being explored but no operational contract is in place.
Is biosimilar uptake actively managed: with formulary preference for biosimilars over reference products in eligible therapeutic areas, prescriber education, and dispensing rate monitoring?
Strong - 3 pointsBiosimilar preference is documented in the formulary with prescriber education, dispensing rate monitoring, and intervention when uptake falls below targets.
Partial - 2 pointsBiosimilars are covered but uptake is not actively managed or monitored.
Weak - 0 pointsNo active biosimilar management strategy.
Question 20
Is there a structured case management programme for high-cost specialty drug patients: providing pharmacist-led adherence support, side-effect management, and coordination across prescribers and care settings?
Strong - 3 pointsA pharmacist-led specialty case management programme is operational with defined enrolment criteria, intervention protocols, and outcome measurement.
Partial - 2 pointsSome case management activity exists but is not structured around specialty drug patients specifically.
Weak - 0 pointsNo case management programme for specialty drug patients.
Section 5 of 5
Analytical Infrastructure & Governance
Evaluates whether the analytical, organisational, and governance infrastructure exists to support PBM as a discipline: data systems, named accountability, board reporting, and integration with the broader claims and clinical environment.
Tests against: Function Without Architecture · PBM in Name Only
Question 21
Is there a named senior executive accountable for pharmacy benefit management as a discipline: with authority over formulary, network contracting, and clinical pathway decisions, separate from general medical claims management?
Strong - 3 pointsA named senior executive holds PBM accountability with documented authority over formulary, network, and clinical pathway decisions, with direct reporting to the CMO or equivalent.
Partial - 2 pointsPBM responsibility is distributed across multiple functions without a single named executive accountability.
Weak - 0 pointsNo named PBM accountability. Pharmacy is managed within general claims operations.
Question 22
Does the board or board-level committee receive a regular pharmacy spending and performance report: covering total spend, generic dispensing rate, specialty drug trajectory, and forward projection?
Strong - 3 pointsQuarterly board reporting covers all four pharmacy performance metrics with trend analysis, forward projections, and explicit decisions on programme direction.
Partial - 2 pointsSome pharmacy reporting reaches board level but not as a structured cycle covering the key metrics.
Weak - 0 pointsPharmacy spending is not reported to the board separately from general medical claims.
Question 23
Are PBM analytics integrated with NPHIES data and the broader claims analytics environment: enabling cross-domain analysis of pharmacy spending against medical utilisation, beneficiary risk, and clinical outcomes?
Strong - 3 pointsPBM data is fully integrated with the broader analytical environment, enabling cross-domain analysis. Pharmacy questions and medical questions can be answered from the same data source.
Partial - 2 pointsPBM data exists but is not fully integrated with medical claims analytics. Cross-domain analysis requires manual data extraction and reconciliation.
Weak - 0 pointsPBM data sits in isolation from medical claims analytics.
Question 24
Has your PBM function assessed its readiness for the AR-DRG transition: understanding how bundled inpatient payments will change drug reimbursement dynamics for hospital pharmacies and specialty drugs administered in inpatient settings?
Strong - 3 pointsAn AR-DRG impact assessment for the PBM function has been completed with quantified projections and operational adjustments planned for the bundled payment environment.
Partial - 2 pointsThe AR-DRG impact on pharmacy is recognised but a formal assessment has not been completed.
Weak - 0 pointsNo AR-DRG impact assessment for the PBM function.
Question 25
Is your PBM function staffed with appropriately qualified personnel: clinical pharmacists, pharmacoeconomics analysts, and contracting specialists: rather than being an extension of claims processing?
Strong - 3 pointsClinical pharmacists, pharmacoeconomics analysts, and contracting specialists are embedded in or available to the PBM function. PBM is staffed as a distinct professional discipline.
Partial - 2 pointsSome clinical pharmacy expertise exists but the function is not fully staffed with the specialist disciplines required for mature PBM.
Weak - 0 pointsPBM is operated by general claims and operations staff without specialist pharmacy expertise.
PBM Governance Diagnostic - Results
Your PBM Governance Profile
0
/ 75
Calculating...
Processing...
Domain Breakdown
Formulary Management
0/15
Prescribing Intelligence
0/15
Network & Generic Substitution
0/15
Specialty Drug Governance
0/15
Analytical Infrastructure
0/15
Indicative Findings
Calculating...
This self-assessment shows the methodology. The facilitated diagnostic goes further.
A facilitated HealthElevate PBM diagnostic includes independent formulary review, prescribing pattern analysis from NPHIES data, and a board-ready PBM capability roadmap with sequenced investment recommendations.
PBM Governance and Pharmacy Cost Integrity in Saudi Healthcare
The analytical context behind this instrument: what the CHI-289 generic policy has and has not achieved, why specialty drug growth is now the primary cost driver, and what mature PBM capability requires.