Development of a Pharmacy Benefit Management Framework for State Health Insurance Schemes in North Central Nigeria

Expanding health insurance coverage in North Central Nigerian states requires robust pharmacy benefit management frameworks that balance access, quality, and cost-effectiveness in drug benefit design. This study developed a pharmacy benefit management framework for state health insurance schemes in Benue and Kogi States. A policy development methodology incorporating health insurance scheme audit, stakeholder consultation, and comparative policy analysis was adopted. Review of the existing drug benefit lists, reimbursement procedures, and pharmacy network management in both states identified critical gaps including fragmented drug lists, absence of generic substitution policies, inadequate pharmacy quality audit, and limited pharmaceutical care provisions. Policy briefs from Ghana, Kenya, and South Africa on pharmacy benefit management in social health insurance were analysed for applicable lessons. The proposed framework encompasses five policy pillars: evidence-based essential medicines list design, pharmacy network credentialing standards, generic prescribing and substitution mandates, pharmacist consultation fee reimbursement, and drug utilisation review mechanisms. An implementation roadmap with legislative requirements, administrative procedures, and information technology requirements is provided. The framework was reviewed by a panel of 14 health economists, pharmacists, and insurance commissioners, with consensus achieved on 87 percent of components. The study recommends adoption of the framework as the pharmaceutical component of state health insurance scheme reform in North Central Nigeria and calls for federal harmonisation of pharmacy benefit standards across all state schemes.

Keywords: pharmacy benefit management, health insurance, North Central Nigeria, drug benefit design, pharmaceutical policy