Objective: Ministry of Health (MOH) hospitals in Saudi Arabia should develop, organize and administer a formulary system that follows the principles to optimize patient care by ensuring access to clinically appropriate, safe and cost-effective medications. This can be achieved through the Pharmacy and Therapeutic Committee’s (PTC) role in the evaluation of hospital’s drug formulary and decision-making. The primary purposes of the PTC are policy development, communication and education and formulary management. Therefore, in this study, we aimed to explore the hospital drug formulary evaluation and decision-making at MOH hospitals in Saudi Arabia. Methods: This is a 4-month cross-sectional national survey of PTC at MOH hospitals in Saudi Arabia. The survey consisted of two parts: the first part collected demographic information and the second part consisted on 93 questions divided into four domains. An electronic survey was distributed to all drug information centers at MOH hospitals and analyzed the evaluation of drug formulary and decision-making through the Survey Monkey system. Results: A total of 50 drug information centers responded to the questionnaire (100%). Restricted drug usage (3.88), new drug entities (3.74), new dosage form (3.6) and new strength (3.6) were the majority of the requests for inclusion in the formulary. A total of 1-3 medications were evaluated monthly by the PTC at 41 (82%) hospitals. Most of the healthcare providers were allowed to request for the addition or deletion of medications: PTC members 38 (76%), attending medical staff 35 (70%), pharmacy staff 10 (20%) and formulary subcommittees 10 (20%). The formal economic analysis of the drug formulary revision was rarely or never conducted at 26 (42%) hospitals. The responsible person for the economic evaluation was drug information pharmacist (21 (42%)), pharmacy department (nonspecific) (17 (34%)) and the pharmacy and medical department (14 (28%)). Conclusion: Evaluation of hospital’s drug formulary and decision-making was not adequate at the majority of the hospitals. Education and training about drug evaluation with an emphasis on cost analysis and impact are mandatory. An electronic addition new medications with close formulary is required with close monitoring for all MOH hospitals in Saudi Arabia.