Pharmacy Benefit Managers (PBMs), prescribers, and pharmacists all play a crucial but different role in communicating prescription savings opportunities to patients.

PBMs work with their clients to create plan designs and provide data to other parties that drives the electronic prescribing process. In addition, PBMs are beginning to encourage their members (patients) to join the discussion.

Prescribers normally have the ability to access understandable and actionable formulary , copay and coverage information within their Electronic Health Record (EHR) system to guide prescribing decisions for their patients, but frequently the information they receive through their EHRs is limited or unhelpful.

Pharmacists also play a role in the prescribing process by identifying prescription savings opportunities as a “backstop” when prescribers have not recognized them.

Patients are increasingly able to use web portals and apps to understand cost considerations and make more informed decisions about their prescribed treatments.

Having robust, complete, consistent and accurate data throughout the process will enable all stakeholders to achieve reduced drug costs.

This article explores the tools used to communicate drug information to prescribers, pharmacists, and patients, what prescription decision support information is available, and the impact of each tool in identifying prescription savings opportunities.

Tools for Communicating Drug Cost Information

There are two predominant methods to pass information about drug coverage to physicians, pharmacists, and patients.  The first is formulary data to physicians, delivered through their EHRs and the second is largely using adjudication systems to price a drug in real time.

Adjudication systems have been used to process claims in pharmacies for decades. Now these systems are being modified for use by physicians and patients. By combining formulary & benefit with adjudication systems, there are now multiple  places where drug benefit information can be accessed: formulary and benefit information (EHRs, mobile/portal) and real-time benefit check information (EHRs, pharmacy claims, mobile/portal).

We review each of these below to better understand the impact on electronic prescribing.

1. Formulary and Benefit Data

Formulary and benefit data, along with eligibility information, is the first opportunity to communicate drug savings options to prescribers. In most cases, formulary information appears during the prescription-writing process, giving doctors much-needed guidance during drug selection regarding drug coverage, copay and alternatives.

There are several components to formulary data:

Patient Eligibility Information

Patient pharmacy benefit eligibility within the physician’s EHR identifies appropriate formulary information including coverage restrictions and copays for each patient. Eligibility information is currently available for over 90% of insured patients according to Surescripts.

Eighty-six percent of providers in a recent survey indicated that reliable electronic prescribing solutions would benefit their patients and assist them in making more informed prescription decisions.

The patient formulary is generally identified the night before the visit based on the provider’s schedule though it can also be run as part of the patient check-in process for walk-in visits. This ‘eligibility’ check enables the EHR to display appropriate drug specific formulary coverage information during the patient visit automatically.

During the visit, the prescriber’s EHR can display formulary information during drug selection, the first step in the prescribing process. The prescriber can select a drug and see formulary information for similar drugs, providing a more informed view of the patient’s benefit.

Formulary Status and Preferred Drugs

Formulary status is the primary way formulary data conveys drug coverage and preferred medications. Formulary status ranges from not covered, non-formulary/off formulary, on-formulary, and multiple levels of “preferredness” where a higher formulary status value is better. Using preferred levels ranks the most preferred drugs, signaling to prescribers the more preferred on-formulary drugs.

Prior Authorization Indicators

Formulary information can communicate to prescribers that a drug requires prior authorization (PA) for it to be covered under the patient’s insurance. Having accurate prior authorization indicators in formulary data allows prescribers to initiate and submit a PA request electronically, many times right from their EHR.

According to CoverMyMeds, PA requests submitted electronically allow health plans to respond up to three times faster than other submission methods like fax or phone, getting patients their medications sooner. Effective communication of PA requirements allows initiation of the PA request at the point of prescribing, reducing the need for rework and retrospective submission after the patient has gone to the pharmacy.

Drug Alternatives

Formulary data can communicate alternatives to a selected drug. The amount of information provided depends on the payer. Drug alternatives can be vague if poorly selected, like including a first-line generic treatment as an alternative for a more expensive second line brand. We discussed the need for good alternatives in our article, “Automating Alternatives Across a Formulary”.

Well considered and relevant alternatives covering a majority of medications offers a superior way to aid the prescriber in selecting a cost-effective medication for the patient.

Cost Information

Cost information can also be included in formulary data, though it may be limited to the copay tier or, at best, the patient copay amount. There are other factors like deductibles and coverage limitations that might change this amount. Payers can also add additional estimated drug cost messages. This is particularly helpful for health systems at risk for drug costs by helping physicians understand the plan cost of a drug. A future version of the formulary data used in EHR will explicitly support an estimated drug cost range.

Overall, as a physician is reviewing drug options, copay amount or drug cost messaging are excellent inputs to drive savings for patients and plans.

Step Therapy

Formulary data can also indicate that step therapy is required. Payers use step therapy to restrict access to certain drugs until the patient tries another approved drug first.

Step therapy information in formulary data can signal that patients must use other drugs before approval is granted and what specific drugs are included in that requirement. Formulary data provides the background and clarity around these PBM step therapy restrictions.

Formulary data has the potential to be expanded to include critical information prescribers need during patient visits. A recent survey revealed that 3 out of 4 doctors are influenced by drug costs when making a prescription decision.

But formulary information can be perceived as vague if it does not include all applicable coverage indicators. In addition, pricing and insurance information can often be hard for prescribers to locate and even with access to formulary information, its scope is limited.

2. Real-Time Prescription Benefit

The information received from Real-Time Prescription Benefit (RTPB) information is similar to what is available in the formulary except that the physician has to enter most information for a complete prescription (including drug strength and form, quantity, and days’ supply) and then select the pharmacy to submit the information. Consequently, the RTPB information is delivered at the end of the prescription writing process.

RTPB transactions return much more precise cost information because the systems treat these transactions as test claims. This allows the system to calculate the patient costs, identify any coverage edits and, in some cases, determine the patient deductible remaining. This information can also include quantity limits, prior authorization requirements, and drug alternatives.

Receiving information at this point in the prescribing process requires the prescriber to create a new prescription for a new medication, leading to some level of rework while the patient is in the office if a change is needed.

Unlike formulary information, which casts a wider net on information returned, RTPB focuses on the drug requested and possibly a few alternatives. In implementations seen so far, prescribers report drug alternatives being available for only a fraction of transactions. The search for a second drug without alternatives requires another attempt that might find a less expensive alternative or a drug without a prior authorization, or it may not.

Sometimes prescribers have selected the best option and do not require a drug alternative to save the patient money. Other times there are potential alternatives that aren’t (yet) provided by the PBM. Drug alternatives are not required in RTPB information returned to physicians and patients. Still, RTPB information represents a significant opportunity to communicate savings to physicians.

Yet much of real-time information has yet to make an impact. A recent survey from CoverMyMeds revealed that nearly half of providers indicated that they never have out-of-pocket medication price information available at the time of prescribing, even though 80% say patients are requesting this information.

3. In the Pharmacy

After receiving the prescription, the pharmacy staff processes the prescription and submits a claim for payment. As part of the claims process, PBMs communicate patient drug costs, deductibles, prior authorization requirements, and quantity limits.

Drug alternatives may also be included as part of the claims process to assist in identifying options for patient savings. This represents the last opportunity for a drug alternative suggestion and is the final point before the prescription is dispensed.

If there is a savings opportunity that requires a prescription change, the pharmacy staff may need to contact the physician to obtain a revised prescription. Revising a prescription usually requires rework by both pharmacy staff and the prescriber and may result in delays in the patient starting treatment.

4. Patient-Direct

Keeping patients updated on their benefits and the cost of prescriptions is an ongoing challenge. Patients are more eager than ever to engage in treatment decisions and include cost as part of those decisions. Help is available in the form of health plan member-facing web portals and apps.

These websites and apps provide drug price transparency information, indicate if prior authorization is required, include quantity limit information, and suggest available drug alternatives.

Prescription cost information is useful before and during an office visit and somewhat less useful retrospectively. When a patient does not have access to cost prior to visiting their pharmacy, they are more likely to abandon expensive drugs or request a new, more affordable prescription.

Along with those health plan websites is a growing number of apps from tech startups that include the ability to compare prices across local pharmacies both through benefits and cash prices.

The bottom line is that patients should be involved in the prescription decision-making process, particularly where cost considerations are a factor. Patients should know what they’re expected to pay and what their other options are at the point of prescribing. This ultimately saves time and lowers drug costs for everyone involved.