Providers often have a limited knowledge of a specific patient’s insurance coverage when prescribing medications, and a real-time benefit check program may be a solution for this. Real-time benefit checks can provide information on coverage (quantity limits, prior authorization, step therapy), channel options (retail, mail order, specialty), patient payment details, and alternative drugs based on the patient’s plan formulary.
During a presentation at the AMCP Annual Meeting, Jacqueline Hager, BS, product manager at Surescripts in Minneapolis, Minnesota, and Roger G. Pinsonneault, RPh, vice president of product innovation at Gemini Health in Alpharetta, Georgia, discussed different options and implementation strategies for real-time prescription benefit check programs.
This program uses a standard format to exchange data between providers and pharmacy claims processors in real time. Providers, prescribers, or the pharmacy originate a request from their practice management system. The pharmacy claims processor adjudicates the requests and communicates a response in real time. The practice management software receives the response and presents the details in the provider’s workflow.
The proposed Medicare Part D rule for 2020 seeks to make revisions to the Medicare Advantage program (Part C) and Prescription Drug Benefit Program (Part D) regulations to support health and drug plans’ negotiation for lower drug prices; and reduce out-of-pocket costs for enrollees. A real-time benefits tool can provide patient-specific cost-sharing information within the prescriber’s electronic health record. Providers can identify a patient’s specific benefit plan and assess utilization management tools that are included. According to the Medicare guidance, these tools “should not be used by providers to evaluate alternatives for drugs prior to discussing whether the patient intends to self-pay for the prescribed drugs. Health care providers … should ensure that individuals are aware that information about services or treatment, such as a future prescription, may be disclosed to the plan by the tool and effectuate the individual’s disclosure restriction request by refraining to use the tool in instances in which the patient intends to self-pay in full.”
According to research presented from Surescripts, the average savings per prescription with the use of a real-time benefit check can range from $21 for cardiology to $228 for psychiatry. The speakers gave an example of the use of this program in action: The prescriber selects 90 capsules of cariprazine—an antipsychotic used to treat schizophrenia or bipolar disorder—at a patient’s preferred pharmacy. The real-time benefit check notifies the prescribed that this medication will cost the patient $1,775.84 but that it is available through their pharmacy benefit manager’s mail order pharmacy for just $125. The prescriber then sends the prescription to the mail or pharmacy for added savings for the patient.
When engaging with a real-time benefit check program, employ a team-based approach to discuss costs with the patient. Establish a process to document cost concerns that the entire team can reference, and train your team to have financial conversations with the patient, the speakers concluded.
Presentation V7: Regulation to Outcomes: The Impact of Real-Time Prescription Benefit Check. AMCP Annual Meeting 2019.