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Consider the last time you visited the doctor with a sore throat. Before you even walked through the door, one of health IT’s unsung heroes quietly did its job in the background: Eligibility and Formulary.

Put simply, this critical technology ensures that your insurance information has been identified and validated in preparation for your visit.

And because this happens behind the scenes, most patients can take for granted that their prescriber has the information they need to choose the most cost-effective medication according to their drug benefit. The result is a seamless patient experience characterized by accuracy, quality and efficiency—and this happens for virtually all patient visits, millions of times each year.

In fact, Surescripts processed 3 billion eligibility responses in 2019—a 14% year-over-year increase driven by an 8% gain in the number of prescribers using Surescripts Eligibility & Formulary. These prescribers benefited from algorithm improvements that increased successful patient matching (with a master patient index covering 95% of Americans) and delivered 45 million additional eligibility responses in 2019 that otherwise would not have been identified for utilization.

Eligibility and Formulary not only informs the prescribing process, but also doubles as the foundation from which several essential technologies arise. It’s the engine that powers seamless and secure electronic prescriptions, quick and easy electronic prior authorization, and the ability to deliver prescription price transparency at the point of care.

In 2019, the Surescripts Network Alliance drove continued progress improving and enhancing Surescripts Eligibility and Formulary service nationwide. As a result, more patients are being accurately matched through eligibility checks to identify the correct pharmacy benefit coverage and enable prescribers to find the most cost-effective medication. And more patients are having their prescription benefit coverage delivered to the point of care. For instance:

  • With an average of 10 eligibility responses per patient in 2019, we were able to facilitate more informed care decisions 70 million more times than in 2018.
  • Pharmacy benefit managers (PBMs) populated the “plan coverage description” field more often, resulting in 30 million transactions with more complete and actionable information for prescribing.
  • PBM eligibility checks that are matched to the patient’s formulary also increased in 2019, meaning that 60 million transactions were matched to more informed data for prescribing.

With this actionable and patient-specific intelligence delivered to the point of care, healthcare providers are avoiding administrative “swirl,” saving time and money, and ultimately improving care quality and patient outcomes.

Check out Surescripts 2019 National Progress Report to learn more about how we're advancing healthcare, enhancing prescribing and informing care decisions–and increasing quality across the Surescripts Network Alliance®. And learn more about the tools that can deliver prescription price transparency as well as clinical history and medication history to the point of care.