With his prescription pad in hand, my doctor warned me that the medication he was prescribing “may or may not” be covered by my health insurance plan. And as it turned out, it wasn’t. I had to learn at the pharmacy counter that the prescription was not covered by my insurance.
If my doctor had used e-prescribing and patient benefit data—using a tool such as Eligibility & Formulary—we could have discovered in his office that this prescription wasn’t the right match and identified alternatives for formulary instead. Although I was lucky that the pharmacist pointed me to an over-the-counter alternative, not everyone has that option and can lead to prescription abandonment.
How Patient Benefit Data Enhances E-prescribing
Eligibility & Formulary is used to determine coverage and inform initial drug selection.
Benefit insights help prescribers make optimal decisions by displaying in their electronic health record (EHR) software, a patient’s coverage status and indicating which drugs are on their formulary. In our 2019 survey of healthcare professionals involved in patient care or the pharmacy benefits process, 83% of respondents said the patient’s benefit information influences their prescribing decision and large majorities would consider changing a prescription based on coverage, formulary tier or prior authorization requirements. Not only is this a win for patients, but prescribers also value these patient benefit insights. Nearly all survey respondents also said they value access to group/plan level prescription benefit information within the e-prescribing workflow.
But to paint a complete picture, Eligibility & Formulary is only the first step. Prescribers can use Eligibility & Formulary to determine coverage information, such as a prior authorization is needed or the drug is non-reimbursable by insurance, to inform the initial drug search. Once the prescriber determines the drug is covered, then Real-Time Prescription Benefit can be used to add patient-specific information, such as patient specific cost information. This results in more streamlined prescription writing process and fewer key strokes.
Fortunately for patients like me, optimizing prescriptions at the point of care is on the rise. In 2019, Surescripts transmitted 3 billion Eligibility responses—an increase of 14% from the year before—from 1.2 million prescribers. But we’re not only improving the reach of this critical service, we’re also improving match rates and accuracy. In fact, recent patient-matching algorithm improvements delivered 45 million Eligibility responses in 2019 that would have otherwise gone unanswered.