Right Around the Corner: 2021 CMS Rule Requiring Real Time Benefit Tools

Beginning in January 2021–which is just six months from now—a new Centers for Medicare & Medicaid Services (CMS) regulation will require that Medicare Part D health plans implement real-time benefit tools. Here’s what you need to know.

Medicare Advantage and Part D Drug Pricing Final Rule

On May 16, 2019, CMS issued its final rule, which states, “In order to accelerate the use of electronic Real Time Benefit Tools (RTBT) in the Part D program, CMS is requiring that each Part D plan adopt one or more RTBTs that are capable of integrating with at least one prescriber’s ePrescribing system or electronic health record (EHR), no later than January 1, 2021. RTBTs have the capability to inform prescribers when lower-cost alternative therapies are available under the beneficiary’s prescription drug benefit, which can improve medication adherence, lower prescription drug costs, and minimize beneficiary out-of-pocket costs.”

Tip: Not all RTBTs are created equal. Here are a few things to look for when selecting a RTBT:

  • Accurate and reliable data from health plans and pharmacy benefit managers.
  • Easy integration with existing e-prescribing workflows using the same screens that clinicians use today. This keeps prescribers in their EHR and away from hunting through a maze of screens or third-party apps.
  • Visibility into therapeutic alternatives and flags for drugs that require prior authorization.

Meet Requirements with Surescripts Real-Time Prescription Benefit

As the Final Rule states, Medicare Part D plans are required to provide accurate pricing to members. The good news is that technologies that meet these new requirements are available now, designed to be built into the same e-prescribing workflows that prescribers use today.

Surescripts Real-Time Prescription Benefit embedded in prescribers’ existing EHR software meets the CMS requirements. The technology gives users the power of price transparency and can help lower costs and improve medication adherence while improving patient satisfaction by removing the friction that can result from phone calls, faxes, and delays. In fact, prescription price transparency tools have the potential to save commercial health plans $795 million annually and the commercial healthcare industry as a whole $3.7 billion annually.  

Nearly half of all prescribers are expected to have access to Real-Time Prescription Benefit by the end of the year, but utilization varies nationwide. Leading the charge is Washington, D.C., where nearly half of all providers have adopted the technology (49.9%). Also, in the top five for provider adoption are Maryland (48.5%), Delaware (44.3%), North Carolina (36.4%) and Louisiana (36.2%). The bottom five states for provider adoption are New Hampshire (11.1%), Washington (10.2%), New Mexico (9.3%), Massachusetts (8.8%) and South Dakota (8.3%).

Health plans that implement a RTBT now will be in compliance with the new rule when it takes effect on January 1, 2021.

Learn more about Surescripts’ Real-Time Prescription Benefit service today.

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