INTELLIGENCE IN ACTION

Strengthening Our Foundation with Eligibility, Formulary and Benefit Data

We have come so far in healthcare technology that we sometimes take the fundamentals for granted.

This can be the case with Eligibility and Formulary. When it’s doing its job well, the average end user might not think about it very much. By identifying and validating patient data and insurance information, Eligibility and Formulary works behind the scenes to help complete a number of mission-critical processes—all before the patient even arrives for their visit.

But when patient information is missing or a clinician receives a “patient not found” response to an eligibility check, trust quickly deteriorates. And without it, many other critical transactions simply aren’t possible.

I recently joined Michael Burger, Senior Consultant for Electronic Health Records and Electronic Data Exchange at Point-of-Care Partners, during a webinar to share perspectives on the importance of having complete eligibility, formulary and benefit data.

Watch now: Leveraging Benefit Data to Improve Patient Satisfaction at the Point of Care


Even modest innovations have a very real and certainly significant impact at scale. Last year, nearly two million healthcare professionals and organizations used Surescripts Eligibility & Formulary to inform more than three billion care events. Imagine the opposite impact if even a fraction of those healthcare interactions went forward without this crucial patient information—or with unreliable information that users don’t trust. 

Think about medication affordability, for example. The prescriber’s ability to partner with their patient on choosing a medication that’s right for them both medically and financially depends on a conversation at the point of care. And that conversation is vastly more effective with plan-level prescription benefit coverage and formulary information in hand.

Eligibility & Formulary is at the heart of Real-Time Prescription Benefit, as well as the foundation for E-Prescribing, Electronic Prior Authorization and Medication History—technologies that improve patient safety and care quality through a better prescribing experience for all.

And we’re making it even better. End users can now leverage Surescripts On-Demand Formulary to access this critical information via a real-time request and response transaction. This recent innovation replaces the traditional download method and ensures that EHRs and providers have the very latest information at the point of care. Along with significant time savings, our cost model shows how the service could help an EHR save nearly $11,000 a month.

“We decided to replace the distributed F&B file with Surescripts’ new On-Demand Formulary service as a way to enhance the Aprima formulary process, and at the same time reduce our development costs, network, bandwidth, and people costs. It’s been a smooth process. The service is reliable, response time is good, and our customers are benefiting from having up-to-date information.”

– Neil simon, Chief Operating Officer, eMDS

Three Quick Reads: Perspectives on the Power of Best-in-Class Eligibility, Formulary and Benefit Data

As a true expert on the topic, Mike Burger has penned a number of articles that get us quickly up to speed on the latest technology and how it delivers value throughout the healthcare ecosystem.

When prescribers have these insights to make medication decisions, everyone—pharmacies, pharmacy benefit managers (PBMs), and most importantly, patients—will all feel the difference.

Be sure to download the whitepaper below and visit Intelligence in Action for more articles on many of our industry’s biggest challenges and the latest innovations to solve them.

Download this:Fierce Healthcare Surescripts Whitepaper (.pdf)

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