Overview

Enhance care with coverage data from source

Save time and boost adherence by placing plan-level prescription benefit coverage information at clinicians’ fingertips. With real-time benefits verification, care teams can move faster in determining the best medication option for their patients and support adherence from the start.

$15.09

potential savings per transaction when accessing benefit information electronically1

2.03 million

healthcare professionals and provider organizations connected2

4.34 billion

care events informed by Eligibility information2

A closer look

What can Eligibility do for you?

Choose your organization type to see how Eligibility can help clinicians find safe, appropriate medications patients can afford and take consistently.

  • Chain pharmacies
  • EHR vendors
  • Health plans
  • Health systems
  • PBMs
  • Pharmacy technology vendors
  • Specialty pharmacy

Increase efficiency and patient satisfaction

Bring clear, accurate information about a patient’s prescription benefit coverage into the pharmacy workflow without needing to view the patient’s insurance card or call the pharmacy benefit manager. Fill prescriptions more efficiently, reduce the chance that orders will be abandoned and avoid associated restocking costs.

icon benefits coverage
View benefit coverage details in your workflow

See the details of patients’ prescription benefit coverage automatically without having to gather additional information from patients or pharmacy benefit managers. 

icon prescription delivery
Make prescription delivery more efficient

Access patient coverage information electronically to fill requests immediately. 

icon prescription negative 2
Reduce risk of prescription abandonment

Ensure that patients receive medications soon after they are prescribed. Avoid the cost of restocking forgotten prescriptions.

icon improve patient experience
Improve the patient experience

Help patients get their medications even if they forget their insurance card. Streamline prescription delivery and avoid frustrating delays.

How it works for pharmacies

A patient doesn’t have their insurance card, but Eligibility means it’s not a problem.

The pharmacist can request the patient’s prescription benefit data without leaving your pharmacy management system.

Eligibility immediately returns accurate coverage information.

Surescripts identifies the patient and transmits coverage information, avoiding the need to call the PBM.

The pharmacist sees the prescription is covered and dispenses it without delay.

Instant benefit validation helps avoid prescription abandonment and its results, like nonadherence and restocking costs.

All Tabs@2x 2

Increase prescribing efficiency and patient satisfaction

Bring clear, up-to-date information about prescription benefit coverage into the prescribing workflow. Use this information to kickstart Record Locator & Exchange and Care Event Notifications workflows and ensure accurate Real-Time Prescription Benefit and Electronic Prior Authorization information.

icon integrate coverage info
Integrate coverage info into prescribing

Show providers whether the patient has prescription insurance and automatically check eligibility information.

icon multiple workflows
Set up multiple workflows for success

Build on Eligibility data to power other products, including Medication History, Real-Time Prescription Benefit, Electronic Prior Authorization and Record Locator & Exchange.

icon get info
Get information from the right payer

For patients covered by multiple insurance plans, Eligibility will indicate which coverage is primary.

icon right coverage easily
Get the right coverage information easily

Use the primary coverage indictor to clarify benefits for patients with multiple coverages and avoid delays, confusion and rework. 

How it works for EHR vendors

A provider accesses benefit eligibility information for an incoming patient through the EHR.

Eligibility can be configured to send real-time data from PBMs to your EHR at recurring intervals or upon request.

Prescribers can make medication decisions with insight into the patient’s coverage.

Instant access to coverage details helps care teams make more informed choices.

Eligibility paves the way for successful care navigation throughout the patient journey.

Prescription coverage data supports processes like checking formulary information and other aspects of care delivery.

All Tabs@2x 2

Increase efficiency and patient satisfaction while decreasing costs

Bring clear information about your members’ prescription benefit coverage into the prescription workflow. Real-Time information access helps solve for affordability and adherence at multiple points in the member’s care journey.

icon reduce costs
Reduce costs and improve compliance

Give prescribers and pharmacists immediate insight into the most preferred and cost-effective medication options at the group/plan level.

icon help members optimize plan
Help members optimize benefit plan use

Ensure members get the most from their prescription benefit plan by helping their providers explain cost and coverage details.

icon update providers
Update providers in real time

Automatically provide the most up-to-date prescription benefit plan eligibility information for your members.

icon inform additional solutions
Inform additional Surescripts solutions

Use Eligibility to kickstart Medication History, Real-Time Prescription Benefit, Electronic Prior Authorization and Record Locator & Exchange transactions.

How it works for health plans

A healthcare provider sends an Eligibility request to support a patient encounter.

Providers can request information on patients’ prescription insurance coverage through their EHR or pharmacy system. 

Surescripts transmits information from your PBM to the provider’s system in real time.

Surescripts’ direct connection to the PBM provides coverage information, including which coverage is primary if needed. 

Eligibility paves the way for successful care navigation throughout the patient journey.

Prescription coverage data supports processes like checking formulary information and other aspects of care delivery.

All Tabs@2x 2

Increase prescribing efficiency and patient satisfaction

Bring clear, up-to-date information about patient prescription benefit coverage into the prescribing workflow. Use this information to kickstart Record Locator & Exchange and Care Event Notifications workflows and ensure accurate Real-Time Prescription Benefit and Electronic Prior Authorization information. 

icon integrate coverage info
Integrate coverage info into prescribing

Show providers whether the patient has prescription insurance and automatically check eligibility information.

icon multiple workflows
Set up multiple workflows for success

Build on Eligibility data to power other products, including Medication History, Real-Time Prescription Benefit, Electronic Prior Authorization and Record Locator & Exchange.

icon route prescriptions
Route prescriptions to the correct insurer

For patients covered by multiple insurance plans, Eligibility indicates which coverage is primary. 

icon right coverage easily
Get the right coverage information easily

Use the primary coverage indictor to clarify benefits for patients with multiple coverages and avoid delays, confusion and rework. 

How it works for health systems

A patient visit is approaching. Their eligibility information is pulled into your EHR.

Eligibility sends the patient’s prescription eligibility information from the PBM in real time, when you need it. 

Prescribers can make medication decisions with insight into the patient’s coverage.

Instant access to coverage details (including primary coverage) helps care teams make more informed choices.

Eligibility paves the way for successful care navigation throughout the patient journey.

Prescription coverage data supports processes like checking formulary information and other aspects of care delivery.

All Tabs@2x 2

Increase efficiency and patient satisfaction

Bring clear information about your members’ prescription benefit coverage into the prescribing workflow. Real-time information access helps solve for affordability and adherence at multiple points in the member’s care journey. 

icon reduce costs
Reduce costs and improve compliance

Give prescribers and pharmacists immediate insight into the most preferred and cost-effective medication options at the group/plan level.

icon help patients optimize plan
Help patients optimize benefit plan use

Ensure patients get the most from their prescription benefit plan by helping their providers explain cost and coverage details.

icon update eligibility details
Update eligibility details in real time

Provide the most up-to-date prescription benefit plan eligibility information for patients.

icon multiple workflows
Set up multiple workflows for success

Build on Eligibility data to power other products, including Medication History, Real-Time Prescription Benefit, Electronic Prior Authorization and Record Locator & Exchange.

How it works for PBMs

A healthcare provider sends an Eligibility request to support a patient encounter.

Providers can request information on patients’ prescription insurance coverage through their EHR or pharmacy system. 

Surescripts transmits eligibility information from you to the provider in real time.

Rely on Surescripts to send your coverage data straight to providers, including which coverage is primary if needed. 

Eligibility paves the way for successful care navigation throughout the patient journey.

Prescription coverage data supports processes like checking formulary information and other aspects of care delivery.

All Tabs@2x 2

Increase efficiency and patient satisfaction

Bring clear, accurate information about a patient’s prescription benefit coverage into the pharmacy workflow so staff don’t need to view the patient’s insurance card or call the pharmacy benefit manager. Help your customers fill prescriptions more efficiently, reduce the chances that orders will be abandoned and avoid associated restocking costs.

icon benefit information workflow
Add benefit information to your workflow

Let users request patients’ prescription benefit coverage electronically without leaving your system. 

icon pickup rate
Make prescription delivery more efficient

Provide instant access to patient coverage information so pharmacies can fill requests immediately. 

icon reduce prescription abandonment
Reduce prescription abandonment potential

Help your customers ensure that patients receive medications soon after they are prescribed and avoid the cost of restocking forgotten prescriptions.

icon improve experience
Improve the patient experience

Enable patients to obtain their medications even if they forget their insurance card. Streamline prescription delivery and avoid frustrating delays.

How it works for pharmacy technology vendors

A patient doesn’t have their insurance card, but Eligibility means it’s not a problem.

The pharmacist can request the patient’s prescription benefit data without leaving your pharmacy management system.

Eligibility immediately returns accurate coverage information.

Surescripts identifies the patient and transmits coverage information, avoiding the need to call the PBM.

The pharmacist sees the prescription is covered and dispenses it without delay.

Instant benefit validation helps avoid prescription abandonment and its results, like nonadherence and restocking costs.

All Tabs@2x 2

Increase efficiency and patient satisfaction

Bring clear, accurate information about a patient’s prescription benefit coverage into the pharmacy workflow without needing to view the patient’s insurance card or call the pharmacy benefit manager. Fill prescriptions more efficiently, reduce the chances that orders will be abandoned, and avoid associated restocking costs.

icon benefits coverage
View benefit coverage within your workflow

See the details of patients’ prescription benefit coverage automatically without having to gather additional information from patients or pharmacy benefit managers. 

icon prescription delivery
Make prescription delivery more efficient

Access patient coverage information electronically to fill requests immediately. 

icon prescription delays
Reduce prescription delays

Ensure that patients receive medications soon after they are prescribed for a better experience. 

How it works for specialty pharmacies

A new prescription arrives, and your team needs to check the patient’s benefit coverage.

Eligibility is integrated into your electronic workflow for easy access.

Pharmacy staff submit an Eligibility request and receive accurate coverage information.

Surescripts identifies the patient and transmits coverage information, avoiding the need to call the PBM.

Your team can confirm coverage and dispense the medication without delay.

A more efficient workflow for pharmacy staff means less time to treatment and a better experience for patients.

All Tabs@2x 2
Features in Focus

Get clarity for patients with multiple coverages

Our primary coverage indicator simplifies the coverage selection process for prescribers and pharmacists when requesting prescription benefit coverage information. 

Correctly process prior authorizations

Confidently send electronic prior authorization requests to the patients' primary insurance. 

Aid adjudication at the pharmacy

View which prescription coverage is primary in order to properly adjudicate pharmacy claims.

Reduce administrative burden

Avoid delays, confusion and rework by connecting with the right coverage provider the first time.

FAQs

Find out more about Eligibility

What type of message is used for transmitting prescription eligibility information?

The Eligibility request will transmit the request (270 request message) directly to Surescripts with the patient’s demographics. The Surescripts Master Patient Index pulls any additional demographic information and sends it to the pharmacy benefit manager for prescription coverage information. The pharmacy benefit manager responds (271 response message) back to Surescripts with the patient’s benefit plan information, which is forwarded to the provider.

What types of care events can trigger a request for prescription eligibility information?

Eligibility can be set up to pull information on a timed cadence or ad hoc. For instance, it can be configured to access information automatically on a nightly cadence for scheduled patient appointments. It can also be set up to run as needed to support drop-in visits to doctors and pharmacies. 

How does a provider know the primary coverage for a patient if they have multiple coverages?

The primary coverage indicator identifies the patient’s primary prescription coverage and ranks multiple coverages in the order in which the pharmacy should adjudicate the claims. 

Can you use Eligibility to look up patients’ prescription benefit information without a copy of their benefit card?

Yes. Eligibility uses the Surescripts Master Patient Index to pull any additional demographic information to assist with identifying the correct prescription benefit plan for the patient. 

How can my organization connect to Surescripts Eligibility?

We are always expanding our partnerships for Eligibility with EHRs, PBMs and other organizations. Partners get step-by-step guidance through our proven certification process.

To get the conversation started, click the “Get in touch” button below.

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