According to a survey of 1,000 patients, half did not fill a prescription because it cost too much when they arrived at the pharmacy.1
This is partially attributed to a lack of price transparency at the point of prescribing where formulary and benefit (F&B) coverage information, patient assistance, pharmacy cost and cash price options – among other cost-contributing factors - are rarely available. In situations where formulary and benefit data is available, providers indicate they do not trust the accuracy of the data. In a survey of over 1,300 providers, the average trust factor in the accuracy of F&B data was only 5.7 out of 10.2
Real-time benefit check is a technology innovation that surfaces prescription benefit details, such as patient out-of-pocket cost, drug alternatives and prior authorization (PA) information, enabling providers to make informed medication choices at the point of prescribing. An effective RTBC solution facilitates discussion between a provider and patient about the most clinically appropriate and affordable medication for the patient. By providing true price and coverage transparency, the patient is less likely to be surprised at the pharmacy and more likely to remain adherent.
RTBC & the
75% of patients report they have received a prescription that cost more than they expected. 1
Cost transparency for patients is critical to successful treatment because prescription cost is the primary predictor of medication abandonment. 3 Thirty-seven percent of patients surveyed responded that they stopped taking a medication because it was too expensive.1
As a result, they abandon treatment before taking their first dose, contributing to billions of dollars each year in avoidable health care spending. Currently, medication non-adherence costs the U.S. health care system up to $289 billion and accounts for 10 percent of all hospitalization admissions.4
Eighty-six percent of providers surveyed stated that a reliable RTBC solution would benefit their patients and assist them in making more informed decisions when it comes to treatment.2
Current RTBC solutions support pharmacy benefit investigation; however, the need for medical RTBC is apparent. That being said, because the prescribing and PA process for treatment covered under medical benefits is more complex and without standardization, we expect RTBC for medical benefits to require a longer implementation. Real-time benefit check for medical benefits is often referred to as electronic benefit verification (eBV). This report will be updated as developments occur.
The majority of patients do not expect a provider to know the cost of medication; however, 87 percent of patients surveyed indicate it would be valuable to them if their provider knows the cost of the medication they intend to prescribe.1
Stakeholders & RTBC Standard
Who Are the RTBC Stakeholders & What Do They Contribute to the Solution?
Payers, providers, pharmacies, EHR systems and pharmaceutical manufacturers can all play a role in bringing real-time benefit check technology to the point of prescribing to facilitate better prescribing decisions and improved patient outcomes.
Impact by Stakeholder
By participating in RTBC, EHR systems can surface better quality data and methods of providing the right information to the provider (and patient) at the right time, directly within their E-Prescribing workflow.
As it stands, many providers do not trust their current system of formulary and benefit information, so by having an innovative solution that provides true cost transparency at the point of prescribing, EHRs can improve and enhance the way providers prescribe medications.
Patients are the beneficiary of an effective RTBC solution.
They reap the rewards of prescribing decisions and increased insights when they are able to have informed dialogue with their provider about out-of-pocket cost and other factors that impact adherence at the point of prescribing. In order to avoid sticker shock at the pharmacy, patients can have more say in their care in terms of what they are able to afford and their preferred method of delivery.
Motivation for payers to adopt an RTBC solution is led by a desire to manage patient health with the goals of optimizing patient outcomes while controlling health care costs.
Payers contribute to RTBC solutions through the ability to deliver patient-specific benefit information and surface accurate formulary alternatives in the provider workflow.
For details on what different payer types are looking for in current and evolving RTBC solutions, along with a list of payers currently committed to or available with RTBC solutions, see Payer Availability below.
Pharmaceutical manufacturers can provide significant cost savings that help patients initiate and adhere to therapy through patient assistance programs. These programs provide assistance to help patients avoid out-of-pocket costs.
By participating in RTBC, manufacturers increase awareness of the availability of patient assistance programs, which can be critical when patients are evaluating if they can afford the medication. Seventy-four percent of U.S. providers agree that it would be valuable to know about availability of these programs at the point of prescribing.2
By participating in RTBC, pharmacies can provide information that is relevant to patients, regardless of their insurance (example: cash price), and have the ability to provide benefit information for all payers for any prescriptions, directed to the patient’s preferred pharmacy.
Additionally, it allows pharmacies to ensure their pharmacists and technicians are not doing the heavy lifting when it comes to providing patients with medication cost and cost assistance information, since that information was given when the patient was with the provider. This in turn could help the pharmacy fill more prescriptions, provide medication education and get the patient out the door with their medication in hand on their first visit.
For more details on how pharmacies can benefit from RTBC and what they can contribute to RTBC solutions, see Pharmacy Availability below.
A provider’s adoption of RTBC directly impacts their patient’s experience. It is important that the price data be as accurate and reliable as possible.
The prescription benefit information, including out of pocket cost, is presented to the prescriber up front, within their normal E-Prescribing workflow. When displayed, the information can be utilized to drive a productive conversation between the provider and their patient. This conversation can result in the removal of cost barriers by way of assistance programs which can be understood before the patient arrives at the pharmacy to pick up their medication.
NCPDP & RTBC
There is currently no published RTBC standard; however, a standard is being developed by NCPDP. As mentioned in the executive summary, the standard in development is currently limited to use cases between the payer and electronic health record (EHR) and does not account for some functionality providers indicate they value most in an RTBC solution, including cash price and availability of patient assistance programs.
There is no timeline for the establishment and release of a standard. While the standard continues to be written, stakeholders are quickly implementing RTBC functionality to meet the demand of the industry, as illustrated by the fact that 83 percent of EHRs have already committed to a solution. We will continue to monitor for updates through NCPDP work and task groups.
The standards in development are for “Real-Time Prescription Benefit” and will include the “Telecom Standard” or “SCRIPT Standard” model.
Telecom & SCRIPT
NCPDP supports different standards for transmitting data between partner organizations. The two most widely used are the Telecom Standard and the SCRIPT Standard. Historically, while both standards transmit similar data, they have been used for different purposes.
Telecom: Supports pharmacy drug claims and workflows.
SCRIPT: Supports E-Prescribing and ePA workflows.
Real-time benefit check intersects these two purposes, and as a result, an RTBC transaction is being developed within both standards, allowing individual partners to determine which standard works best for them.
The Need for RTBC Implementation
Patients as Consumers
With the evolution of consumerism and patient access to health-related technology such as patient portals and fitness trackers, patients are insisting they participate in decisions related to their own care now more than ever.
Patients look to software such as GoodRx and BlinkHealth to research the lowest possible out-of-pocket expense and available discounts. In fact, 42 percent of patients with a high deductible have used or tried one of these platforms when deciding where to purchase their medication, indicating price shopping is on the rise.1 These tools are not as comprehensive of a solution as patients want.
Without an RTBC solution, patients are creating workarounds to improve access and adherence, such as relying on manufacturer portals to see what coupons are available.
Real-time benefit check is the answer to the growing trend of consumerism on behalf of the patient by providing the information they are looking for earlier in the prescribing process and saving them valuable time in the process.
Nearly Half of Patients Surveyed with High-Deductible Plans Have Tried Price-Shopping Platforms
The Rising Trend of High Deductibles
According to the Centers for Disease Control and Prevention (CDC) high-deductible plans are on the rise — escalating from 25.5 percent in 2011 to 43.4 percent in 2017, resulting in patients being required to pay more for their medication on the way to meeting that deductible for themselves or their family.5 High-deductible plans are defined as any plan with a deductible of more than $1,350 for an individual, and over $2,700 for a family.6
The average annual premium contributions are $1,129 for single coverage and $5,277 for family coverage. The average dollar contribution for family coverage increased 78 percent from 2006 to 2016.7
Due to these statistics, 46 percent of patients surveyed on high-deductible plans stated that the cost of medication is a burden.1 That same percentage say they price-shop at multiple pharmacies, potentially delaying therapy.
In 2017, patients spent $57.8 billion in out-of-pocket costs for medication.8 Patients having a co-pay of $50 were nearly four times more likely to abandon a prescription at a pharmacy than patients paying $10.9 Providers report discussing cost with their patients when they realize the medication may cost the patient more than $50.2
Worker Contribution Increased 78% in a 10-Year Period
The Path Forward
Real-Time Benefit Check Functions Required for Success
The key determinate for a successful RTBC solution implementation is surfacing the most precise patient pay amount prior to prescription submission which providers are stating does not exist within the current formulary and benefit model. Additionally, providers have to be willing to adopt a solution. In order for them to factor RTBC into their workflow, the solution has to deliver the elements they say are important, for example: cash price, patient assistance programs, PA requirements and medication alternatives.
From a patient perspective, three out of every four report that a medication cost more than they expected when they arrived at the pharmacy, and 50 percent of those same patients surveyed chose not to fill the prescription — this is why transparency at the point of care is so critical.1
RTBC Implementation Models
Each implementation model centers around the same need: surface RTBC information to the providers at the point of care when they can have a conversation with the patient about the most clinically appropriate and affordable treatment options.
There are several implementation models for EHRs by way of payer direct connect, via an intermediary solution, or both. Third-party intermediary solutions leverage direct connections to the payer or pharmacy networks, or provide an open network solution with multiple stakeholders.
The intermediary contracts directly with individual payers and individual EHRs to surface formulary data and patient out-of-pocket cost information to the provider. The payer provides patient-specific formulary information and rules.
The intermediary contracts directly with individual pharmacy chains and systems with individual EHRs to surface data, including patient pay amount and pharmacy specific information.
The intermediary contracts directly with both individual payers, pharmacies and EHRs to deliver detail for a patient’s benefit information and medication pay amount. An open network may also surface patient assistance programs made available through pharmaceutical manufacturers.
The EHR contracts directly with individual payers to surface formulary data and patient out-of-pocket cost information to the provider. This model would require each EHR to contract with every payer and for each payer to develop connectivity to every EHR in order to bring widespread functionality to providers.
|Functionality by Solution|
|Patient Out-of-Pocket Cost|
|Patient Assistance / Affordability Programs|
All Payer/All Pharmacy – The RTBC solution includes connections with all payers and pharmacies.
Alternatives – An alternative medication that may cost less than a prescribed medication but have the same therapeutic outcome or efficacy as the original.
Cash Price – Patient pay amount if they choose to not go through, or do not have, insurance.
Deductible – An amount of money a patient must pay before their health plan will pay a claim over a period of time.
Mail Order – Prescription medication sent directly to a patient via their pharmacy benefit manager (PBM).
Patient Assistance/Affordability Programs – Programs designed to help patients obtain their medication at a lower cost.
Patient Out-of-Pocket Cost – A payment made by a patient for a particular service or medication.
Patient-Specific Data – Plan/PBM details returned on an individual member level.
Pharmacy-Specific Information – Payment details for a patient from a specific pharmacy location.
Prior Authorization – A requirement from a health plan to obtain more clinical information before deciding whether or not to cover a medication.
Retail Availability – The RTBC solution indicates which retail pharmacies carry the medication.
The integration of RTBC solutions in EHRs has the ability to transform the way providers make prescribing decisions through discussion with their patient about medication efficacy and cost factors.
When surveyed, providers cited cash price, patient out-of-pocket cost information, alternative options, PA requirements and patient assistance program availability as some of the top elements they require to have a clear plan for patient care and better conversations.2
Integrations missing these capabilities may result in a lack of true pricing information and delayed or avoided treatment for the patient.
We will continue to monitor and provide updates on RTBC adoption as it becomes available.
Current percentage of the EHR market, representing the majority of market share, committed to an RTBC solution.
An alternative medication that may cost less than a prescribed medication but have the same therapeutic outcome or efficacy as the original.
Patient pay amount if they choose to not go through, or do not have, insurance.
Patient Assistance/Affordability Programs
Programs that are designed to help patients obtain their medication at a lower cost.
Patient Out-of-Pocket Cost
A payment made by a patient for a particular service.
A requirement from a health plan to obtain more clinical information before deciding whether or not to cover a medication.
Motivation for payers to adopt an RTBC solution is led by a desire to manage patient health on an individual basis. Top motivators include: achieving optimal patient-care outcomes, drug utilization and administrative cost savings.
Payers create awareness of patient-specific benefits, formulary alternatives and estimated out-of-pocket costs in workflow, which are critical components of provider decision support and success of an RTBC solution. Payers assist their members by presenting the most cost-effective and clinically appropriate medication options to providers based on patient benefit information and formulary guidelines.
To further benefit patients, the direct connection between payers and providers in an RTBC solution can be enhanced through the ability of some third-party intermediaries to support more complete price transparency. This is accomplished by supplying pharmacy-specific data on member pricing at the patient's preferred pharmacy location. Different types of payers view what matters differently, we will focus on pharmacy benefit managers (PBMs), integrated PBM/health plans and PBM/Payer with retail and specialty pharmacies.
Current percentage of the payer market, representing the majority of market share, committed to an RTBC solution.
|DST Systems (Argus)||
* - Committed/available status and integration method were left intentionally blank because information on those payers was unavailable at the time of publication
Drivers for Participation in an RTBC Solution by Priority10
Payers recognize RTBC as an investment. The near-term focus is to drive preferred formulary compliance for guiding the patient care journey and optimizing PA. The long-term focus evolves to more complex elements such as reducing prescription abandonment, increasing therapy adherence and streamlining the process for specialty medications.
Payers acknowledge that the value of RTBC goes beyond mitigating drug spend and administrative costs to supporting a lasting strategy for management of patient outcomes that reduces prescription abandonment, encourages medication adherence and improves total cost of care.
Additional drivers for participation in an RTBC solution10
Providing directions on payer-preferred channel to fill prescription (e.g. mail order, retail or specialty pharmacy)
Lower Priority Higher Priority
Accurately determining patient out-of-pocket costs*
Lower Priority Higher Priority
Communicating pharmacy restrictions to patient
Lower Priority Higher Priority
Expected Impact of RTBC for Payers10
With a common denominator of increasing patient access to the appropriate medication, payer types perceive the value of an RTBC solution differently:
Pharmacy Benefit Manager (PBM)
PBMs see the most value in reducing drug spend via member-specific formulary, a more accurate display of preferred drug alternatives and reduction of administrative cost associated with PA.
Integrated PBM/Health Plan
Integrated PBMs and health plans see the most value in member satisfaction and safety, reductions in time to therapy and additional drug-cost transparency.
PBM/payer with Retail or Specialty Pharmacies
These PBMs and payers see the most value in drug-cost transparency for member satisfaction, directions regarding payer-preferred channel for dispensing prescriptions (e.g. mail order, preferred specialty pharmacy) and transparency into pharmacy restrictions for specialty drugs.
Evolution of RTBC Solutions
As RTBC solutions evolve, PBMs will be watching for advancements in pharmacy network restrictions, specialty medication coverage, messaging for specialty restrictions and clinical messaging at the point of prescribing (e.g. medical, safety).
To return the most value from an RTBC investment, payers should consider implementation of next generation RTBC solutions that offer a range of benefits. More established vertically integrated payers (i.e. merged health plans and PBMs) are already experiencing the benefits delivered by second and third generation RTBC solutions.
Increase preferred formulary compliance; reduce need for PA; reduce administrative costs of PA; reduce time to therapy; reduce abandonment
Accurate member out-of-pocket costs; accurate presentation of preferred dispensing channel (e.g. mail order, retail or specialty pharmacy)
Increase medication adherence; ability to direct patients to the appropriate pharmacy for specialty drugs; accurate determination of pharmacy restrictions
Pricing Models for RTBC
As the value of RTBC is recognized industry-wide, pricing models that promote sustainability of solutions will be key to lasting success for payers.
Until RTBC gains more traction and cost-saving outcomes can be properly evaluated, payment for RTBC solutions will be based on number of transactions. As RTBC transaction volume grows, it may become necessary to adopt a more complex pricing model that will allow payers to accurately forecast based on factors like prescription and PA volume. As more complex pricing models are explored, progression to outcome-based payment is possible wherein reimbursement for the RTBC service is based on the explicit value to the payer (i.e. substitution to on-formulary alternative, substitution to a medication not requiring a PA request or utility of a preferred dispensing channel).
The value of RTBC to promote patient adherence and care is being recognized by pharmacies. Currently, at least 45 percent of pharmacies by market share are partnered with an RTBC solution.11
Pharmacies play a critical role in helping patients on their journey to health by getting them the medications they need. Real-time benefit check solutions that leverage pharmacy connections have the ability to provide patient pay information that goes beyond insurance coverage alone.
In addition to benefit information, such as copay amounts, deductible amounts and PA requirements, pharmacies have access to information that can clarify or reduce out-of-pocket cost for patients . For example, RTBC solutions connected with pharmacies can surface the cash price for medications at a patient’s preferred pharmacy and display the availability of patient assistance programs. Pharmacies also keep complete records of patient prescription history that can help providers safely prescribe medications and avoid dangerous contraindications.
Real-time benefit check encourages medication costs and patient assistance information be communicated at the point-of-prescribing, rather than at the pharmacy. With pharmacists’ role in patient care expected to expand (78 percent of surveyed pharmacists anticipate a greater role in patient care),17 RTBC may free the necessary time to review patient data for safety considerations, counsel patients on recommended clinical services and educate patients on therapy.
Advisory Board & Sources
The RTBC National Adoption Scorecard is written and published by CoverMyMeds with guidance from industry experts on the RTBC National Adoption Scorecard Advisory Board:
Director, HPS Clinical Integration & Implementation
Vice President, Integration Services
Chief Medical Information Officer (CMIO)
American Medical Association (AMA)
Pharmacy Patient Medication Access Principal Coordinator
University of Virginia Health System
Manager of Pharmacy Operations
Blue Cross Blue Shield North Carolina
Dr. Eric Weidmann
Chief Medical Officer (CMO)
1 - CoverMyMeds Patient Survey, 2018 ^
2 - CoverMyMeds Provider Survey, 2018 ^
11 - CoverMyMeds data on file, 2018 ^
If you have feedback on the content or are interested in a slide deck of the report, please email RTBCscorecard@covermymeds.com