icon representing RTPB

04 ― Real-Time Prescription Benefit

The landscape of health care IT continues to rocket toward a value-based care system. To remain viable in the changing market, companies are beginning to optimize and develop methods that allow providers to have full visibility into all aspects of a prescription.

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05 - Legislation

Functionality ranges from out-of-pocket costs, to whether medication will need a PA, and allows providers to have informed conversations with the patient before they ever leave the clinic. When a provider is writing a prescription, their intent is to make clinically appropriate decisions based on the patient’s needs.

Beyond what medication is most beneficial for the patient’s health, a provider and their patient need to consider several aspects that contribute to adherence and reduce friction at the point of prescribing. Specifically:

  • Is the medication covered by the patient’s prescription benefits, or can it be covered through a PA request? If not, what would be the cash amount?
  • Can the patient afford the co-pay?
  • Is the medication available at the patient’s preferred pharmacy? If not, is it available at a pharmacy that’s convenient for the patient?

Feedback from providers and industry research indicates this information is lacking in the current prescribing workflow and a demand exists for it to be included.

A study completed by AIS Health indicates that during the prescribing process, physicians have little visibility into benefit coverage and co-pay information.10

30% of physicians have access to co-pay information while prescribing.

31% of physicians reported knowing if a PA will be required while prescribing.

50% of physicians have access to the correct formulary tier information while prescribing.

“Anticipating patient copays (in order to prepare assistance if needed) is made difficult by insurance imposed pharmacy restrictions. We usually have to obtain the authorization and then contact the contracted pharmacy who may or may not be willing to run a test claim. If copays come back too high and provisions have not been made this usually keeps the medication out of the patient’s hands.

― Health Care Employee, Oncology

In order to narrow down the best possible option, providers need visibility into patient benefits to determine if a PA is going to be needed, accurate patient pay information, patient out of pocket cost and patient’s preferred pharmacy, when applicable. In order to fully assist their patients, prescribers need access to this information in prescribing workflow.11

A workflow that provides these details enables the provider and patient to have an informed discussion and make the best decision on which therapy to prescribe. It is also likely to increase the patient’s ability to receive and adhere to the medication they need to successfully manage their drug therapy and improve their health.

The objective of RTPB solutions is to meet these needs and should be designed to support the provider and their patient at the point of prescribing. It also eliminates various prescribing barriers that may lead to callbacks from the pharmacy and may help improve physician and patient satisfaction.

RTPB Benefits to Stakeholders

The benefits of a true price transparency RTPB solution are felt by all health care stakeholders but more importantly, the patient.

NCPDP and RTPB

The National Council for Prescription Drug Programs is in the process of developing RTPB standards. The uniqueness in RTPB, from a NCPDP standpoint, is the task group is working on a standard which can be utilized using either the Telecom or SCRIPT model. While no standard currently exists, progress is being made.

Available RTPB Solutions

There are several solutions currently available to the market. Similar to ePA, the success of RTPB solutions will be based on provider adoption. Ease of access to the provider is key; however, more critical will be delivering information in the RTPB transaction that reflects the data providers and their patients need to make informed clinical decisions.

Based on conversations with providers, the following elements will be critical for adoption:

Real-time, Accurate Patient Benefit and Patient Pay Information

An indicator of patient coverage by a plan will not be enough. Providers will want to see data similar to what the pharmacy sees, which reflects real-time patient coverage and cost based on their specific plan and deductible.

Available Patient Assistance Programs

Medication cost is a significant factor to adherence and should be part of the prescribing discussion. Visibility at the point of prescribing into patient assistance programs will support the provider and their patient making an informed decision on treatment options.

Pharmacy Availability and Cost

Pharmacies are best equipped to provide accurate data on cost to help the provider and patient decide on a convenient pharmacy to fill the script, and the actual cost the patient will encounter when they arrive at the pharmacy.

All-Payer Coverage

Similar to ePA, the need for RTPB solutions to have coverage for all payers is critical to provider adoption.

PA Requirements and Other Coverage Restrictions

An indicator of when a PA is needed to fill the script will enable the provider to initiate the PA automatically if they choose to prescribe therapy requiring PA. The most comprehensive solutions will include an indicator when PA is required and provide the option to proactively initiate an ePA to any health plan. This capability increases the likelihood the PA is reviewed by the plan by the time the patient arrives at the pharmacy to pick up the prescription, bolstering adherence to their therapy.

Key Takeaway

Key Takeaway

The industry continues to implement RTPB solutions and quantify the impact on providers and patients. This report will track EHR, health system and provider adoption information as it becomes available.