BioPharma: Better Formulary and Benefit Information

HIT Perspectives Biopharma Insights – September 2015

Better Formulary and Benefit Information Pay Off for Payers

By Bruce Wilkinson Contributor

Electronic prescribing (ePrescribing) is the norm for prescribing most medications these days – so much so that it is often a ‘check box’ for health plans and pharmacy benefit managers (PBMs). However, the ePrescribing process is only as good as the information in the electronic health record (EHR) system – the most common method for ePrescribing – and how it is made available to the prescriber. Opportunities exist to provide better and more detailed information at the point of ePrescribing that will yield better outcomes for payers, prescribers and patients. Formulary and benefit information is a case in point. Currently, many health plans and PBMs provide only formulary status, and most do not go past the minimum Medicare Part D standards for the information they provide to ePrescribing systems. Yet ePrescribing systems can accommodate a wide range of relevant formulary and benefit details. Examples include copays by pharmacy networks, coverage restrictions, preauthorization alerts and next steps, lower-cost and safer alternatives, step therapies and age-specific safety risks.

While providing additional formulary and benefit information is outside the work flow and radar of many plans and PBMs, the payoffs could be significant for payers and other stakeholders. For example, it could improve: Star ratings. Providing more advanced formulary and benefit information at the point of care can help payers improve their affiliated physicians’ star ratings, such as for high-risk medications. With access to a wider array of cost-effective and less risky alternatives, providers can demonstrate they are better managing the care for their high-risk patients – and even moving them to less risky therapeutic options, if appropriate. In addition, better information will improve physician performance with payer evaluations and ratings. Medication adherence. Research shows that high out-of-pocket costs, such as copays, cause patients to abandon prescriptions or not take medications correctly to save money. This results in 100,000 deaths each year and costs the health system $200 billion in unnecessary hospitalizations and doctor visits. Communicating better formulary and benefit information at the point of care informs prescribers of the lowest covered price drug options for their patients’ medications, thus improving the chances of patients filling their prescriptions and following their prescribed course of therapy.

A copay tier is simply not enough information on which to make an informed decision. Patient outcomes. Improved formulary and benefit information at the point of ePrescribing can help physicians prescribe the appropriate drug for the patient. This translates into improved patient management, healthier patients and better outcomes, which in turn reduces costs of care. Cost control. Making sure that patients stay on medications covered by their insurance is a major way that payers control costs. Providing more detailed formulary and benefit information in ePrescribing systems helps ensure physicians know which medications are covered by a patient’s health plan so they can ePrescribe drugs that are on formulary. It also helps them identify less costly but therapeutically appropriate alternative medications or less expensive dispensing methods, such as a 90-day mail order supply or preferred pharmacy networks. Prescribing efficiency. Improved formulary and benefit information at the point of care means physicians can more appropriately ePrescribe the correct drug from the get go.

The result: improved efficiencies due to fewer phone calls for clarification between the pharmacy and the physician’s office and less rework. Patient satisfaction. ePrescribing an appropriate, cost-effective drug during the office visit also helps improve patient satisfaction, a new metric on which providers and many health plans are now being evaluated. This helps prevent patient sticker shock at the pharmacy and frustrating waits for prescriptions while prior authorizations and reimbursement issues are sorted out. All in all, improved formulary and benefit information at the point of ePrescribing is a win-win for payers, physicians and patients. Proactive medication management enables payers to leverage EHR systems so as to enable providers to make optimal and informed decisions for their patients based on their plan formulary and pharmacy benefit. Let Point-of-Care Partners position your firm to help physicians to make use of better formulary and benefit information – a valuable but underutilized tool in the ePrescribing toolbox.