Biopharma Insights: Drug Benefit Cost Information at the Point of ePrescribing: What Lies Ahead

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Biopharma Insights – February 2018


Drug Benefit Cost Information at the Point of ePrescribing: What Lies Ahead


By Brian BambergerLife Sciences Practice Lead


Cost information from a patient’s drug benefit is needed at the point of electronic prescribing (ePrescribing)—especially in light of the growing focus on medication adherence due to patient noncompliance with their drug regimens. High out-of-pocket costs are a main reason why roughly half of the 3.2 billion prescriptions dispensed annually are not taken as prescribed; that number is even lower for patients with chronic conditions. Lack of affordability can lead to prescription abandonment and noncompliance, which results in as much as $289 billion a year in unnecessary deaths, needless hospitalizations and preventable doctor visits.

Despite its usefulness, drug cost data for patients usually are not available to the physician at the point of ePrescribing through use of an electronic health record (EHR). That is changing with the advent of the real-time benefit check (RTBC).

ePrescribing Today. Today’s ePrescribing systems have the ability to perform formulary and benefit (F&B) checks. While the information is useful, it is not as complete, accurate or timely as a clinician would like. For example:

  • Formulary data currently are not patient specific and are displayed only at the plan level
  • Data quality is problematic. Insurance plan data (such as for health maintenance organizations and preferred provider organizations) are often not reflected in what is displayed in the ePrescribing formulary data. This creates an information disconnect for coverage and out-of-pocket cost information.
  • F&B files for ePrescribing are static and provide a “snapshot” of benefits. This means they cannot give the prescriber individualized patient benefit and cost- sharing information at a specific point in time, such as at the point of care.

The Solution: The RTBC. The RTBC is viewed as a solution to the problem because it provides up-to-date information directly from the payer or pharmacy benefit manager (PBM), as opposed to static files. The RTBC provides real-time information about patient-specific, out-of-pocket costs for a medication (including specific amounts for copays, coinsurance and deductibles); alternative pharmacy pricing, such as for a 90-day supply; and which pharmacy will be most cost effective in light of a patient’s insurance coverage and available pharmacy benefit. If the prescription is denied, the RTBC can help the prescriber determine if alternatives, prior authorization or step therapy are required and whether coverage limits would come into play.

All of this adds up to a win-win for payers, prescribers, patients and pharmaceutical manufacturers. It should help the prescriber identify the most cost-effective medication at the point of ePrescribing, thus improving the chances for medication adherence. Use of the RTBC can help create a cleaner prescription, which will improve speed to therapy and reduce patient frustration at the pharmacy. It will also help patients make more informed decisions concerning their care, which fits with the current push toward patient-centered care models. RTBC use should also eliminate calls from providers to pharmacies and manufacturers, improve patient relations as well as increase patient access to specific medications.

The RTBC Today. The RTBC is emerging from of its infancy, though current formulary and benefit checks should continue well into the future. Two versions of the RTBC are coming onboard. One is based on the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, which PBMs and payers have not yet integrated at the appropriate point in their claims adjudication process. The second uses a modification of the NCPDP Telecommunications D.0 standard, which will require significant development and cost for integration into EHRs. The ePrescribing industry currently is moving forward with a third, hybrid standard.

The need for better formulary data, coupled with ever-improving clinical decisions, means that payers and EHRs are likely to put RTBC development into their product road maps sooner rather than later. The RTBC is a sophisticated component that will help improve patient health and safety as well as lower costs. That has appeal to payers moving toward value-based care models, which should provide impetus to adoption.

That said, some improvements are still needed to make the RTBC an even more useful tool for prescribers and pharmaceutical manufacturers. For example, manufacturer copay assistance and specialty pharmacy information need to be combined to understand true patient cost.  A wider view of alternatives also is needed to help alert prescribers to the most appropriate, cost-effective therapies. That is because the RTBC only indicates medication alternatives as determined by a patient’s PBM and does not consider the full class of medications.

It is also worth noting that RTBC is not a replacement for formulary data. There is still a need for baseline data for prescriber selection. The prescriber only sees RTBC after a prescription is fully entered. Formulary information is available at the time of drug selection, usually quite a number of ‘clicks’ before an RTBC request can be sent.

Point-of-Care Partners is working at the forefront of RTBI standards and adoption. We have been closely monitoring their development over the past few years. I’d be happy to bring you up to date.  Drop me a line at