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Alternatives for Formulary Drug Alternatives!

Proactive work on the part of payers can make drug alternatives that appear in EHRs Electronic Health Record systems (EHRs) more useful and resolve differences between alternatives displayed using Formulary & Benefit (F&B) and those that appear in Real-Time Pharmacy Benefit (RTPB) information.

Increasing the relevance and consistency of alternatives is critical for adoption by prescribers. Acceptance and usage of the alternatives by prescribers will assist patients and payers in lowering drug costs through better drug selection and will increase patient satisfaction with their health plan.

Without credible alternatives displayed in the EHR during the prescribing process, payers fail to offer a significant feature within F&B, which could help reduce drug costs for their members and alleviate prescriber alert fatigue.

Two Sources of Alternative Drug Information

EHRs can provide alternative information from both Formulary & Benefit information and from Real-Time Pharmacy Benefit (RTPB) information (sometimes called Real-Time Benefit Tools or RTBT). F&B is displayed as part of the prescription writing process, most often when selecting a drug from the provider favorites list or doing a drug search

For example, if the prescriber selects Dexilant then screen below appears. Note that the screens in this article are mock-ups to reflect how an EHR may display the e-prescribing process. They are simulacrums of what prescribers are currently using.

Note that neither Dexilant nor its generic equivalent is a preferred product. If the prescriber proceeds to select the dexlansoprazole (DEXILANT) 30 MG CAP option, then an alternatives drug screen (or an area on the current screen, depending on the EHR’s user interface) will appear.

The image shows a list of drug alternatives that are therapeutically similar to dexlansoprazole 30 MG capsules and can be easily interchanged.

A much more common view of alternatives is by therapeutic class.

This screen is a list of alternatives by therapeutic class. It shows all drugs that have a better formulary status and are in the same therapeutic class as dexlansoprazole/Dexilant. It’s a longer list and does not provide equivalency which requires the prescriber research which strength is similar to dexlansoprazole 30 mg.

If the prescriber decides to proceed with dexlansoprazole 30 MG capsules, then the next steps will be to complete the prescription. To run a proper RTPB transaction, the pharmacy, quantity and day supply will need to be entered.

Just before the script is submitted to the pharmacy, the EHR may automatically run an RTPB transaction, or the prescriber can run a RTPB. A RTPB transaction may return a similar screen to this one.

For RTPB, if the PBM does return alternatives, then the alternatives will likely be therapeutically similar like the first F&B alternatives screen. Because RTPB is supposed to display with minimal latency, the number of alternatives is typically limited to around 5 (though there can be up to 9 based on the version of RTPB used). 

The PBM’s adjudication engine must price each alternative then sort the results in real-time. For a PBM, performance and system stress limit the number of alternatives sent. Note that the PBMs often provide 90-day cost savings options (retail and mail order). It’s a balance between the number of alternatives, pharmacy options and cost savings. The PBM may focus on fewer alternatives but more pharmacy options to reduce drug costs, but it also reduces the number of drug options. In the example above, only two drugs are provided and most at the 90-day supply.

These two sources can conflict when they display different alternatives causing provider frustration. As we stated in our previous article Physician Perspectives of Real Time Pharmacy Benefit Tools a recent study that interviewed physician users of RTBT information found that the information appeared after the discussion with the patient about adding a proposed new medication to the patient’s treatment plan. Any prescription changes required the prescriber to re-evaluate the medication selected and adjust the prescription after the fact.

Formulary & Benefit implementation rules in place with virtually all EHRs require that when a non-preferred drug is selected by the prescriber that alternatives appear. If those alternatives are not provided by the payer or PBM then the EHR uses their drug database to select similar drugs within the original drug’s therapeutic class and with better formulary coverage as alternatives.

The Impact of Alternatives

Another 2022 JAMA publication, Effects of Real-time Prescription Benefit Recommendations on Patient Out-of-Pocket Costs, indicated that only 4.2% of prescriptions were seen to have an available alternative. The alternatives led to an 11.2% reduction in costs. In high-cost drug classes the savings were more dramatic at 38.9%. Ensuring that the information provided is relevant and consistent throughout the process will help prescribers to find value of the information.

Issues With Simple Alternatives

Our review of the literature and discussions with organizations that use F&B and RTPB tools have identified the following challenges with alternatives. Here’s what our analysis found:

  1. Different alternatives from F&B and RTPB. Many PBMs do not include alternatives in F&B data and leave the selection of alternatives to the EHR software when a non-preferred formulary drug appears. If the PBM does not provide alternatives in the F&B data, the EHR then determines alternatives based on the therapeutic class of the initially selected drug. Therapeutic class alternatives may overlap or even conflict with the alternatives provided in a RTPB response. In addition, the prescriber may need to reconcile the prescribed drug after the prescription has been fully entered.
  2. Non similar drugs in the classification. Either service may include all drugs in a classification even if they are not clinically similar. Not all medications grouped by therapeutic classifications within drug databases are equivalent. A most recent example reviewed by Benmedica of this issue is displaying alternatives a non-formulary insulin that included both long and short acting insulins in the alternatives list. This is too broad a selection of alternatives that are not useful and potentially inappropriate by the prescriber.
  3. Appropriate alternatives are not appearing. Missing potential alternative drugs are typically not seen when alternative drugs fall outside the classification of the initial drug selected.
  4. Alternative strength is not equivalent. Specifically found in RTPB which appears after the initial prescription is completed (including the drug strength), the alternative needs to be the therapeutic equivalent of the initial drug. Recognizing that the appropriate alternative to 10mg of atorvastatin may be 5mg of rosuvastatin.

The result of these challenges is a less than ideal prescriber experience and result in higher drug costs for patients with missed savings for payers and PBMs.

Let’s review the full drug alternatives comparison in greater detail from the previous screenshots.

When the alternatives are expanded for each option, it becomes clear that the therapeutic class alternatives provide some guidance but still require additional effort by prescribers to scroll through the options and determine strength similarity. In addition, some valid alternatives may not be listed if the alternative drug is not in the same therapeutic class.

Therapeutically similar alternatives like Benmedica’s SmartAlts make the alternative drug list significantly more useful by being succinct, overcoming the therapeutic class alternatives limitations.

In this comparison, we see that F&B provides a larger number of chemically distinct alternatives as well as the copay for each pharmacy type. It’s the equivalent of 15 RTPB responses. In addition, F&B would provide additional coverage information details (not shown to keep reduce horizontal space).

RTPB focuses on two drugs that the PBM prefers. RTPB really shines when the patient has not met the deductible or to check if a PA is really required for the patient. That why both transactions are complimentary: F&B provides guidance based on the patient’s benefit design while RTPB confirms the prescription is clean and provides the expected drug costs for the patient.

Both can work independently but it’s more efficient have them work together and to be as consistent as possible to avoid confusion.


Sources for Alternatives

Drug database companies have excellent services that among many other functions, categorize drugs. Those drug databases are a fine starting point for identifying alternatives, but the databases aren’t privy to formulary statuses and net cost information that payers and PBMs have at their disposal.  This is where careful planning of alternatives come into play.  Benmedica offers SmartAlts service which when combined with formulary and cost information can enhance drug alternatives that appear in both F&B and RPPB data.

While providing valued and consistent alternative drug suggestions remains a challenge today, we believe that the solution lies in supplying better information to prescribers. Benmedica is on the forefront of creating, reviewing, and augmenting drug coverage information, including alternatives, so that employers and payers can use robust information to ease the physician prescription-selection burden while improving relationships with patients.

If you have questions, contact us to discuss how we can help your organization improve alternatives with our SmartAlts service please contact the Benmedica team today.