Better Together: Comparing Real-Time Pharmacy Benefit Checks to Formulary and Benefit Data in EHRs

While real-time pharmacy benefit checks are increasingly touted as the answer to formulary needs within Electronic Health Record systems (EHRs), prescribers and patients often require additional information to develop effective treatment plans. High-quality formulary and benefit data in the EHR can provide complete prescribing information without impacting provider workflow. Formulary and benefit data provides more detail than a single product real-time inquiry by offering comparative data across all products in a therapeutic area.


Advantages and Limitations

Benmedica has done significant work with payers to establish processes for ensuring that the right information reaches prescribers at the right time. Based on our experience, real-time pharmacy benefit checks and formulary and benefit data each has its own benefits and limitations.


Formulary and Benefit

In most EHRs, providers can use formulary and benefit information to select appropriate, cost-effective medications for patients. Payers can specify formulary statuses, coverage limitations and even tier copay levels in their formulary information for display within the EHR.  A routinely performed eligibility check identifies the correct formulary and benefit data to use for the patient.

Advantages of Formulary and Benefit Data

  • Capability exists in virtually all EHRs
  • Data is exchanged using a nationally-recognized standard
  • Formulary is comprehensive across all products and EHRs display a wide list of alternatives
  • Quality of the data can be high with payer commitment to complete and accurate F&B data
  • Can include copay tiers and actual copay dollar amounts
  • Format can accommodate plan and group level formularies
  • Allows for drug messaging and supporting web links 

Limitations of Formulary and Benefit Data

  • Is not patient specific to include where restrictions may not apply to a patient because of past treatments or other conditions are met
  • Does not include drug deductible or out-of-pocket amounts 
  • Some payers through system limitations, by sending poor quality formulary data, have discouraged prescriber reliance on formulary and benefit data


Real-Time Pharmacy Benefit Check (RTPBC)

Access to real-time pharmacy benefit information is under development with select payers and EHR systems demonstrating value and testing the structure of data transactions. Early results indicate that the information provided is valuable for creating treatment plans but offers a limited number of treatment alternatives.

Advantages of Real-Time Pharmacy Benefit Check

  • Provides patient-specific pharmacy benefit information at the time of prescribing
  • May include patient deductible or out-of-pocket information 
  • Can offer more accurate patient-specific information than formulary and benefit data such as coverage requirements
  • May pinpoint information on a few alternatives if the payer elects to provide 

Limitations of Real-Time Pharmacy Benefit Check

  • Takes additional prescriber time to run and requires a full prescription 
  • Provides information for only one drug per inquiry (with a few alternatives), not a robust look across the plan formulary
  • There are likely additional costs, such as transaction fees
  • Includes pharmacy benefit products only
  • Does not provide a broad overview of alternatives and formulary status
  • Currently available through proprietary solutions; not all providers or payers can support
  • Transactions do not include the total drug costs for prescribers who are at risk for the cost of medications
  • Prescribers unfamiliar with these new features will need education on what this information means


Better Together

While RTPBC is gaining traction as a valuable tool for prescribers, formulary and benefit information can save time and transaction costs when the payer provides high-quality data.  “RTPBC was originally designed to be a secondary check of the current formulary and benefit data, not a substitute. It also is used in a different place in the ePrescribing process and work flow. While it adds value, it is not a replacement,” says Tony Schueth, Point of Care Partners.  When used to complement formulary and benefit checks, RTPBC information can yield greater insight into the best treatment plan for a particular patient.

Ultimately, providing patient-specific prescription benefit information “at the point-of-prescribing will help improve patient access to medications and also ensure their prescribers are aware of prescription insurance formulary status and less expensive alternatives when appropriate,” says Bernie Monegain, Healthcare IT News.  This is a win-win-win situation for payers, prescribers, and patients.


How Benmedica Can Help

Benmedica assists health plans and payers with optimizing the data sent through Surescripts and other connections to EHRs for use by prescribers. We have deep experience developing processes to best leverage existing data so relevant copay and formulary information, along with preferred alternatives and custom messaging, reach physicians at the time of prescribing.

If you are interested in learning more about the solutions Benmedica has in place to assist payers with delivering the right information at the right time, please contact us or explore our solutions. For updates on our work optimizing payer information for prescriber use, follow us.


About Bruce

Bruce Wilkinson, the founder, and CEO of Benmedica, has leveraged technology to facilitate healthcare since the birth of electronic prescribing and physician connectivity in 2002. Bruce has extensive industry experience with Accenture, Express Scripts, ZixCorp, and CVS Health and continues to lead the development of healthcare standards through NCPDP. You can connect with Bruce on his LinkedIn page.