Formulary and Benefit Standards Version 60:
What You Need to Know

National Council for Prescription Drug Programs (NCPDP) has been busy this year evaluating the Formulary & Benefit (F&B) standard. Based on industry feedback regarding v53, NCPDP and its F&B task group reimagined how F&B should work in the e-prescribing workflow. With the advent of the Real Time Prescription Benefit (RTPB), some areas of F&B have been scaled back while new features have been added to support initial drug selection . In addition, the latest version of F&B, v60, has been significantly streamlined to ease implementation, improve performance and reduce file sizes.

To meet the demand for patient copay amounts, preferred pharmacies, and patient deductible information, NCPDP is finalizing version 60 of its Formulary and Benefit Standard (F&B). While the current version (v3.0) has been in use for over a decade, emerging market changes have spurred new functionality and lead to some soul searching about its design.

What does this mean for you? 

  • Providers will have greater access to actionable information like indication-based coverage that they can use to identify the best option for their patients based on cost and convenience.
  • Patients will be able to select a medication that fits within their budget and choose a preferred pharmacy for the lowest possible cost.
    * Update: Identifying preferred pharmacies were vetoed from the new F&B standard.
  • Payers will experience higher levels of formulary compliance and reduce their drug spend. In addition, it will be easier to use F&B to support HL7’s FHIR DaVinci PDex standard.
  • Payers and EHRs will have a migration path to coordinate and simplify the upgrade process and the timing of changes. 

Continue reading our analysis of this new version or click here to learn more about how we can help you transition to the new version.

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Overview of Formulary and Benefit Version 60 Changes

The new version contains numerous changes and additions, with careful emphasis bridging the incompatibilities between the current version and version 60. We’ve categorized significant changes into three parts: key changes, notable additions, and items removed.

Key Changes to Formulary & Benefit 60

Below are the most impactful changes Version 60 will bring to EHRs (compared to v53). These include:

  • Formulary File to communicate formulary status
    • Additional formulary statuses like brand preferred over generic
    • Level of preferredness
    • Drug Tier File that contains a drug tier description (optional)
  • Copay
    • Deductible support like when does the copay amount apply
    • Preferred pharmacy
  • File Size Reduction
    • Removed
      • Barely used fields (legacy v3.0)
      • Eliminated some v53 fields/functionality 
    • Implemented normalized file management

Together, these changes will provide much-improved cost information to providers and patients with increased sophistication that reflect current benefits designs and hopefully future designs. In addition, increased support for medication alternatives will also help drive improved provider choices when other drugs may offer savings.

Notable Additions to F&B 60 

Notable Additions to F&B 60 

In addition to the changes highlighted above, F&B 60 contains additions to make its capabilities more robust and better aligned with market needs. 

Pharmacy Type and Lists

Preferred Retail and Preferred Mail pharmacies included in the new format will give providers valuable information about pharmacies offering the best options for their patients.

 * Update as of 11/04/2022: Identifying preferred pharmacies were vetoed from the new F&B standard, primarily by independent pharmacies.

Indication-Specific Formulations

Formulary information based on the drug indication (or use) has been encouraged by CMS in formularies for several years. The payer will now have the ability to provide a diagnosis code and diagnosis code description as part of the F&B data. Based on the diagnosis, F&B elements like the drug’s formulary status or PA flag could change. EHRs can either match the diagnosis code or display the diagnosis description to indicate if the drug may be covered for certain diagnosis codes without a PA.

Unlike some medications that are only approved for one disease state, many medications have multiple FDA approved indications. However, payers do not always cover a medication for each of its disease states. For example: Humira is approved for both Rheumatoid Arthritis and Ulcerative Colitis. The payer will cover Humira for Rheumatoid Arthritis, but prefers a different medication for Ulcerative Colitis. If a provider wanted to know what medications are available for his patient that has Rheumatoid Arthritis he would be able to look at the indication-specific formulary and see Humira listed.

Items Eliminated from F&B Version 60

Items Eliminated from F&B Version 60

F&B Version 60 does not contain following items because they were rarely used and deemed out-of-date. 

  • Cross Reference File 
  • Unused drug identifiers 
  • Conditional Logic 
  • Approximate drug cost is less accurate than the real-time prescription benefit (price check) which is becoming widespread
  • Numerous copay fields that were overkill 

Sample Display Mockups for F&B Version 60

The mockup below is a real example of how payers can convey the Medicare Part D copay benefit structure by preferred versus non-preferred pharmacies.

Here, it’s possible to see that the patient would be responsible for varying out-of-pocket copays depending on the preferred status of the pharmacy they chose. With the addition of deductible information, patients can also be aware of when their copay becomes applicable too. For example, Tier 0 and Select Care may state that deductible does not apply compared to tiers 2, 3, and 4 have that copay apply after the deductible has been met.

When doctors have access to this information during the prescribing process, they can equip their patients with the information needed to choose the right pharmacy for their needs.

Here’s a breakdown of how previous F&B iterations would have conveyed preferred pharmacy status compared to Version 60.

Without preferred pharmacy types, there is not a clean way to display preferred copay designs.

Streamlined, EHRs can match preferred pharmacies to preferred pharmacy copay designs to display just the relevant copay based on the patient’s last/most used retail pharmacy.

Ultimately, we believe that this addition will result in significant drug savings for all stakeholders.

Update: As of 11/04/2022, preferred pharmacy was removed from version 60 of the F&B standard. Benmedica will continue to push for its inclusion because it adds significant value to the prescribing solution by making pharmacy networks transparent to both physicians and their patients.

What Happened to Formulary and Benefit Version 53? 

As we discussed in November 2020, an earlier version was approved and brought forward to become a named standard. However, as an implementation date was selected, stakeholders raised several objections:

  1. SCRIPT, TELECOM, RTPB, and F&B were all moving forward with new requirements for implementation creating a burden for organizations using those standards
  2. F&B version 53 is not backward compatible which becomes an issue when payers and EHRs have different timelines for implementation
  3. The 2-year timeline for implementation was not long enough to incorporate the needed delivery infrastructure
  4. Eligibility support was not robust enough to meet user needs

How does F&B Work with Real-Time Pharmacy Benefit Capabilities (RTPB)?

F&B is still useful and complements RTPB. A contributing reason to delay releasing Version 53 was to ensure the latest version is more compatible with RTPB.

By helping prescribers select the optimal prescription during drug selection versus just before sending the script to the pharmacy, it will reduce prescriber alert fatigue and rework from prescription changes. A cleaner view of the patient’s drug benefit helps guide prescriber decisions while RTPB confirms member specific drug coverage eligibility and the pharmacy specific price of the selected medication as well as lower cost options.

Next for F&B Version 60

While the contents of the next version is set, work continues on supplementing the v60 implementation guide to provide examples and best practices to facilitate implementation. Work also continues on the transition plans to the new version. It is expected that the implementation period will begin in a few years and there will be a substantial transition period for payers, intermediaries, and provider systems to update.

Benmedica continues to spearhead the efforts to deliver drug savings to patients and payers by ensuring that providers have access to cost-cutting information at the point of prescribing.

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