Specialty Medications & Medical Benefit Drugs: The Value of Providing Physicians with Actionable Information at the Point-of-Prescribing

Specialty Medication Information is Frequently Unavailable in the Electronic Health Record (EHR)

Prescribing cost-effective specialty medications including those covered under a medical benefit requires physicians to have access to drug-specific information on plan coverage and restrictions. Currently, many physicians can only see that a medical benefit drug is not covered as part of the pharmacy benefit with no additional information. If the specialty medication is covered under the pharmacy benefit, only standard formulary information may be included such as copay tier and a prior authorization requirement. Typically, physicians cannot access information specific to specialty medication pharmacies or other coverage requirements unique to specialty drugs. This can lead to extra work for practice staff to identify payer-specific requirements and cause unnecessary delays in patients starting needed therapies.


Often prescriptions for specialty pharmacy drugs are misrouted and/or require rework by office staff to ensure patients receive their prescriptions promptly.  As evidence of the complexities in prescribing specialty pharmacy products, manufacturers often have extra support in the form of field reimbursement personnel to assist practice staff with sorting out the approval process and getting patients on therapy without lengthy administrative delays.

Specialty Medications: The Value of Formulary & Benefit Information for Prescription Guidance 

The good news is that payers can provide physicians with actionable information on specialty medications including approval pathways, coverage limitations, and restrictions using currently available tools and technology. Formulary and Benefit (F&B) information can be easily enhanced to include the specifics physicians need to select the right drug for each patient at the point-of-prescribing. Doctors who use EHRs already have the infrastructure necessary for accessing more robust data on specialty medications. Formulary & Benefit information from Pharmacy Benefit Managers (PBMs) and payers has been flowing to EHRs for over a decade and this information can consist of more than the typical copay tier ranking.  Even specific messages in the form of hyperlinks and text information can be included and will be visible to physicians.

Standard solutions are in development to provide more information about medical benefit drugs but implementation may be years away from mainstream adoption. Formulary and Benefit offers a methodology that works today using technology that doctors have already adopted.

Medical Benefit Drug Information in EHRs

While medical benefit drug information isn’t common in formulary data, it can be included. Here, a web link to more information on coverage and restrictions can save practice staff time while communicating valuable information on coverage.

Enhanced formulary results when drug is available from a specialty pharmacy

Having access to additional coverage information allows providers to choose the specialty medications that their patients can afford and can guide pharmacy selection. Payers can also use F&B information to communicate cost share, minimum/maximum copay, coverage restrictions such as days’ supply limitations, and prior authorization requirements. Enhanced formulary information can indicate when a drug is available from a specialty pharmacy.

Specialty Drug Information that can be Communicated through EHRs
Payers have an opportunity to leverage EHRs to communicate pertinent information about specialty medications to physicians, including messaging information about:

  1. Copay, whether a flat amount, percentage, or percentage with a maximum copay
  2. Where to find coverage information including clinical criteria
  3. Pharmacies that may expedite orders to get the patient on therapy quickly
  4. Alternatives that might create savings for the patient or practice
  5. Information on appropriate dosing including reminders for specialty drugs
  6. Links to education on the condition or medication that could be shared with patients

Providing access to this information through EHRs improves the patient’s experience, helps physicians make the right prescription decisions, assists practice staff in supporting patients, and leads to better outcomes.

Formulary results for a medical benefit with a text note about coverage


How to Get Started Communicating Enhanced Specialty Drug Information Today

Benmedica helps health plans and PBMs augment the data sent to physicians through EHRs, resulting in significant savings and convenience for all stakeholders. Our process includes a gap analysis to quantify potential savings, expert assistance shaping F&B data to provide information that supplements typical formulary and benefit information, and ongoing analysis to measure improvements and build on positive results.

Learn more about Benmedica and our team of industry-leading professionals here or check out our library of resources on optimizing EHR prescribing.